St. Anns Healthcare Center
Facility I.D. Number: 0023390
Date of Survey: 05/12/03
Incident Report Investigation of 04/11/03
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.
General nursing care shall include at a minimum, the following and shall be practiced on a 24-hour, seven-day-a- week basis:
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.
All exterior doors shall be equipped with a signal that will alert the staff if a resident leaves the building. Any exterior door that is supervised during certain periods may have a disconnect device for part-time use. If there is constant 24-hour-a-day supervision of the door, a signal is not required.
These regulations are not met as evidenced by:
Based on interviews, record review and observation the facility failed to prevent 1 of 8 residents identified as a wandering risk (R4) from entering the second floor stair well without supervision. R4 fell and sustained fractures to her cervical (neck) vertebrae.
R4 is an 82 year old individual with diagnoses that include visual and auditory hallucinations, macular degeneration, psychosis, degenerative arthritis, osteoporosis, diabetes and depression.
Review of an incident involving R4 on 04/11/03 at 4:50 PM showed that R4 was found at the bottom of the staircase, that is located at the east, 2nd floor Nurses Station, by the facility Administrator, E1. The resident wore a personal protection bracelet but no alarm was sounding. The bracelet should have alarmed when she opened the door into the stairwell from the second floor where she resides. E3, Licensed Practical Nurse (LPN), from the second floor was summoned and responded. E2, Director of Nursing, also responded. A physical assessment was done. R4 was moving about and attempted to raise herself.
R4 did complain of pain in her neck. R4's physician (Z1) and responsible party were notified. R4 was sent to a local hospital by ambulance. R4 was then transferred to another hospital. R4 sustained a fracture to her neck (C1,C2) and some bruising. R4 returned to the facility on 4/15/03 with a cervical collar in place and orders for follow up visits with the specialist.
Review of R4's record showed the following:
R4 has a history of falls and her fall risk assessment placed her at risk for falls. R4's fall risk assessment dated 3/8/03 indicated her cognitive status is impaired, vision status is moderately impaired, ambulates without problems with a device(walker), and that during the balance test she either needed partial physical support or stands but does not follow directions.
R4's Minimum Data Set (MDS) dated 3/8/03 documented that she had wandering behaviors that occurred 1 to 3 days during the last seven.
R4 was care planned as a risk for wandering from the facility unattended on 3/5/03 due to her insistence on leaving the building.
R4 had had an electronic monitoring bracelet applied on 02/10/03 because of her wandering and making statements that she does not live here and was going to leave.
E1 and E2 stated when interviewed on 5/6/03 that R4 was ambulating on second floor without assistance using a wheeled walker prior to the incident.
On 5/08/03, when interviewed, E1 stated that he felt R4 was intending to leave the building on 4/11/03 when the incident occurred.
R4 was interviewed on 5/6/03 at 1:15 PM. It was determined that she was not a reliable historian of the incident.
Z1 ( R4's physician) was interviewed on 5/7/03. When asked if it would be safe for R4 to maneuver stairs without assistance, Z1 said "no".
Maintenance logs for the personal alarm bracelets were reviewed. Prior to the incident the bracelets were tested weekly. R4's bracelet was checked on 02/ 14, 21, and 28/03 and was found to be functioning. R4's name was not forwarded to the 3/07/03 check list. R4's bracelet was not evaluated for functioning any more until the incident. E1 said at the time of the incident on 4/11, R4's personal alarm was not operating. E1 had a signed statement from the E4 (Activity Assistant) that R4's personal alarm was working on 4/10/03.