GREENWOOD TERRACE NURSING & REHAB
Facility I.D. Number 0045070
Date of Survey: 12/13/01
Annual Licensure, Incident Investigations of 10/29/01, 11/04/01, 11/08/01, 11/19/01
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 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.
These requirements are NOT MET as evidenced by:
Based on interviews and record reviews, the facility failed to supervise residents that had a history of attempting to elope. Of 19 residents sampled, four had a history of eloping and one resident, R12 did not receive supervision to prevent her from eloping on 11/4/01.
1. On 11/27/01, at 9:45 a.m., the Reportable Incident Notification form, dated 11/4/01, regarding R12 eloping from the facility was reviewed. It noted that on 11/4/01, at approximately 12:30 p.m. the following occurred: "Res wandered away from premises across the street. Resident escorted back to facility by staff. An investigation of incident being conducted. Staff believe another resident had turned off door alarm."
R12 was found across the street within visual sight of the front door of the facility. The facility is located in a low traffic, residential area. R12 was returned to the facility without harm or injury.
On 11/27/01, at 10:00 a.m., E1, the administrator, was interviewed regarding this incident. She said that R12 was last seen around lunch time, which was at approximately 12:00 p.m. - 12:15 p.m. She said that around 12:25 p.m., a neighbor called to let the receptionist know that they had a resident from the facility. E1 said that two Certified Nurses' Assistants (CNAs) retrieved R12. She said that several CNAs saw the 300 solarium door ajar. She said that one of these CNAs checked the alarm system on the 300 hall and found that it had been shut off. She said that staff members believe that another resident shut off the alarm system so she could go outside and smoke. She said that staff were not aware that R12 had left the building.
On 11/27/01, at 2:00 p.m., R12's medical record was reviewed. Her physician's order sheet, dated November 1 through November 30, 2001 noted that she had the following diagnoses: uncontrollable diabetes mellitus, Alzheimer's disease, hypertension and syncope.
On 11/27/01, at 2:05 p.m., R12's Wandering Risk Assessment, dated 10/1/01, was reviewed. It noted that she approached exit doors repeatedly, opened exit doors, and exhibited ambulation that appeared aimless in nature. The determination of this assessment noted that she was "At risk" for wandering.
On 11/27/01, at 2:10 p.m., her Minimum Data Set, dated 10/2/01, noted that she had long and short memory problems, had moderately impaired decision making skills, was easily distracted and wandered (moved with no rational purpose, seemingly oblivious to needs or safety). She ambulates independently. On 11/27/01, at 2:15 p.m., her care plan , updated on 10/10/01, noted that she was at risk for elopement. The problem noted that she had Alzheimer's disease with impaired safety awareness. It also noted that she packs clothes frequently. The goal for this specific problem was that she would not leave facility grounds without supervision through 1/10/02. Some of the interventions to address this problem were as follows: Monitor resident's whereabouts; check personal security monitor placement each shift; staff to answer door alarms immediately; if no witness-call 'Code-Yellow unknown resident'; and redirect resident away from exit doors.
On 11/28/01, at 1:30 p.m., E9's written statement regarding R12's elopement was reviewed . In the written statement, E9 wrote that the Certified Nurses' Assistant that brought back R12 into the building noticed the 300 hall solarium door was cracked but no alarm was going off. E9 said that these CNAs checked the main control and notice that the alarm was "cut off." At 1:50 p.m., E9 re-read her statement and confirmed the information. She also said that R12 has periods of confusion when she wants to leave the building.
On 11/28/01, at 1:40 p.m., E12's written statement was reviewed regarding R12's elopement. She wrote "I went out and saw resident down the street and I went and got resident. I ask the man what time did he get her and he said around 12:25 p.m. I walked her back in the building to the hall. I saw the 300 hall sol. door open so I check the door and alarm and it was off which another resident said that she turn the door alarm off. I ask her not to turn alarm off anymore." At 2:00 p.m., E12 re-read her statement and confirmed the information.
On 11/29/01, at 12:45 p.m., E14's written statement regarding R12's elopement was reviewed. At 12:50 p.m., an interview was conducted with E14. He stated that she (R12) would pack her bags at least one time every few weeks. He said that when she did this, the staff knew to keep their eyes open because she would head towards the doors.
On 11/29/01, at 12:55 p.m., E10's written statement regarding R12's elopement was reviewed. E10's statement also noted that the 300 and 400 hall alarms were shut off. E10 confirmed this statement on 11/29/01 at 12:57 p.m.
On 12/13/01, at 9:00 a.m., an interview was conducted with R12 at the 400 nurses' station. When questioned regarding the elopement incident of 11/4/01, R12 said "I've never left the building. A girl in school started those stories." R12 could not recall her elopement attempt on 11/4/01.
On 12/13/01, at 10:25 a.m., a telephone interview was conducted with Z2, R12's physician. He said that R12 had a diagnosis of Alzheimer's and had severe confusion. When the surveyor questioned Z2 if R12 had safety awareness regarding traffic hazards, difficult terrain, and hot or cold weather he said, "I doubt if she is aware." When the surveyor asked Z2 if R12 could function outside the facility without supervision, he said, "No, that is why she is there."