| ELMWOOD CENTER Facility I.D. Number 0037911 Date of Survey: 08/21/02 INCIDENT INVESTIGATION OF 07/09/02 "A" VIOLATION(S): The facility shall provide a Resident Services Director who is assigned responsibility for the coordination and monitoring of the resident’s overall plan of care. The Director of Nurses or an individual on the professional staff of the facility may fill this assignment to assure that resident’s plans of care are individualized, written in terms of short and long range goals, understandable and utilized; their needs are met through appropriate staff interventions and community resources; and residents are involved, whenever possible, in the preparation of their plan of care. The facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of the resident, in accordance with each resident’s comprehensive assessment and plan of care. Adequate and properly supervised nursing care and personal care shall be provided to each resident to meet the total nursing and personal care needs of the resident. All necessary precautions shall be taken to assure that the residents’ environment remains as free of accident hazards as possible. All nursing personnel shall evaluate residents to see that each resident receives adequate supervision and assistance to prevent accidents. All exterior doors shall be equipped with a signal that will alert the staff if a resident leaves the building. Any exterior door that is supervised during certain periods may have a disconnect device for part-time use. If there is constant 24-hour-a-day supervision of the door, a signal is not required. Based on observation, medical record review and interviews, the facility failed to provide the level of supervision needed to prevent a confused resident that had been identified by the facility as a wanderer, from leaving the facility undetected on 07/09/02. (R1) The Findings include: The Assessments dated 1/16/02, 4/16/02 and 7/15/02 assessed R1 to have short and long term memory problems with moderately impaired decision making ability with periods of altered perception. Z2 (visitor) was interviewed on 8/09/02. Z2 revealed that Z2 had found R1 on 07/09/02 around 7:30 p.m.. R1 was 'lying face down on the cement pavement bleeding from the face.' R1 sustained lacerations to the left side of the nose, multiple skin tears to the left forearm and an abrasion to the left lower leg as documented in the nurses notes and the incident report dated 07/09/02. Interview with E7 on 08/08/02 at 4 p.m. in the East side television room, revealed that E7 and E11 were outside the Main Entrance on break after dinner around 7:30 p.m. Z2 approached E7 and E11, "with a pitcher in his hand, like he was going to water something, he asked if we had a stretcher or something because one of the residents fell and was lying face down bleeding." E7 said ,"you could not see R1 from where they were." "So we went there, I saw it was R1. I stayed with him while {E11}left and went to get R1's nurse, E4, and a wheelchair." E7 said R1, " had a lot of blood on his nose and hands, I cleaned him up and put him to bed." Interview with E4 at 2:50 p.m. on 08/08/02 in the admissions office, revealed that he found R1 outside at 7:30 p.m. lying face down on the cement near the North West exit door. E4 said he last saw R1 walking toward the dining room before supper, between 5:30 p.m. and 6 p.m. E4 said he asked E5 if she had seen R1. E7 said, "He was last seen walking back toward his room after dinner." E4 said he and other staff did a room search to look for R1 and did not find R1. E4 said he then went outside to look for R1. E4 said he found R1 laying face down on the cement. E4 said this all occurred at the same time E11 was telling him that Z2 had found R1. In the post incident observations documented 07/09/02 at 8 p.m. and 10 p.m. E4 documented no bleeding. Interviews with E4, E7, Z3, Z4 revealed R1 continued to bleed from the areas on the nose. E4 notified Z1 for orders. The time is uncertain. The nurses notes document on 07/09/02 at 9 p.m., " family request resident to be transferred to hospital, MD paged regarding family request". Resident left facility per stretcher at 10 p.m. E4 verified that Z1 did not return the call. R1 was treated in the emergency room. The nurses notes dated 07/10/02 at 12:15 a.m. document resident returned with nasal packing to the left nostril. Interview with Z1 on 08/09/02 revealed that he was notified of R1's incident. Z1 said that R1 "should not be out of the facility by himself because he is moderately demented with limited ability to make decisions, he needs custodial care." Interview with Z3 on 08/08/02 and interview with Z4 on 08/13/02 said they were present and requested R1 be sent to the emergency room because his nose bleeding would not stop. Z3 said when R1 went through the Main door on the way to the emergency room, the electronic monitoring device did not go off. Interview with E4 at 3:45 p.m. in the presence of E1, revealed he had no knowledge that R1's electronic monitoring system was not working. E4 said he found out when Z4 arrived that evening around 9 p.m. E4 said Z4 told him it had not been working earlier. During an interview in her office on 08/08/02 at 2:30 p.m., E5 said she wrote a statement for E1 on 7/10/02. This statement was regarding R1. This statement was read to E5 on 08/02/02. E5 verified this statement to be true by signing her signature. E5 wrote in her statement that R1, " had made many attempts to go out the front door. I stopped him at the front door, E1, Z4 and R1 were together at the front door. I told E1, " that R1's alarm was not working, this was at 12:30 p.m. later." Interview with Z4 on 08/13/03 revealed the facility was aware that R1's electronic monitoring system was defective on 07/09/02. Z4 said she arrived at the facility between 2-3 p.m. on 07/09/02. R1 was seated by front (Main) door. R1 had been restless and trying to leave the building the staff told her. R1 looked exhausted. E5 said R1's alarm was not working, she got him a wheelchair to take him to his room. There were one or two aides around. The administrator came up during this time and wanted to know what was going on. They told her his alarm ( electronic monitoring device) was not working. Interviews with the CNA's (E5, E6, E7) who worked the evening of 07/09/02 revealed they were not told that R1 was missing and a room search was not conducted by them. E5, E6, E7 also said they were not informed that the electronic monitoring system was not working or functioning properly. During interview on 08/08/02 at 2:30 p.m., E5 who was assigned to the unit that R1 resides on, said that she was not told that R1 was missing. E1 presented a, "WANDER GUARD DAILY INSPECTION LOG" for review. The log contains information on the condition of the South, East, North, West and Northwest electronic monitoring system. On 07/09/02 all columns contain a check mark. This check mark said E1 indicates that all doors were checked at 4: 30 p.m. The documentation on the log for 7/09/02 reads, "range off at 4:30 p.m. when checked by E1." E1 said that the facility was without a maintenance director from 6/07/02 thru 7/15/02. E1 said she, " conducted the daily wander guard inspections and documented in the log from 06/07/02 through 07/15/02." There was a note dated 07/17/02 from Z8 that, "all alarms checked for sensitivity checked ok." "All devices but Front , East and Rear parking lot door reconfigured to work with proximity to unit". This check occurred eight days after R1 eloped. |