Center Home for Hispanic Elderly Facility I.D. Number: 0038893 Date of Survey: July 29, 2003 Complaint Investigation "A" VIOLATION(S): 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. AN OWNER, LICENSEE, ADMINISTRATOR, EMPLOYEE OR AGENT OF A FACILITY SHALL NOT ABUSE OR NEGLECT A RESIDENT. (sections 2-107 of the Act) This REQUIREMENT is not met as evidenced by: Based on observation, record review and staff interviews, the facility failed to provide adequate supervision to one resident (R1), with a diagnoses of Dementia (Alzheimer's type) and Insulin Dependent Diabetes. R1 had made frequent attempts to leave the facility and had been identified by the facility as an elopement risk. R1 eloped on 7/8/03 while wearing an electronic monitoring device and was found 4 blocks away by a family member at the heavy traffic intersection of California and North Avenue (4 lanes each way) during rush hour. The family member was enroute to the facility to visit and recognized R1 at the intersection. There were nine other residents that were assessed to be at risk of elopement (R2, R3, R4, R5, R6, R7, R8, R9 and R10) in the facility at this time. Findings Include: R1 is a 79 year old female with a diagnoses that includes Diabetes Mellitus, anxious/sleep disturbance and dementia. R1 was observed on 7/24/03 at 12:15P.M. on the second floor ambulating independently. R1 is alert but confused. During the interview with R1 on the second floor, R1 was unable to remember when she left the facility alone. Review of R1's clinical record reveals R1 was identified by the facility in April 2003 as a high risk for elopement. Further review of R1's clinical record indicates R1 had a detailed elopement assessment completed by the facility. Every department within the facility signed it and it recognizes R1 as a high elopement risk. R1's Minimum Data Set (MDS) reveals R1's cognitive skill for daily decision making is at a level 2. R1 has poor decision making skills and requires cues and supervision. R1's care plan, dated 4/1/03 and 7/03 lists R1 as a wanderer. This care plan states: likes to leave building and go outside and is high risk to escape. Each of these concerns has several approaches to address R1's identified problems. Review of the facility's incident report dated 7/8/03 reveals at 4:00P.M. R1, a confused resident was seen by a nurse and 2 times attempted to go down stairway to leave the facility, assurance was given to R1 that her daughter will come. At 5:00P.M. R1 was seen pacing around. At 5:30P.M. R1's accuccheck was done and the nurse telephoned R1's daughter at home. R1 is still confused and redirected in dining room. At 5:45P.M. resident unable to find...then nurse states I went to the ground floor and I see resident,(R1), and daughter outside of building. During phone interview with Z1(attending physician) on 7/24/03 at 2:10P.M., Z1 told surveyor that R1 needs supervision on a daily basis. R1 would not remember one moment to next because R1 has Dementia/Alzheimer disease. This is why R1 could not remember leaving the facility alone when questioned. During phone interview with E10 on 7/29/03, E10 said," I saw the electronic monitoring device when R1 re-entered the building and there was no battery in it". E10 stated it happened about 5:00P.M. During interview with E5 (Activity Director) on 7/24/03 at 2:00P.M. in the conference room, E5 told surveyor she left the facility early that day before her regular schedule time off, approximately 5:30P.M. E5 told surveyor she stepped out of the door and just happened to look down the street and notice one of the residents (R1), standing by a phone and someone holding R1's hand. E5 said she did not recognize the person holding R1's hand, but she informed the unfamiliar person that R1 is a resident of the facility and needed to be brought back into the building. E5 also stated that she physically escorted R1 and the other person back into the facility and immediately told the Director of Nursing (DON) of R1's whereabouts. After R1 was returned, E5 was told by the DON that the person with the resident was R1's daughter. During phone interview with Z3 (family member), on 7/25/03 at 4:20P.M., Z3 told surveyor she saw R1 just about to cross the street at North Ave and California, 4 blocks away from the facility. Z3 was in her car and on her way to visit R1 at the facility. Z3 told surveyor it was about 5:00P.M. in the evening, during rush hour traffic. During interview with E8 (facility coordinator) on 7/24/03 at 3:00P.M. in the conference room, E8 told surveyor she was aware that all 10 electronic monitoring devices were expired. This included the device used by R1. E8 further went on to tell surveyor she checked all 10 electronic monitoring devices just before leaving for the weekend (7/4/03). E8 told surveyor the devices were in working condition, but the alarms were not as loud as usual and more difficult to hear. According to review of personnel file, E8 was give a written reprimand dated 7/11/03 for not having the electronic monitoring devices in working order and clearly audible. During interview with E4 ( staff nurse), on 7/24/03 at 1:50P.M. in the conference room, E4 told surveyor he was R1's nurse the day R1 eloped from the facility. E4 also told surveyor the time R1 eloped from the facility was between 5:00P.M. and 5:30P.M., he could not be sure of the exact time. E4 also told surveyor he had taken R1's accucheck (blood glucose level) and the results were 240. E4 further went on to tell surveyor he had administered R1 some insulin according to R1's physicians orders. He then redirected R1 to the dining room and assisted her to a chair. E4 left the room and could not tell surveyor which staff member he left in charge to monitor R1. E4 told surveyor the next time he saw R1 was when R1 was being escorted through the front door by a family member. During interview with E1( Director of Nursing), and E2 (Assistant Administrator), on 7/24/03 at 3:30P.M. in the conference room, E1and E2 told surveyor that they thought R1eloped from the facility through the front door. E2 told surveyor the security guard left his post and went to the back of the building. R1 apparently left the building while the security guard was in the back of the building. R1eloped unseen and unsupervised with an electronic monitoring device on. E1 further went on to tell surveyor immediately after R1 re-entered the building she checked R1's electronic monitoring device. E1 told surveyor the device was working but the alarm was very faint. E2 also confirmed this. During interview with E9 (Maintenance Director) on 7/24/03 at 1:30P.M., E9 told surveyor the alarms all were in working condition. The system attached to the wall is his responsibility and they were working. |