Health inspection·November 14, 2024

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, policy review, review of facility documentation, observation, and staff interview, it was determined that the facility failed to provide necessary supervision to monitor a resident's whereabouts and prevent an elopement (unauthorized departure from the facility) which resulted in actual harm for one of 10 sampled residents at risk for elopement. (Resident 1) The incident has been identified as past non-compliance. Findings include: Review of the facility policy entitled, Elopement/Unauthorized Absence Policy, last reviewed on August 2, 2024, revealed that staff was to identify residents with potential and/or actual risk factors for elopement and protect the resident through development and implementation of safety interventions. Clinical record review revealed that Resident 1 was admitted to the facility on [DATE], and had diagnoses that included vascular dementia (impaired cognition, or a disease that causes progressive cognitive impairment that includes memory loss and personality changes), anxiety, and dissociative and conversion disorder (causes a person to be disconnected from their thoughts, memories, consciousness, and identity, and causes physical symptoms that a person can't control). According to the Admission/readmission assessment, dated November 8, 2024, the resident could walk without assistance and was identified as a potential elopement risk. According to the care plan, the facility identified that the resident was at risk for elopement since admission to the facility and interventions implemented were for staff to place a Wanderguard (a security apparatus worn by an at risk resident that prevents doors from opening to prevent elopement when the resident is nearby) on the resident's left wrist and to place the resident on the third floor of the facility. Review of the nursing notes revealed that Resident 1 did not express any desire to leave the facility or exhibit exit-seeking behaviors from admission on [DATE], through November 9, 2024. On November 9, 2024, a nurse noted that at approximately 7:15 p.m., Resident 1 was observed lying on the ground outside the perimeter of the building. His personal belongings were scattered on the ground around him. A blanket/sheet was observed hanging from the window of Resident 1's room above him. According to the facility investigation into the incident, the resident was last seen at approximately 6:35 p.m. seated in the dining room. The investigation indicated that the resident broke the window safety device and used bed sheets to climb out the third story window, experiencing a fall and sustaining a dislocated knee (disruption of the knee joint), subarachnoid hemorrhage (bleeding in the space between the brain and tissue covering the brain), and a vertebrae fracture (broken spine). Page 1 of 2 395711 395711 11/14/2024 Elkins Crest Health & Rehabilitation Center 265 E. Township Line Road Elkins Park, PA 19027

F 0689 Level of Harm - Actual harm Residents Affected - Few In a interview on November 14, 2024, at 11:31 a.m., the Administrator stated that the resident broke the chain device on the window, and then tied bed sheets and hospital gowns together and climbed out the window. As a result, the resident was able to leave the facility unattended and sustained serious injuries. Information available to the Department included the following corrective actions implemented by the facility in response to Resident 1's elopement: 1. Resident 1 was sent for immediate medical attention. 2. The facility conducted an immediate head count of all residents in the facility to ensure that facility accounted for all residents. 3. The facility audited all residents' records to ensure their elopement risk assessments were current and accurately reflected resident risk. 4. All windows were checked by maintenance and were further secured (permanently affixed closed). 5. Secured doors and the alarm system also checked for proper function. 6. The facility educated all staff in the facility on the facility's elopement policy. 7. Elopement drills were completed. On November 14, 2024, a review was conducted to verify the complete implementation of the facility corrective action plan. Licensed employee LPN 1, and non-licensed employees NA 1, housekeeper E 1, and activities assistant E 2, were interviewed regarding education provided to prevent elopement. All staff interviewed confirmed that they received the training described in the facility action plan. All nursing staff were aware of the requirements for supervising residents who were at risk for elopement. All facility windows, doors, and safety devices (Wanderguards) were checked and were functioning properly. All sampled resident were being supervised by staff when needed. 28 Pa. Code 201.18(b)(1)(3) Management. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 212.12(d)(1)(5) Nursing services. 395711 Page 2 of 2