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Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 31, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review conducted during an Abbreviated Survey (NY 619), for one (Resident #1) of three residents reviewed, the facility did not ensure adequate supervision and monitoring systems were in place to prevent a resident from elopement (when a resident leaves the facility without supervision with a possible threat to their health and safety). Specifically, Resident #1 had mild cognitive impairment with a history of wandering and eloped from the facility during a power outage. Resident #1 was absent from the facility for approximately two hours and was found approximately one mile away. This is evidenced by the following: The undated facility policy, Elopement, included if a resident is found to be at risk for elopement, an individualized care plan will be developed. If a resident does leave the building the Missing Resident Plan (emergency procedure used to locate a missing resident), will be put into effect immediately. The facility procedure Elopement Prevention Protocol, dated 02/04/2021, included if a resident cannot be located within the unit, the nurse in charge shall be responsible to notify the Director of Nursing and Administrator. Resident #1 had [DIAGNOSES REDACTED]. The Minimum Data Set Resident Assessment, dated 06/04/2024, revealed Resident #1 was cognitively intact and had no wandering behavior. Review of the Comprehensive Care Plan, dated 09/08/2022, revealed Resident #1 could walk independently without devices (walker) and was at risk for elopement due to asking for door codes and to go outside alone. Interventions included, but were not limited to, routine checks/observations of the resident and a wander guard (a bracelet that triggers alarms at monitored doors to help protect a resident from elopement) applied to the left ankle. Review of an interdisciplinary progress note, dated 03/20/2025, Registered Nurse #1 documented they were notified by a Certified Nursing Assistant that Resident #1 was not in their bed. After a thorough search of the facility, the resident could not be located and 911 was called. Registered Nurse #1 documented that Resident #1 was located on Long Pond Road, fully dressed, and unharmed. Review of the facility investigation, dated 03/20/2024, revealed there was a power outage at approximately 1:00 AM that lasted approximately 2 hours and 15 minutes. The staff performed a head count at 2:00 AM and at 3:30 AM, Resident #1 was not in their room. The staff on shift called 911 and the police escorted Resident #1 back to the facility at 5:15 AM. The investigation findings included Registered Nurse #1 failed to notify Maintenance and the Leadership Team of the power outage. Review of a Police Report, dated 03/20/2024, included during the timeframe from 2:39 AM to 5:01 AM, Resident #1 was reported by Registered Nurse #1 as a missing person and was found on the corner of West Ridge Road and Apollo Drive (approximately one mile from the facility). During an interview on 01/24/2025 at 1:06 PM, the Director of Maintenance stated when the power goes out the generator would automatically turn on, but the door alarms were not connected to the generator and would not work. The Director of Maintenance stated if the power went out, they were supposed to be notified but had not been notified at the time of this incident. During an interview on 01/24/2025 at 4:37 PM, the Administrator stated if the power went out, that staff should call Maintenance and the Director of Nursing. Staff should immediately monitor the emergency exits, complete a headcount and round (routine checks/observations) on all residents. The Administrator stated this elopement incident was a procedure failure. 10 NYCRR 415. 12(h)(2) | Plan of Correction: ApprovedFebruary 20, 2025 Preparation and/or execution of the ?ôPlan of Correction?Ø does not constitute admission or agreement by the provider of the truth of facts as alleged or conclusions set forth in the ?ôStatement of Deficiencies.?Ø The Plan of Correction is prepared and /or executed solely because it is required by provisions of State and Federal Laws. 1. Resident #1 was found and brought back to facility safely and unharmed. Resident #1 was assessed by RN #1 and unharmed by incident and Resident #1 stated ?ôhe wanted to go for a walk outside?Ø. Completion Date: 3/20/2024 2. All residents at risk for elopement or wandering behaviors were reviewed and accounted for to be safe and located in building during time of power outage incident on 3/20/ 2024. Completion Date: 3/20/2024 3. RN #1 was counseled on Elopement Policy and Procedure, Missing Resident Procedure, Loss of Power Procedure and Proper Notification and Wander Guard System. Administrator, Director of Nursing and Environmental Services Manager reviewed Policy and Procedure on Elopement/Missing Resident, Loss of Power Procedure and Emergency Preparedness Plan with no revisions needed. All staff were re-in-serviced and re-educated on the following: a. Elopement Policy and Procedure b. Missing Resident Procedure c. Loss of Power Procedure and Proper Notification d. Wander Guard System Completion Date: 2/17/2025 4. A Quality Assurance Audit was developed on residents at risk for eloping from facility during a power outage. Audits will be completed by Director of Nursing/Maintenance Manager monthly for 3 months and quarterly thereafter, with the results presented to the Quality Assurance committee for action, if needed. Completion Date: 3/31/2025 |