Facility I.D. Number 0024356
Date of Survey: 02/05/02
Incident Report of Investigation of 01-10-02
The facility shall have written policies and procedures, governing all services provided by the facility and these written policies shall be followed in operating the facility.
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 medical treatment and procedures shall be administered as ordered by a physician.
These requirements are not met as evidenced by:
Based on observation, staff interview, clinical record review, and review of the facility policy and procedure for door alarms, the facility failed to provide supervision for one resident (R1) who has a diagnosis of Alzheimer's and has had eloped from the facility multiple times. R1 has poor safety awareness and records show that from March 2001 to January 2002, R1 eloped 16 times unobserved by staff. The facility failed to monitor R1every 15 minutes as specified in a November 25, 2001 physician order.
R1 is a 68 year old male with diagnoses including Alzheimer's disease, dementia and depression.. Clinical record review revealed physician orders on the following dates:
November 19, 1999 - May go out on pass with medications and supervision and may have electronic monitoring device.
November 25, 2001- Monitor resident's whereabouts every 15 minutes.
December 12, 2001- May go out on pass with medications and supervision and monitor resident's whereabouts every 15 minutes.
There was no evidence in the clinical record that the facility actually monitored R1 every 15 minutes as ordered by his physician as early as November 25, 2001. Clinical record also confirms that R1's elopements were all unsupervised or unescorted even with the physician order that R1 can only go out with supervision.
Further review of R1's clinical record, revealed an evaluation dated August 11, 2001 (after several elopements of R1) by a neuropsychologist identifying R1 as having problem-solving deficits and poor insight, which placed R1 at considerable safety risk for walking independently in the neighborhood. The evaluation also showed that R1 "cannot articulate an adequate plan for finding his way if he became lost. (R1) does not have the capability to make decision for himself and can not appreciate safety risk and thus can not make reasoned decisions accordingly." According to the neuropsychologist recommendation, it is for the best interest of R1 to restrict his activity and not to allow the resident to leave the facility at all.
Record review showed the following elopements:
1) March 29, 2001- Lost and was picked up by the facility staff in a hotel.
2) March 30, 2001- Lost and was picked up by the facility administrator in a hotel.
3) April 05, 2001- Lost and was picked up by the facility staff in a hotel.
4) April 26, 2001- Lost and found in a hotel.
5) June 17, 2001- Walked all the way to a hospital unescorted.
6) July 26, 2001- Went out of the facility unescorted.
7) August 09, 2001- Found sitting by the lake.
8) August 15, 2001- Walked to a restaurant unescorted.
9) September 12, 2001-Went to a grocery store.
10) September 20, 2001- Went off of the facility grounds unescorted.
11) September 30, 2001- Went out to a grocery store unescorted.
12) October 19, 2001- Went to a restaurant unescorted.
13) October 20, 2001- Went unescorted to a bank.
14) November 01, 2001- Went to a grocery store and was picked up by the police.
15) November 25, 2001- Was found at a fire station.
16) January 10, 2002 - Was found in a hotel and was picked by the police.
Record review showed that R1 had removed his electronic monitoring device on the following dates:
August 20, 2001, August 27, 2001, September 12, 2001, September 30, 2001 and November 16, 2001by cutting it off. Facility staff reapplied the electronic monitoring device and no other interventions were made.
Interview with E1on January 31, 2002 revealed that the facility approached the family of R1 on November 1, 2001 to move R1 to the facility's secured unit. According to E1, the family of R1 refused and insisted that R1 stay on the first floor unit of the facility. The first floor consists of intermediate care residents requiring little daily assistance and supervision. The first floor has easy access to outside with four exit doors. Two of the doors are equipped with electronic device monitoring alarms. The other two doors are equipped with an audible alarm that sounds only when the door is opened and immediately ceases to sound when the door closes. Time frame for the audible alarm lasts only 4 to 5 seconds. E1 also stated to surveyors that one to one monitoring of R1 did not start until after the incident on January 10, 2002.
Interview with E2 on January 31, 2002 revealed that R1 was last seen at 4:00 p.m. on 01/10/02. E2 claimed that the alarm went off between 4 to 5 p.m. E2 stated that she peeked at the exit doors (north and south) from a distance and did not check to see who and why the door was opened. Review of the facility's policy and procedure for door alarms shows that the staff must respond to the alarm by checking to see who and why the door was opened. Further interview with E2, revealed that she finally realized that R1 was missing at 5:15 p.m.
In an interview with E3 on January 31, 2002, E3 stated that most likely the reason why R1 left the facility unnoticed was that there are staff who turn off the alarm without checking. According to E3, this incident of staff turning off the alarm without checking has happened before.