Facility I.D. Number 0001099
Date of Survey: 09/27/01
Incident 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 with each residents 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:
1. A review of a 08/13/01 incident report indicated that R1 an 89 year old female residing in the annex of the facility exited the facility at approximately 4:05 P.M. E3 (Care Plan Coordinator) while on the way to her car discovered R1 lying on the ground near the south west corner of the facility at approximately 4:30 P.M. R1 was transferred to an acute care hospital for evaluation. R1 sustained a bruise to the right hip from the incident.
Interview with E3 revealed that R1 resides on the upper level of the annex. Interviews between 8:30 A.M. and 1:30 P.M. on 09/24/01 with licensed staff who were on duty at the time of the incident could not give a time when R1 was last seen on the wing.
Interview at 8:30 A.M. on 09/24/01 with E2 (Director of Nursing) revealed that R1 who normally uses a walker for assistance with ambulation had either taken the stairs or the elevator to the lower level and exited the outside door. R1 was found twenty-four feet from the doorway. R1 was lying on her right side with her feet on the grass and her head on the concrete side walk. R1 had left her walker inside the building on the lower level near the elevator.
The facility is located in a rural farming environment with fields on three sides of the building and a major state highway on one side of the building. R1 was wearing an electrical monitoring device at the time of the elopement. Interview with E2 revealed that the only door with a sensor and alarm for the device was the front door of the facility which was believed to not be the door from which R1 exited.
Review of R1's medical records revealed that R1 has a diagnoses of Alzheimer's Disease, Progressive Dementia with Paranoia, Congestive Heart Failure, Osteoarthritis, Vertigo and Hypotension. A review of R1's current Care Plan dated 11/13/00 and updated quarterly on 08/06/01 indicated that R1 is confused and "attempts to leave the facility". The current Care Plan for falls lists approaches as: "Accident Prevention Program.", "Monitor resident whereabouts at all times", and "check resident for safety every thirty minutes". The accident prevention program assessed R1 at a high risk for accidents and additions were made to R1's care plan. Additions include wearing an electronic monitoring device, supervision with ambulation, monitor R1's whereabouts and to redirect R1 when she wanders into inappropriate areas.
Interview at 8:30 A. M. on 09/24/01 with E2 indicated that R1 was not a reliable person to interview.
Interview at 10:00 A.M. on 09/24/01 with R1 revealed that R1 knew her name, but was confused concerning place, date, or time of day. R1 also indicated that she did remember leaving the building last month but did not know where she was going.
Interviews between 8:30 A.M. and 1:30 P.M. on 09/24/01 with facility nurses E2, E3, E6, E7, E8, and E9 and Certified Nurse Aides E4, E10 and E11 revealed that they all considered R1 not aware of her own safety and unable to make appropriate decisions regarding her safety.
Observation at 9:00 A.M. on 09/24/01of the exit door signaling system revealed that the exit door on the lower level in the south west corner of the building has an alarm that signals at the two annex nursing stations when the door is opened. The signal stops sounding when the door closes. The opening and closing of the door is recorded on a computer system and is visible as a message on a computer monitor located at the annex nursing stations. The computer records the door location, how it was opened and closed and the time of the operation.
Per review at 10:30 A.M. on 09/24/01 of the computer records from 08/13/01 at 16:07:18 the "#1 Unit Door D(1.5) Basement Door" was "Forced Open" and that at 16:07:32 the same "Door Closed". This indicated that the door was open with the alarm sounding for fourteen seconds. The next time that the basement door was opened was recorded at 16:30:01 by E7. When the door alarm sounds, staff at the nursing station check the monitor for the location and announce over the intercom system that the door needs to be checked. The staff checking the door announces an all clear after checking the door as delineated in the facility's Door Alarm System Policy. The alarm sounds only on the second floor of the facility and not on the lower level.
Interviews between 8:30 A.M. and 1:30 P.M. on 09/24/01 with E2 through E11 confirmed that none of the staff on duty in the facility at the time of the 08/13/01 incident heard the alarm sound. None of these staff checked the monitors at the nursing stations until after it was discovered that R1 was outside the facility.
These staff indicate that they were not at the nursing station but were taking care of residents or on break in a different part of the facility at the time the alarm sounded. When tested on 09/24/01, the alarm could be heard at all hall way locations on the second floor annex of the facility.