Dogwood Health Care Center
Facility I.D. Number :0043521
Date of Survey: 07/16/2003
Incident Report Investigation of June 8, 2003
Personal care shall be provided on a 24-hour, seven-day-a-week basis.
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.
This REQUIREMENT is not met as evidenced by:
Based on record review, interview and observation, the facility failed to supervise a known wanderer with Alzheimer type dementia, by not:
a) Following the facilitys policy and procedure for door alarms.
b) Following the facilitys policy and procedure for missing residents and/or elopements.
c) Having a specific monitoring plan to supervise R1 to prevent an elopement from the facility.
d) Develop a plan of care to deal with R1's repeated attempts to leave the facility.
This was for one (R1) of seven identified wanderers in the facility. These failures resulted in R1 successfully eloping from the facility between 10:30 and 11:10 a.m. out of the northeast door on 06/08/03.
The findings include:
R1's social service admission progress note dated 03/26/03 was reviewed. It documented, R1 is a 71-year-old female with a diagnoses of Alzheimer disease. R1 ambulates independently is pleasantly confused and is an elopement risk.
R1's Elopement Risk Assessment dated 04/08/03 identified R1 as an elopement risk.
R1's Minimum Data Set (MDS) dated 04/07/03 identified R1 as having short and long term memory problems and has severely impaired cognitive skills for daily decision-making.
Review of R1's nurses notes from 03/26/03 until 06/08/03 documented 13 attempts to leave the facility. On 3/30/03 at 10:15 a.m. the nurses note documents, "R1 went out the northeast door staff went after her and R1 became combative and it took three staff to return R1 to the facility." R1's nurses note of 06/08/03 documents, "Alarm went off. Search of building. Resident noted to be missing." Phone call received stating resident was two blocks away.
Review of R1's care plan dated 04/15/03 does not include any approaches to address R1's attempts to leave the facility.
During an interview with E1 (LPN) on 07/14/03 at 9:40 a.m., about R1's elopement on 06/08/03, E1 stated , "I was up by the front door when I heard a door alarm go off. I am not sure what time it was. I checked the front door and found the front door alarm hadn't gone off. I went to the nurses station and told E2 (RN) it wasn't the front door. I went to silence the alarm. That is when I discovered it was the North East Door alarm (NE Door). One of the Certified Nursing Assistants (CNA), I don't remember which one, said she had checked the NE door and no one was out there. We did a resident count and found out that R1 was missing. I went up to the front to call the police and the phone rang and a neighbor said there was an elderly woman out in front of her house (two blocks away). I got in my car and went and picked her up and returned her to the facility. There were four CNA's and a nurse on duty that day. "
E2 was interviewed on 07/14/03 at 9:30 a.m. about R1's elopement, E2 stated, "I was at the nurses station transferring a doctors order. I'm not sure of the time. I did not go and check the door. E1 came into the nurses station and said she checked the front door alarm it had not gone off. E1 checked the alarm panel and discovered the NE door alarm was going off."
E3 (CNA) and E4 (CNA) where interviewed on 07/10/03 at 10:30 a.m. about R1's elopement and stated, "We were out of the building at lunch when this happened. We went to lunch at about 10:30 a.m.. And came back around 11:00 a.m.."
E5 (CNA) and E6 (CNA) were interviewed on 07/10/03 at 11:00 a.m. about R1's elopement and stated, "We were on the south hall in an isolation room getting a resident ready for the nurse to do a dressing change. E6 went to get the nurse and heard a door alarm going off." E5 stated, "I came out of the room and went to the
front door. The front door alarm was going off. I went out the door and looked around and no one was out there. I didn't go to the street then because I didn't know anyone was missing. When I came back in we did a head count and found out that R1 was missing. I then went out the front door and went west on the street on foot." E6 stated, "I went out the NE door and looked around and didn't see anyone. I did not go across the yard to the street."
E1, E2, E3, E4, E5 and E6 all stated that R1 had made many previous attempts to leave the building.
On 07/10/03, R1 was observed ambulating in the facility. R1's was observed to have an unsteady gait. R1 did not recognize her husband and stated to him, "It was nice of you to come and visit me." R1 was looking for her friend. (This was a CNA who had just helped her with a bath.)
On 07/10/03 at 11:30 a.m., R1 was asked about the elopement on 06/08/03 and she replied "I don't have any idea what you are talking about. That door makes it handy to go for walks. I wouldn't have any idea."
R1's physician (Z1) was called on 07/10/03 at 11:55 a.m., Z1 stated, "R1 has no safety skills and had no business being out on that road alone."