Burnside Nursing Home
Facility I.D. Number: 0007153
Date of Survey: 09/18/2003
Incident Report Investigation of September 18, 2003
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.
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.
Based on observations, interview and record review, it was determined that the facility failed to ensure that one of one sampled residents (R1) was properly supervised so as to prevent the resident from leaving the facility unnoticed on 08/27/03. This failure resulted in R1 gaining access to a nearby wooded area where she was found.
Review of a facility incident report transmitted via facsimile on 08/28/03 to the State Survey and Certification Agency Regional Office reflected that a confused and disoriented resident of the facility, R1, left the facility without staff supervision on 08/27/03 and was reportedly last seen at 3:00 p.m. The report stated that R1 was found at approximately 4:20 p.m. in a wooded area south and east of the lake located on the facility property. The report reflects that R1 was found uninjured and without ill effects from the incident. According to the report, R1 was returned to the facility, ankle transmitter (electronic monitoring device) still intact and operational.
Interview with E1, Administrator on 09/17/03 at approximately 9:30 a.m. confirmed that R1 no longer resided at the facility due to mutual agreement between all parties and related that her needs could not be met.
Review of the facility incident report dated 08/28/03 reflects the following pertinent information: "...(R1) was admitted to our facility on August 26, 2003, with diagnosis of : Alzheimer's Disease, Anxiety, CHF (congestive heart failure), CAD (coronary artery disease), HTN (hypertension), and pacemaker. Resident is disoriented X (times) 3 (time, place, person). Resident is ambulatory without difficulty. Resident has spent most of her waking hours since admission wandering about the facility, packing and unpacking personal belongings. Resident has been pleasant and cooperative with staff during care. Resident is more anxious during late afternoon and evening hours. On 08/27/03 at 15:00 (3:00 p.m.), resident received an injection of Vistaril 50 mg IM (intramuscular) in her left hip area due to agitation. Resident had gathered her clothing together and made several attempts to leave the facility. Resident was seated in a geri chair at this time as a nursing safety measure and taken to her room. Resident appeared calming at this time. On 08/27/03 at 15:10 (3:10 p.m.), a staff member went to check on resident and did not find her in her room. A search of the unit resident resides in was immediately initiated. Resident was not located, so a search was expanded to include the rest of facility...On 08/27/03 at 16:20 (4:20 p.m.), resident was located in wooded area directly behind facility by a Burnsides staff member...Resident had no apparent injuries and was voicing no complaints...resident was returned to facility...Administrator noticed resident secure care bracelet (electronic monitoring device) was intact and on resident ankle when she (R1) was located. Secure care bracelet tested upon re-entry to facility and was in good working order. No secure care alarms noted when resident was discovered missing..."
Review of R1's clinical record confirmed the above diagnoses. The record reflects that R1 is an 85-year- old female, who is independent with ambulation. Review of a document entitled "inquiry information" (a preadmission screening tool used by the facility) dated 08/05/03, prior to R1's admission reflects that R1 was considered "very confused" and "will require secure guard" (electronic monitoring device).
Review of the document "General Assessment" completed on 08/27/03, prior to R1's incident reflects that R1 was assessed as "walks...Alzheimer's as a dx (diagnosis)...up ad lib (up as desired)...needs close supervision". Review of the document "Risk for Elopement Assessment" dated 08/27/03 and confirmed by E5, Assessment Coordinator on 09/17/03 at 2:50 p.m. per interview, to have been completed prior to the incident reflects that R1 was assessed as "High Risk for Elopement-Proceed with Security Bracelet (electronic monitoring device)".
Interviews conducted on 09/17/03 with staff who were present at the time of incident on 08/27/03 reflected an awareness of R1's tendencies to attempt to leave the building. Interviews with E4, LPN (Licensed Practical Nurse) at 2:20 p.m., E6 CNA (Certified Nurse Aide) at 3:45 p.m., E5 LPN at 2:50 p.m., E9 Activity Aide at 11:30 a.m., and E10 Activity Aide at 11:45 a.m. all confirmed awareness of R1's frequent exit seeking behaviors since being admitted the previous day.
Interviews with E4, E5, E2 DON (Director of Nursing) on 09/17/03 at 3 p.m., and E7 ADON (Assistant Director of Nursing) on 09/17/03 at 3 p.m. each confirmed that R1 had no personal safety awareness.
Interviews with E6, E9, and E10 at the above times confirmed that they recalled hearing exterior door alarms sounding at the approximate time that R1 is believed to have left the building. Each related that they responded to audible door alarms that were sounding in the chapel and the three staff stated that they investigated by looking out the windows and by going outdoors but did not see any resident. The three staff confirmed that the exterior door alarms they responded to (located in the activity hall corridor and Chapel) were not secure care bracelet alarms, but rather the "regular door alarms". Surveyor investigation confirmed that no staff person witnessed or had knowledge of where or how R1 exited the building. E1 confirmed this fact on 09/17/03 during interview.
Observations made in the facility on 09/17/03 with E1 (Administrator) present confirmed that all exterior doors in the facility were equipped with functioning audible signals when exterior doors were opened. The signals are designed to alert staff if a resident were to leave the building according to E1 and E8, Maintenance Supervisor. The facility has approximately 20 exterior doors, three of which are equipped with the secure care system (electronic monitoring devices) which is to detect known residents who are prone to attempting to leaving the building.
During review of the building it was discovered that a single door on F-Wing leading to an attached apartment complex was equipped with an audible alarm. The alarm could be disabled upon opening the door by pushing a single button beside the door and would not reset itself for 33 seconds. The signal device was easily disabled and remained off for 33 seconds before automatically re-arming, an amount of time that could permit exiting of an ambulatory resident without staff's knowledge to unsupervised areas of the apartments and outdoors.
Observations made outside the facility on 09/17/03 at 10:40 a.m. with E1 and E3 CNA (first responder to the scene on 08/27/03) reflect that R1 traveled approximately 200 yards from the facility where she gained access to a wooded area. Between the nursing facility and the location where R1 was discovered sitting on the ground is a paved road lined with apartments on one side and an open grassy field on the other. Along the east edge of the grassy field is standing timber and on the west edge is an unfenced lake with adjacent standing timber. These edges funnel to a trail head where the terrain becomes hilly and the trail becomes enclosed on both sides by dense woods. A steep ravine is present immediately to the south and east entrance to the trail head.
According to interview with E3 on 09/17/03 at 10:40 a.m. she said she was off duty when she heard discussion of a missing elderly woman on her personal citizen's band scanner. She stated she immediately began searching for her on a four-wheel all terrain vehicle in the woods. She stated that she made her way from the back of the timber to the trail head and barely saw the top of R1's head over a rise in front of her. E3 stated that she found R1 sitting on the ground approximately halfway down the embankment of the ravine, arms outstretched behind her with her hands on the ground, screaming "I need help, I need help". E3 stated she immediately assessed for injury and found no evidence of any. E3 stated that although it was very hot outdoors,
estimated at 90 degrees Fahrenheit and sunny, R1 didn't feel hot. E3 stated she then reported that she had found R1 at which time emergency personnel were dispatched to her location.
Interview with E1 on 09/17/03 and E7 on 09/18/03 confirmed that there have been no other unnoticed absences by residents in the past year. E1 and E5 provided information which reflected that there are currently seven other residents in the facility who are considered at risk for leaving the facility, but none have done so.