W Frank Wells Nursing Home

Review of monitoring tools for door checks, wander guard device checks.

5.

Staff education on the arming of the door system with the key.

6.

Continue with wander guard device checks and placement as ordered for those residents at wandering risk.

7.

Staff education upon hire and quarterly of the Elopement policy and procedures.

8.

Performance Improvement Plan (PIP) to assess and monitor progress of the initiatives put into place to avoid further occurrence.

Review of PIP with QA&A committee for the next three-month period or until substantial compliance.

9.

Review of Interdisciplinary Team (IDT) assessment upon resident admission for residents deemed to be at risk for wandering behaviors, and continuation of wandering resident assessments quarterly with updates to elopement book as required.

10.

All residents re-evaluated for wandering resident risk assessment.

In response to the facility's alleged corrective actions, the facility's staff education plan and training was reviewed.

Per the facility's annual in-service training calendar, abuse and neglect training were required every year in July.

Elopement training was not a requirement at any time during the year. (Photographic evidence obtained)

The facility's All Staff New Hire Orientation training program/syllabus was reviewed and revealed that although it was three pages long, the facility's policies and procedures for elopement prevention and response were not included.

Elder Abuse and Resident Rights training was reviewed during orientation.

A review of the facility's employee roster found there were a total of 84 staff dedicated to working in the facility, but a total of 131 shared staff between the hospital and the nursing facility. A review of employee training transcripts found that after the 4/25/24 elopement by Resident #1, only 57 of 84 facility staff and 131 combined staff had received any training in the facility's elopement prevention and response policies and procedures. (Photographic evidence obtained)

An elopement drill was conducted on 5/15/24.

Only 27 of the facility's 84 staff members participated. No elopement drills were conducted in the year leading up to the incident. (Photographic evidence obtained)

105210

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 105210 B.

Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

W Frank Wells Nursing Home 210 N 2nd St MacClenny, FL 32063