CARRINGTON CARE CENTER
Facility I.D. Number 0038802
Date of Survey: 10/09/01
Incident Report Investigation of 08/13/01
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 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.
Objective observations of changes in a resident's condition, including mental and emotional changes, as a means for analyzing and determining care required and the need for further medical evaluation and treatment shall be made by nursing staff and recorded in the resident's medical record.
All nursing personnel shall evaluate residents to see that each resident receives adequate supervision and assistance to prevent accidents.
Each facility shall maintain all signaling systems in a functioning condition. This shall include regular inspections of these systems.
An owner, licensee, administrator, employee or agent of a facility shall not neglect a resident.
These requirements are not met as evidenced by:
Based on observation, resident and staff interviews, and record review, the facility failed to adequately supervise 2 residents (R1 and R2) with cognitive and physical impairments. R2 left the facility unnoticed by staff on 2 occasions and sustained injuries, and R1 left the facility unnoticed by staff and was found two blocks away from the facility.
The examples are:
1) Review of the medical record of R2 shows this 99 year old resident was admitted to the facility 9/30/00 and has diagnoses including dementia, osteoporosis, and chronic disequilibrium. Risk assessment for abuse and neglect, fall risk assessment, and elopement risk assessments dated 10/2/00 assess R2 as having confusion, disorientation, forgetfulness, sensory deficits, difficulty in communication, and poor safety judgement. Bowel and bladder assessments dated 1/31/01 and 4/10/01 score R2 as being very confused. Siderail assessment dated 3/28/01 shows R2 is alert, confused, hard of hearing, has poor standing balance/coordination and weakness to both lower extremities. Resident assessment instrument dated 6/14/01 assesses R2 as having a short term memory problem and modified independence in decision making. R2 is assessed as requiring a one person limited assist with transfer and with locomotion on the unit.
Observation and interview with R2 at 11:15 a.m., 9/18/01, in the main dining room, reveals an elderly resident seated in a wheelchair appearing alert, unable to tell surveyor the name of the place where she is staying. R2's speech rambled with the resident making little sense as the interview progressed. R2 was noted to be very hard of hearing.
Review of the nursing notes of R2 shows an entry on 4/7/01 that reads: "11:20 a.m. Pt (patient) was seen in lobby waiting for her son to pick her up. A few minutes later a visitor came in and said pt is on sidewalk and she fell out of her wheelchair......has 1/2 inch laceration on right side/top of head with minimal bleeding. Pts right knee with small abrasion ..left knee with slight discoloration. Pt was brought back into facility via wheelchair....it is unknown how pt exit (sic) building...front door is locked/alarmed. It is thought that a family member may have let pt out. Pt is unable to open the front door per self." The physician was notified, R2 was sent to the hospital where staples were used to close the wound.
Another nursing note for R2 dated 7/30/01 at 7:30 p.m. states: "Summoned by another resident and was informed that (R2) fell out of her wheelchair in front porch of the building, alert and conscious. Resident is confused and disoriented and can't relate what happened. Nobody knows how resident got out of the building. Front door noted to be locked and alarmed. Resident sustained a bump on right top of head, abrasion on right knee with discoloration......resident complained of (?) pain on right knee and swelling noted..then on top of right head."
Interview with E2 at 12:00 p.m. on 9/18/01 in the Occupational Therapy (OT) room reveals E2 believes that on 4/7/01 R2 was wheeled out the front door of the facility by another resident's family member. E2 stated the front door is alarmed and needs to be released for opening by buttons located at the receptionist desk and the first and second floor nursing stations. Each of these locations was noted to have a monitor which visualizes the front door of the facility. According to E2 staff are to visualize who is entering and exiting the facility before "buzzing" them in or out. Surveyor noted when entering and exiting the front door that the door opened only when the buzzer had been activated. (This door also has a 15 second delay switch.) Neither E2 or E1 were able to explain how R2 exited the facility on 7/30/01.
Review of the resident record shows the elopement risk assessment dated 10/2/00 notes R2 has a diagnosis of dementia/or severe mental illness, that R2 "demonstrated impaired judgement and/or physical status limitations that would place him/her at risk in the community" and R2 "has physical ability to leave the building." The elopement risk decision, however, is determined to be that R2 is not at risk for elopement and the elopement risk protocol is not indicated. There is no further information given to show why this confused, mobile resident who has been determined to be at risk in the community would not be an elopement risk. The care plan, dated 01/02/01, notes the resident has periods of wandering into other's rooms and taking items but does not address R2's elopement potential. Approaches are to: explain to resident that hoarding can be dangerous, when taking other's items redirect the resident, if resident is upset take her to a quiet place, routinely check wheelchair and room for items, discuss behavior with nursing, monitor whereabouts.
