Emergency Preparedness Deficiency: Missing Resident Procedures Absent
Summary
The facility was found to be non-compliant with emergency preparedness requirements during a review of their Disaster Manual Disaster Plan and associated assessments. The review, conducted in conjunction with a Life Safety Code survey, revealed that the facility's Disaster Manual Disaster Plan, Facility Assessment, and both facility-based and community-based risk assessments lacked documentation regarding procedures for missing residents. This deficiency affected all resident use floors, including three resident units, the administration area, and the basement. During an interview, the Administrator confirmed that the Disaster Manual Disaster Plan, last reviewed in October 2024, was the current Emergency Preparedness Plan in use, and that an updated plan was being developed but had not yet been implemented. The absence of documentation for missing residents was noted as a deficiency under 42 CFR 483.73-Emergency Preparedness.
Plan Of Correction
Plan of Correction: Approved December 29, 2024 1. Administrator completed updated HVA and included elopement into assessment on 12/29/2024. 2. All Residents are at risk for deficient practice for not having HVA assessment including elopement risk as a risk in the EPP. 3. All staff were trained on the emergency preparedness plan which included elopement risk and steps to follow in case of risk by RN Educator. Education was completed for all staff on 1/24/2024. 4. The HVA will be reviewed quarterly in the QAPI meeting to ensure updated HVA is reviewed and updated on any new risks. Any deficient practices will be corrected and further reviewed at QAPI Meeting. Person Responsible: Administrator
Penalty
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