Greek American Rehab & Nursing Facility I.D. Number: 0044149 Date of Survey: 06/11/2003 Complaint Investigation "A" VIOLATION(S): 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 Regulations are not met as evidenced by: Based on record review, interviews, and review of the facility's incident reports, the facility failed to:
The facility was unaware that the resident had gained access to the stairwell, resulting in the resident falling down the stairs and sustaining multiple traumatic injuries. Findings include: R2 was admitted to the facility on 11-12-02, with diagnoses including Alzheimer's Disease, Dementia with Behaviors, and Anxiety. Review of an incident report indicates that on 05-26-03, the resident was found sitting against the wall at the bottom of the stairs. Review of R2's medical record documents four separate incidents (02-04-03, 02-17-03, 05-06-03, and 05-17-03) where resident was found on the floor by staff or had fallen. Review of the facility's incident reports further documents and additional incident on 05-06-03, where staff found resident on the floor. Minimum Data Set (MDS) dated 04-28-03, under Accidents, documents a resident fell in the past 31-180 days. There was no evidence that the facility had implemented a care plan to address R2's falls. Continued review of the resident's medical record documents multiple entries in the nurses notes, from 01-06-03, to the present, that the resident wanders around the entire unit in enclosed rolling ambulatory walking device. MDS dated 04-28-03, under Behavioral Symptoms, scored wandering as 2/1 (behavior occurred 4-6 days/not easily altered) and Cognitive Skills for daily decision making as 2 (moderately impaired-decisions poor; cues/supervision required). There was no evidence found that the facility implemented care plans to address the resident's wandering and use of the enclosed rolling ambulatory walking device. During an interview on 06-06-03, E1 (Director of Nursing) stated that she interviewed all staff working at the time that R2 fell down the fourth floor stairwell. Per her investigation, she found that staff did not respond for at least 15 minutes to the alarm that R2 triggered when R2 gained access to the stairwell. She further stated that all staff were responsible for monitoring/supervising R2. E1 stated that during her investigation, she interviewed the following employees: E5 (CNA, 4th Floor), E10 (Nurse, 4th Floor), E9 (Nurse, 4th floor), E8 (CNA, 4th floor) and E7 (Nurse, 2nd floor). She informed surveyors that: E5 continually responded that he did not know how to turn off the alarm. E10 stated that she heard the alarm but did not know where it was coming from and did not respond. E9 stated that she heard the alarm but did not respond because it was not on her side. E8 did not respond to the alarm. E7 told 4th floor staff that someone needed to respond to the alarm that was triggered. During telephone interviews: E5 informed surveyor that R2 was not his resident, and that he did not recall any details regarding R2's fall. E7 stated that the alarm was going off when she came up to the 4th floor at approximately 6:30 A.M., and that two staff members (E9 and E10) did not take a long time to respond to the alarm. E8 stated that she placed R2 in the resident's enclosed rolling ambulatory walking device, in a locked position, in front of the 4th floor nurses station at 6:30 A.M.. The last time E8 saw the resident was at 6:45 A.M.. The resident was still in the enclosed rolling ambulatory walking device in front of the nurse’s station. E8 stated that when the alarm was triggered, she was in a room with E9 rendering care to a resident who had expired, and E9 responded promptly to the alarm. E8 also related to the surveyor that R2 had attempted on previous occasions to get out of the enclosed rolling ambulatory walking device, and that the resident would wander from one end of the 4th floor to the other. E9 and E10 were unavailable for an interview. Z1 informed surveyor during a telephone interview that R2 was very active and in an enclosed rolling ambulatory walking device with no safety awareness Z1 further stated that she was told by facility staff that there was some confusion as to whether the alarm was working, and that it took some time for staff to get to the resident. Z1 stated that she voiced a concern about the time it took a resident in an enclosed rolling ambulatory walking device to get through an alarmed door without response by staff. Review of R2's medical record documents that 911 was called. The resident was transported via ambulance to a hospital and admitted with the following diagnoses: Multiple trauma, status post fall, sub-dural bleeds, fractures of the 12th thoracic vertebrae and nasal bone, and multiple abrasions. |