WOODBRIDGE NURSING PAVILION
Facility I.D. Number 0034157
Date of Survey:11/07/01
Incident Investigation of 10/09/01 Incident
The facility shall have written policies and procedures, governing all services provided by the facility which shall be formulated by a Resident Care Policy Committee consisting of at least the administrator, the advisory physician or the medical advisory committee and representatives of nursing and other services in the facility. These policies shall be in compliance with the Act and all rules promulgated thereunder. These written policies shall be followed in operating the facility and shall be reviewed at least annually by this committee, as evidenced by written, signed and dated minutes of such a meeting.
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.
The residents attending physician shall be notified of medications about to be stopped so that the physician may promptly renew such orders to avoid interruption of the residents therapeutic regimen.
Based upon staff interview and record review, the facility failed to follow its policy to obtain and
confirm admission medication orders within 24 hours and to administer psychoactive medications, antiepileptic and anti infective medications that were necessary to 1 of 2 residents newly admitted to the facility on 10/08/01. The facility also failed to follow its policy to monitor residents that are at risk for elopement for 1 of 1 residents in the facility, and failed to protect and prevent a resident from suffering mental anguish to the extent that R1 jumped from a 4th floor window to his death on 10/09/01.
R#1 did not receive any medications for 24hours, from admission 10/8/01 at 5:30p.m. until 10/09/01 at approximately 5:45p.m. at which time, R#1 was able to smash open a window in R#1's room with a dresser drawer. R#1 was removed from his room and left unattended while E#6 went to the second floor to look for help. R#1 then opened a window in the room next to R#1's room, removed the screen and jumped from the 4th floor window onto the balcony below to his death. R#1 was found lifeless on the balcony on 10/09/01 at approximately 5:45p.m.
On 10/08/01 at 5:30p.m., R#1, a 58 year old male was admitted to the facility from a hospital in
leather restraints on all four extremities with a diagnosis of Altered mental status and Seizures.
R#1 was combative and unable to be redirected, and resisted care.
The transfer hospital current medications at the time of discharge included: psychoactive medications (haldol liquid 0.5gms three times a day, haldol 5 mg intramuscular four times a day when necessary, librium 50mg by mouth every six hours and additionally aricept 5 mg at bedtime) and antiepileptics: dilantin 100 mg three times a day. These medications were not given from 10/8/01 for 5p.m. dose through 10/09/01 for the 5p.m. dose as is documented on the medication and treatment sheet; E#3 stated I did not give the medications because (Z#1) and (Z#2) did not respond to my calls or the telephone lines cut the calls off. The policy for validating admission medications states E#2 was to be notified only after 24 hours without response from Z#1 or Z#2.
The facility policy "Admission/Readmission medication verification policy" was not followed for the following points:
1. all admitting nurses are to confirm orders for all new and readmitted residents with attending physician;
4. If the attending physician fails to respond to call within 24 hours, notify Director of Nursing of the situation;
5. Notify Medical Director of situation for confirmation of medical orders.
The attending physician, Z#1, was called on 10/08/01 at 8p.m.and 10/09/01 at 10:35a.m. The telephone call did not reach the nurse as the line was disconnected before the nurse picked up the phone. Z#1 was also called on 10/09/01 at 3p.m. without a response. The Medical Director, Z#2, was called on 10/08/01 at 8p.m. without response back to the facility.
E#2 was not called regarding behavior outbursts involving R#1 on 10/8/01 nor 10/9/01, however E#2 was aware that R#1 did not have physician orders as E#3 stated during interview "I did
document on the communication board for the nurse on 11-7, to contact the physician for orders for (R#1)." Based upon interview with E#2 on 11/7/01 at 2p.m., E#2 stated E#2 knows what has occured on each shift through the 24 hour communication board. Review of the communication board dated 10/08/01 reveals E#3 did document on 10/08/01 on the 3-11 shift that admission medications had not been validated and please call M.D.
Z#1 stated on interview on 11/2/01 at 1:30p.m. "they called me and I returned the call however the phone was not switched to the right person. I expected the nurse to call me again or to follow the appropriate procedure. I found out, later that (R#1) did not receive any medications since the time he was admitted."
The facility policy regarding missing residents, and elopements was not followed. The policy stated: Residents at risk for elopement shall be provided at least one of the following safety precautions: a wanderguard, door alarms on facility exits and/or staff supervision either by visual contact or by video camera of facility exits.
The hospital transfer physical therapy evaluation stated as a condition of discharge that R#1 must have 24 hour supervision. E#3 was interviewed on 11/7/01 at 10a.m. and stated staffing was adequate on the floor, however, I didnt have enough staff to give 1:1 supervision for (R#1) on 10/08/01 on 3-11 shift nor on 10/09/01 at 3p.m. when (R#1's) behavior began to escalate again with agitation, pacing and threatening to leave the facility.
During interview, E#6 stated on 11/2/01 at 10:30p.m. that on 10/09/01 at 3:30p.m., R#1 was stating Im going to break out of this joint. E#6 stated (E#3) was aware that (R#1) wanted to leave and made no effort to monitor (R#1).
E#4 stated on 11/5/01 at 10:15p.m. that (E#4) was not given any specific instructions to monitor (R#1)when (E#4) came on duty 10/09/01 at 3p.m. E#4 further states I saw (R#1) in the hallway in the wheelchair, (R#1) said he didnt need any help, so I made rounds and checked all other patients and got them to the dining room for dinner. Dinner is served approximately 5p.m.
Behavior Manifestations: Based upon interview with E#3 on 11/7/01 at 10a.m., E#3 stated "on
10/08/01 after admission, (R#1) became incontinent during the last rounds at about 10p.m. Although (R#1) was extremely sedated, he was violent and would not let us do anything. He told us to get out of the room. Although he was extremely angry, we released the restraints because there was no order for restraints. The MD failed to answer every attempt to reach him."
Based upon interview with E#3 at 10a.m. on 11/7/01, E#4 on 11/5/01 at 10:15p.m. and E#6 on 11/2/01 at3:30p.m., on 10/09/01, R#1's behavior escalation occurred at 3p.m.with agitation, pacing, and statements that R#1 was going to leave the facility; then at approximately 5p.m., R#1 broke out of the window in his room with the dresser drawer from R#1's room. R#1 was then escorted from his room by E#6 and was left unattended in the hallway while E#6 tried to get help on the second floor. R#1 then proceeded to return to the room next door to his room and then to jump out the window onto the balcony below. R#1 was discovered laying on the balcony lifeless, at approximately 5:45p.m. on 10/09/01 by E#4 and E#6.
E#3 stated during interview on 11/7/01 at 10a.m. that staffing was adequate, however E#3 stated "I did not have enough staff to provide 1:1 supervision for (R#1)"; Due to poor safety awareness, as a condition of discharge from the hospital, the transferring hospital's physical therapy evaluation for safety awareness recommended 1:1 supervision.
E#2 stated on interview on 11/7/01 at 2p.m. that the 24 hour communication report is utilized to report unusual and resident conditions to each shift and to E#2. Documentation on the communication board for 10/08/01 (3-11) states for R#1, MD paged several times, no response, please validate meds. (11-7 shift) 10/9/01 report states, please verify with MD today levoquins stop date. (7-3 shift) states Z#1 called times 2, but did not return call. No other actions were taken to supervise and monitor R#1 to prevent R#1 from jumping from the 4th floor window to his death.
A resident care plan with the residents immediate needs was not initiated with appropriate approaches.