CAPITOL CARE CENTER
Facility I.D. Number
Date of Survey: 06/18/03
Incident Investigation of 6/9/03
The facility shall provide a Resident Services Director who is assigned responsibility for the coordination and monitoring of the residents overall plan of care. The Director of Nurses or an individual on the professional staff of the facility may fill this assignment to assure that residents plans of care are individualized, written in terms of short and long range goals, understandable and utilized; their needs are met through appropriate staff interventions and community resources; and residents are involved, whenever possible, in the preparation of their plan of care.
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.
These regulations are not met as evidenced by:
Based on record review, interviews and observation it was determined that the facility failed to adequately supervise R23 which led to R23 eloping from the facility without staff knowledge. R23 was noted to be missing from the facility on 06/09/03 at about 3:40 p.m. R23 was approximately 1.5 miles from the facility when local police were alerted by a homeowner. The local police responded and returned R23 to the facility. R23 had made previous attempts to wander from the facility or made statements alluding that she wanted to leave without assessment for wandering and/or eloping being conducted.
R23 is a 70 year old individual admitted to this facility on 05/16/03 from a hospital. R23's diagnoses includes intracerebral hemorrhage, falls, convulsions, unspecified psychoses and ETOH (alcohol abuse).
Review of R23's assessment completed on 05/24/03 indicated the following: R23 has no long or short-term memory problems; no cognitive or decision making problems; walks about freely with no problems; has no wandering or abusive tendencies and does not resist care.
R23's care plan identifies R23 as having a history of falls related to unsteady gait.
Her care plan did indicate decreased "...safety awareness, ambulates with min. assist has unsteady gait. Dx [diagnosis] psychosis..." As well as "At risk for injury r/t seizure disorder..."
R23's care plan did not identify any problems with wandering tendencies.
Review of R23's nurses notes of 5/16/03 through 5/19/03 indicates R23 as being confused, pacing up and down halls and sometimes going into other residents' rooms. Notes indicate R23 would become belligerent when redirected by staff.
Undated entry between 05/25/03 and 05/27/03 "Res. alert et confused, wanders through fire exit door several times a night. Res. pleasant, delusional..."
(Note that on the first floor of this facility there are four designated fire doors exiting to the parking lot on the south side of the building. There is one additional exit door leading to the north grounds of the facility.)
Nurses's notes dated 5/31/03 indicate R23 told staff she wants to walk to the bank to get money and inquiring how to get out of the building. Notes dated 6/08/03 indicate R23 tried to leave the facility through the emergency exit door.
Entry made in nurses notes dated 06/09/03 at about 3:40p.m. reads Pt not in room-Inquires made from other staff and had not been seen...At 4p.m. a search of rooms was conducted, then grounds were searched. At about 4:40p.m. Z4 (R23's nice/P.O.A.) notified E1 (Administrator) that ...Pt was found per [city policy] and to return to facility presently...R23 returned to the facility at 5p.m. A body check and assessment showed nothing unusual. An electronic monitoring device was place on R23 with checks being completed on her every 15 minutes. She was then moved to the fourth floor at about 5:30p.m.
The distance from the facility to where R23 was picked up by police is about 1.5 miles (based on distance clocked on surveyors car odometer). This is a heavily populated area that has many major busy city streets.
R23 was transferred to a local hospital on 06/11/03 due to behaviors (multiple attempts to leave the building and not cooperating with care).
R23 was interviewed on 06/11/03 at the hospital with Z4 (R23's niece/P.O.A.) present. R23 answered correctly her name, birthdate and current president of the United States.
She indicated that she'd spent the previous night in Elko, Nevada. She identified the current month as October (it is June) and she identified the year as 1965 (it is 2003). These were asked twice during the 15 - 20 minutes spent with R23. She did not recall having left the facility a few days prior and being returned to the facility by police.
R23 ambulated at surveyor's request. She could walk independently but had an unsteady gait.
