Health inspection·August 14, 2024

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies and clinical records, and staff interview, it was determined that the facility failed to develop a comprehensive care plan for one of one residents reviewed regarding an elopement (Resident R30). Findings include: Facility policy entitled, Care Plans, Comprehensive Person-Centered revised March 2022, included: the comprehensive, person-centered care plan includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident; care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relation ship between the resident's problem areas and their causes, and relevant to clinical decision making. Resident R30's clinical record revealed an admission date of 1/12/24, with diagnoses that included dementia, weakness, unsteady on feet, abnormalities of gait and mobility, and repeated falls. Resident R30's clinical record revealed the following departmental progress notes: -8/07/24, at 2:08 a.m. indicated the lounge alarm going off, notified nursing staff and registered nurse, back door alarm went off, began bed checks and staff left to search outside and on the unit. Found resident by bridge outside, licensed practical nurse and staff was able to bring him/her back inside. Resident claimed he/she went outside because he/she didn't want to miss his/her appointment. - 8/07/24, at 2:29 p.m. indicated that Resident R30 was relocated to room [ROOM NUMBER]B (Memory Care Unit). Further review on 8/14/24, of Resident R30's current care plans lacked evidence that a comprehensive person-centered plan of care was developed to address Resident R1's elopement from the facility on 8/07/24. During an interview on 8/14/24, at 1:56 p.m. the Director of Nursing confirmed that the facility should have developed a comprehensive person-centered care plan to address Resident R30's recent elopement from the facility. 28 Pa. Code 211.12(d)(1)(5) Nursing services Page 1 of 3 395853 395853 08/14/2024 Crawford Care Center 20881 State Highway 198 Saegertown, PA 16433

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on review of facility policy and documentation and clinical records, and staff interview, it was determined that the facility failed to thoroughly investigate an elopement (unauthorized leave from a safe area) for one of one residents reviewed for elopements (Resident R30). Findings include: A facility policy entitled, Wandering and Elopements revised March 2019, revealed that when the resident returns to the facility, the Director of Nursing or charge nurse shall: examine the resident for injuries; contact the attending physician and report findings and conditions of the resident; notify the resident's legal representative; complete and file an incident report; and document relevant information in the resident's medical record. Resident R30's clinical record revealed an admission date of 1/12/24, with diagnoses that included dementia, weakness, unsteady on feet, abnormalities of gait and mobility, and repeated falls. The most recent Quarterly Minimum Data Set (federally mandated process that assesses the clinical needs and functional capabilities of residents in nursing homes) with a reference date or 5/09/24, Section C0500 (cognitive patterns) indicated Resident R30's Brief Interview for Mental Status score was 13 (cognitively intact). Resident R30's clinical record revealed the following departmental progress notes: -8/07/24, at 2:08 a.m. indicated the lounge alarm going off, notified nursing staff and registered nurse, back door alarm went off, began bed checks and staff left to search outside and on the unit. Found resident by bridge outside, licensed practical nurse and staff was able to bring him/her back inside. Resident claimed he/she went outside because he/she didn't want to miss his/her appointment. -8/07/24, at 8:35 a.m. phone message left for granddaughter to return call, ensured via phone message all was well and to just return call to discuss resident care. -8/07/24, at 1:41 p.m. this author tried to notify granddaughter of elopement issue, left two messages. Resident R30's clinical record lacked evidence that the facility examined the resident for injuries; contacted the attending physician and reported findings and conditions of the resident; successfully notified the resident's legal representative; completed and filed an incident report; and documented relevant information in the resident's medical record. During an interview on 8/14/24, at 11:00 a.m. the Director of Nursing confirmed there was no evidence that the facility examined the resident for injuries; contacted the attending physician and reported findings and conditions of the resident; successfully notified the resident's legal representative; completed and filed an incident report; and documented relevant information in Resident R30's clinical record. 28 Pa. Code 201.14(a) Responsibility of Licensee 28 Pa. Code 201.18(b)(1) Management 395853 Page 2 of 3 395853 08/14/2024 Crawford Care Center 20881 State Highway 198 Saegertown, PA 16433

F 0689 28 Pa. Code 201.18(e)(1) Management Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 211.12(d)(1)(5) Nursing Services Residents Affected - Few 395853 Page 3 of 3