Harborview Rehabilitation Care Center At Doylestow

jeopardy to resident health or safety

the jeopardy at the time of the incident, August 6, 2025, at 4:15 p.m., and implemented the following corrective action plan: 1.

The facility conducted an immediate count of all residents to ensure all were accounted for.2.

All doors were checked by maintenance and were found to be in good working order.3.

All safety devices were checked to ensure they were in place, including electronic devices applied to residents to prevent doors from opening (Wanderguard). 4. Resident 1's room was changed from the first floor to the third, and a Wanderguard was placed on the resident.

The resident's care plan was updated to include risk for elopement.5.

Elopement drills were conducted immediately to ensure that all staff are proficient in the facility's procedure if a resident was missing.

Additional future drills were scheduled bi-monthly.6.

All residents were audited to ensure they were assessed for risk of elopement, and that care plans were in place for those at risk.7.

The facility educated all staff in the facility on the facility's procedure for finding a missing resident.

Receptionist staff were educated on their responsibilities to ensure only authorized people leave the building.8.

The Director of Nursing or designee was to initiate weekly audits and report results to the QAPI (Quality assurance, performance improvement) committee.

The first audit was done on August 7, 2025.9.

All staff members were required to be trained on this plan before being permitted back to work.On August 12, 2025, a review was conducted to verify the complete implementation of the facility corrective action plan.

Licensed employees RN 1 and LPN 1, non-licensed employees NA 1, NA 2, NA 3, and NA 4, and receptionist E 1, were all interviewed regarding education provided.

All staff interviewed confirmed that they received the training described in the facility action plan.

All nursing staff were aware of the requirements for supervising residents who were at risk for elopement.

The receptionist stated that she was aware of her responsibility to monitor the front door for residents.

All facility doors and safety devices (Wanderguards) were checked and were functioning properly. Resident 1 was observed on the third floor with safety devices in place.

All sampled residents were being supervised by staff when needed.

All training was completed by August 7, 2025, with the exception of staff who were not on the schedule.

Those staff were not permitted to return to work until they received the training.

The Immediate Jeopardy existed on August 6, 2025, from 2:45 p.m. until August 7, 2025, at 4:15 p.m.

Verification of all elements of the action plan was completed on August 12, 2025, at 5:00 p.m., and the Immediate Jeopardy was officially lifted as of August 7, 2025.

The Nursing Home Administrator and the Director of Nursing were informed the residents were no longer considered to be in immediate jeopardy.28 Pa.

Code 201.18(b)(1)(3) Management.28 Pa.

Code 211.10(d) Resident care policies.28 Pa.

Code 212.12(d)(1)(3)(5) Nursing services.

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