Information derived from interview of Z4 (R23's niece/ P.O.A.) included that Z4 has been R23's P.O.A. for five years. She indicated that R23 had had a fall, that she had fallen often, but this last fall she ended up in the hospital with the intracerebral hemorrhage. Z4 stated that R23 had abused alcohol heavily and had not lived by herself for quite some time prior to her last hospitalization. Z4 indicated that she would not have been able to keep R23 at her home and it would be unsafe for R23 to be left alone. Z4 was interviewed on 06/11/03.
The following information was obtained from staff interviews conducted on 06/12/03:
1.) E16 (Social Services Director) said that the facility always had "wander" book located at nurses station.
E16 indicated that staff members who witness a resident attempting to leave, making statement about wanting to leave, or making other references to elopement risk are required to report such conduct to Social Services. Social Services then update the wander book and assure that an electronic monitoring device is placed on the resident. E16 indicated that had she been aware of R23's wandering tendencies that she would not have been placed on the first floor because the safety risk [to R23] was too high.
2.) E17 (C.N.A. - Certified Nurse's Aide) indicated that R23 would wander the halls on first floor and would often sit in the smoking area off the end of east hall. (This is an outside area).
3.) E19 (C.N.A. - Certified Nurse's Aide) stated that on 06/09/03 in the morning R23 had been on the west end of first floor (R23 resided on the east end). "Usually the west end nurse caught her before she got around to the ambulance door." She later found R23 wandering towards the exit door in the "family dining room" on first floor, west end. (This doors opens to the outside on the north side of the building; this is an open non-fenced area.) E19 intervened and then had R23 walk with her while she delivered lunch trays. After lunch, E19 washed R23's hair. Last time she saw R23, R23 was on the patio. R23 liked to sit out there and smoke.
E19 indicated that R23 "...wants to go to the bank all the time..." and that R23 had been moved to the East end of first floor so she would be away from the West end door. (This door was at the ambulance entrance and was not alarmed).
4.) E18 (C.N.A. - Certified Nurse's Aide) told the surveyor that R23 had approached her on Saturday
(06/07/03) requesting to go to the bank. R23 told E18 that she needed to go to the bank for cigarettes. E18 said that she reported this to the nurse. She said that the nurse then gave R23 a cigarette and went with the resident to smoke.
5.) E21 (R.N. - Registered Nurse) indicated that R23 was confused at times. She could not remember as to why the resident had been moved from the west end to the east end of first floor but said that R23 "...probably was moved because of [R23]'s confusion and increased activities associated with location of original room assignment..." (R23's original room would have been one of the closest resident rooms to the ambulance exit door.)
6.) Z5 (R23's physician) indicated that with R23's cognition she could not safely be out of the building unsupervised.
7.) Z6 ( City Police Officer) said that the City Police Department received a call from a homeowner saying that there was a woman sitting on their porch. The police responded and found R23 to be calm but confused. She said she had hitchhiked from [a town about 35 miles away] and that that was where home was. She told them her name. The police radioed the police in the other town. The police there were familiar with R23 and knew where she had lived when she had maintained a residency in their town. They sent an officer there who spoke with the current occupants who gave them the phone number for Z4. Z4 was then called and told the police as to where R23 belonged; this information was then radioed to the police on the scene and they returned R23 to the facility at about 4:45 p.m.
E22 (R.N. - Registered Nurse) indicated the following when interviewed on 06/13/03:
The first night [R23] was in the facility she was in a room on the west end. She walked out by the vending machines - you have to go by the ambulance entrance to get to the vending machines. Staff returned her to her room, then she wandered to the opposite end of the hall (east end) and went into a room and fell asleep. So her belongings were moved there. R23 did continue to wander that night but the CNAs stayed with the resident.
E22 indicated, when asked, that she had not reported R23's wandering to anyone because "...there's no one on nights to report to..." (E22 works the 11 p.m. to 7 a.m. shift).
E22 said that R23 might occasionally hallucinate and see and talk about things that weren't there. E22 did not believe that R23 would be safe out on the street by herself; R23 would need 24 hour care. Anytime R23 was up on the night shift, she'd be wandering up and down the halls.