WEST MAIN NURSING HOME
Facility I.D. Number 0031757
Date of Survey: 01/17/02
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 record reviews, interviews, and observations, the facility failed to supervise one, cognitively impaired, resident (R1) to prevent this resident from getting out of the facility unattended without the knowledge of staff.
On 12-06-01 at approximately 6:30 P.M. an unidentified male was observed coming into the front door of the facility to inform staff that a female resident was outside unattended. Staff responded and found the resident outside approximately 20 feet from the facility. (Information taken from the incident report completed by Z4, agency nurse.)
In a telephone interview on 1-15-02 at 4:30 P.M., E7, dietary staff, stated that R1 had been observed going towards the front door exit on 12-06-01 at about 3:30 P.M. Staff redirected her away from the door several more times. At 6:30 P.M. on 12-06-01 when the unidentified man came in to get staff assistance for R1, the glass enclosed front porch of the building was dimly lit and it was dark outside. E7 and E5, CNA, went outside to bring R1 back into the building. Both E7, E5 and the only other two staff on duty at that time E6, CNA, and Z4 were unaware that R1 had gotten out of the facility. R1 was dressed in street clothes, shoes and socks. She was not wearing a coat. (The facility investigation of the incident documented the outside temperature to be 53 degrees Farenheit.)
In a telephone interview on 1-15-02 at 12 noon, Z4 stated that she was the nurse in charge on the evening of 12-06- 01. She was in the facility when R1 was found to be outside. Z4 did a body check on R1 when she was brought inside. R1's temperature at that time was 98, Pulse 80, Respirations 18 and blood pressure was 126/80. Z4 concurred with E7 that she did not know R1 had gone outside of the facility. R1 told Z4 that she was "going home, going to see her sister."
In a telephone interview on 1-15-02 at 1:50 P.M., E6 stated that she did not know that R1 left the facility until after she had been returned to the building. E6 stated that the doors are alarmed with an alarm that sounds the same as the sound of the call lights. E6 stated that staff and visitors come in and out all of the time and the alarm sounds while the door is open then stops when the door closes. E6 stated that employees use the back door for smoking and the door buzzes all of the time. E6 concurred with E7 that R1 had been seen going toward the front door earlier in the day stating that she wanted to go home.
In an interview of E2, Director of Nursing and E3, Care Plan Nurse on 1-15-02 at approximately 9:15 A.M., they both stated that a 72 hour observation was made on R1 every 15 minutes after she had been brought back into the facility on 12-6-01. On 12-11-01 Z6 (psychiatrist to R1) increased R1's Risperdal from 2 to 3 mg. twice a day. E2 and E3 stated that R1 has not attempted to leave the facility since that time.
Observations were made of the door alarms on all days of the survey: 1-15-02, 1-16-02 and 1-17-02. There are 7 exterior exit doors to the facility. All seven doors work with an alarm that sounds when the door is open and continues to sound only while the door is open. As the door shuts, the door alarm turns off. On 1-15-02, the audible sound of the door alarm was the same sound as that of the resident call bells. The audible sound for the door alarms was changed on 1-16-02.
Observations of R1 on all days of the survey revealed her to walk with a slow steady gait. She looked downward as she walked. She was unable to answer questions of person, place or time on 1-15-02 at 11:15 A.M. R1's Minimum Data Set, dated 11-5-2001, assesses her to have short term memory problems and moderately impaired cognitive skills for daily decision making. She was assessed as being easily distracted, periods of altered perception, episodes of disorganized speech, periods of restlessness and mental function varying over the course of the day. Her medical conditions include: Diabetes Mellitus, Hypertension, Anxiety Disorder, and Schizophrenia. R1 is 75 years old. Nursing Notes on 11-28-01 address "numerous attempts to leave the facility. "
On 1-15-02 at 2:25 P.M. Z1 (R1's physician) was interviewed over the telephone. Z1 stated that R1 is "not aware of dangers," and should not be out of the facility unattended.
The facility is located on the main street near the edge of town. The speed limit in front of the facility is 35 miles per hour slowing from 55 miles per hours in a distance of 0.3 miles to the west of the facility. The front of the facility is approximately 20 feet from the street.