Sprenger Health Care Of Port Royal

Penalty

Inspection fine: $21,645

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when a resident with multiple diagnoses, including alcohol dependence, withdrawal delirium, anxiety disorder, depression, liver disease, and spinal stenosis, successfully eloped from the facility. The resident had a BIMS score indicating moderate cognitive impairment and was initially assessed as non-ambulatory and not at risk for elopement. However, staff observations and interviews revealed that the resident had become more alert and mobile over time, with some staff noting increased awareness and wandering tendencies prior to the incident. On the day of the incident, the resident was last seen in a common area before being discovered missing. Staff initiated a search, and the resident was found across the street in a parking lot, having exited the facility unsupervised in a wheelchair. The facility's automatic doors likely enabled the resident's exit. Staff interviews indicated that the resident had previously attempted to approach exits and expressed desires to leave, but these behaviors were not reflected in the most recent elopement risk assessment prior to the incident. The facility's policy required elopement risk assessments on admission and after any change in condition, with care plans to be updated accordingly. Despite these requirements, the resident's increased mobility and wandering behavior were not promptly reassessed or addressed in the care plan before the elopement occurred. Staff responses and documentation did not reflect timely recognition of the resident's change in status, resulting in inadequate supervision and failure to prevent the elopement.

Removal Plan

• DON conducted a whole house audit to ensure that elopement risk assessments were complete, and all at risk residents were in the secured unit, with wander guard orders. No concerns were noted.
• DON/designee conducted a whole house audit of elopement assessments completed and accuracy ensured. Any discrepancies corrected and appropriate parties notified. All notifications and any changes to plan of care to be documented. No concerns were noted.
• An ad hoc Quality Assurance Performance Improvement (QAPI) meeting was held with the Administrator, Regional Quality Assurance Nurse, Director of Clinical Services, Regional Administrator, COO, CEO, Executive Director of QA via telephone. The meeting discussed requirements of physician visits, elopement risk, notifications, communication, current orders, conditions, and corresponding policies.
• DON educated all Nursing staff on elopement policies and procedures, such as frequency of assessment, appropriate intervention (secured unit, wander guards), tools used to communicate any issues (elopement assessments, behavior charting, nurses' notes).
• DON completed education for all nurses on notification of change in condition policy and recognizing signs and symptoms of a change in condition.
• Dr. [NAME], Medical Director, was notified of QAPI meeting discussion and the corrective action plan.
• Administrator and DON/Regional Quality Assurance Nurse completed verbal education to all facility physicians and nurse practitioners regarding facility elopement policy and procedures, elopement risk, change of condition including elopement risk changes.
• DON/designee would audit all admissions for elopement assessments, notifications and documentation every business day for four weeks then randomly thereafter for a total of two months. Quality Assurance (QA) would review the results of the audits weekly.
• DON/designee would audit all nurses' notes for significant change and proper notification and documentation each business day for four weeks, then randomly thereafter for a total of two months. QA would review the results of the audits weekly.
• DON/designee would audit four residents elopement risk each week to check for any changes in elopement risk, if new risk identified, MD and RP notification completed, orders for secured unit and wander guard implemented as well as any needed follow up was completed for four weeks, then randomly thereafter for a total of two months. QA would review the results weekly.