2) Review of the medical record of R1 shows the resident was admitted to the facility on 7/27/01 with diagnoses including cerebral vascular accident, renal insufficiency, and hypertension. Risk assessment for Abuse and Neglect (undated and unsigned) notes R1 as having confusion, disorientation, forgetfulness, and poor judgement skills. Bowel and bladder assessment dated 7/27/01 assesses R1 as forgetful. Fall risk assessment dated 7/30/01 assesses R1 as alert and oriented to all spheres, judgement impaired for safety, and having a history of falls prior to admission. Siderail assessment dated 7/27/01 notes R1 had poor standing balance, history of hypertension, and is confused. R1 had physician orders for occupational and physical therapies.
Nursing notes of 7/27/01 state R1 is "alert, oriented," "able to ambulate per aid of walker." Other nursing notes of 7/28/01, 7/30/01 and 8/2/01 show R1 propelling himself per wheelchair. Nursing notes of 8/5/01, 11-7 describe R1 as "confused and disoriented. Needs assist going back to his room." R1 is also described as confused, disoriented in notes of 8/6/01, 8/7/01 and 8/10/01.
Nursing notes of 8/13/01 at 6 a.m. state: "Noted up per wheelchair, able to propel self. Res stayed in front of the nurses desk." "6:30 a.m. Noted resident not in his wheelchair, nurses and CNA's started to search from within the building. Resident was nowhere to be found." "6:45 a.m. Writer (identified as E4 by E2) started to drive around the vicinity and found resident two blocks away. Paramedics were at the scene. Writer learned that a concerned citizen called paramedics when he saw resident sitting on the curb. Resident was conscious and coherent. Not in distress. Assisted back to facility." The entry goes on: "When asked by this writer why he went out, resident responded `I want to go home'."
No elopement risk assessment was completed for R1 until 8/13/01 when staff placed R1 at risk for elopement. No care plan was developed to address R1's potential for elopement until 8/13/01, after the elopement incident.
E4 is not currently in the United States according to E2 and was unable to be interviewed, however E6 was interviewed at 11:15 a.m. on 9/18/01 in the OT room. E6 stated she had gotten R1 dressed about 6 a.m. the morning of the above incident. E6 stated she last saw R1 about 6:30 a.m. seated in his wheelchair near the door to his room on the first floor. According to E6 she then went to finish her tasks and when she returned to the area she noted R1 was not in his wheelchair. E6 stated R1 was usually confused, always stated he wanted to go home, and often got up from his wheelchair and ambulated. After searching for R1, E6 stated she notified E4 who, E6 stated, went out the front door of the building looking for R1. E6 stated she made another room to room search, checked the basement, and outside, then as she was going to get in her car to search for R1, she observed E4 returning to the facility in his car and carrying R1 in the car. E6 stated E4 said he had located R1 about 2 blocks away on Dean Street. R1 was discharged to his family on 8/24/01.
Both E1 and E2, during interviews, stated they felt R1 had left the facility when staff had entered or exited the facility however they could not explain why this may have occurred.
A review of the wandering resident list on 09/18/01 showed only 2 resident names and photos are posted at the second floor nursing station. There was no list posted at the first floor nursing station. At 1:45 p.m. surveyor obtained a list entitled "Resident Safety Concern List" dated 9/14/01 from the reception area. This list includes 23 residents identified as "safety concerns" At 2:00 p.m. an (electronic monitoring/personal alarm device) book was given to the surveyor and this list, dated as compiled on 9/14/01, also lists residents as "safety concerns" and includes 15 additional residents. The book contained descriptions and photos of 16 of the 38 residents identified as safety concerns and did not contain a photo or description of R2.
During a subsequent visit to the facility on 9/28/01 at 1:30 p.m. surveyors noted that opening the first floor south outside exit door and opening the south outside patio door on the first floor did not cause an audible nor visible alarm at the main panel at the first floor nursing station. In addition two residents, R4 and R5, whose photos appear in the "wanderer's book" kept at the front desk do not appear on the "Elopement list" maintained by the facility and kept at the nursing stations. Two other residents, R2 and R6 appear on the list but their photos are not in the "wanderer's book."