Concord Extended Care Facility I.D. Number: 0026914 Date of Survey: 07/08/2003 Complaint Investigation “REPEAT A” VIOLATION(S): Facility failed to follow the IPOC for the survey of December 2, 2002, by failing to ensure that “. . . all areas inside and outside the building are thoroughly searched in order to locate a resident”. 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 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 resident receives adequate supervision and assistance to prevent accidents. This REQUIREMENT is not met as evidenced by: Based on observation, interviews and record review the facility failed to:
Findings include: R9 is a 72-year-old male with multiple diagnoses to include Dementia, Parkinson's disease, Hypertension, Glaucoma, Anemia and Schizoaffective disorder. R9 is ambulatory and wears electronic monitoring device due to wandering behavior. Review of R9's incident report investigation dated 06/06/03, showed that R9 was last seen on 06/06/03 at 4:30 p.m., when E6 (Certified Nurse Assistant) and E4 (assistant director of nursing) were attending R9's personal care. Further review of this report revealed that the facility's northwest exit door alarm was triggered at 4:35 p.m., on 06/06/03. E4 started to check the northwest door from left to right, then started census head count. During the facility census head count, the facility had received a call from the Fire Department at 4:45 p.m. and had identified R9 as a missing resident. The police department returned R9 to the facility at 4:50 p.m.. Further review of this report revealed that R9 was found 1 ½ blocks from the facility when discovered outside. Review of a police investigation report dated 06/06/03 showed that R9 was found 1 ½ blocks from the facility by the fire department on 06/06/03, at 4:35 p.m. The distance that R9 was found from the building and the facility's location indicated that R9 had crossed a busy street and intersection in order to come across to the location where he was found. This report disagrees with and does not reflect the time that facility had stated their door alarm had triggered. Facility documents that the door exit alarm was triggered at 4:35 p.m. but per review of the police report, this was the actual time that R9 was found wandering outside the building some distance away from the facility. Interview with E4 on 07/7/03, at 3:45 p.m. stated that on 06/06/03 at around 4:30 p.m., she was assisting E6 providing personal care to R9 in R9's room. E4 also stated that R9 was exhibiting some agitation that was identified. E4 further stated that based on her assessment, R9 did not need 1:1 staff monitoring and did not require any medication intervention because R9 had calmed down after reassurance from E4 who only had to stay with R9 for few minutes. During this interview, E4 also stated that she heard the facility's northwest exit door alarm at 4:35 p.m.. E4 stated that she proceeded to check the northwest door exit and admitted that she did not go out to check the outside perimeters of the facility building. Further interview with E4 revealed that R8 who was also wearing an electronic monitoring device was nearby the northwest door. E4 assumed R8 was the one who triggered the alarm door. However, E4 announced to the facility staff to initiate census count anyway. When surveyor asked E4 how the facility implemented the census count, E4 replied that each unit wing started the census count by going through the facility roster list and that she started the census count on the south wing (entrance wing). The facility roster is a list of updated census for all the residents at the facility. E4 also added that she should have implemented to search and check residents with an electronic monitoring device (wanderers) first before going through the facility roster. Interview with E1 (administrator) on 07/08/03 at 10:00 a.m., stated that per facility's policy search protocol/searching for a resident outside the facility, investigation should start by checking outside perimeters, looking at both sides of the street and also up and down the street including the side street since the facility is close to a busy 4-lane street. E1 also stated that during the time of external search, there should be an ongoing census count inside the facility. This is an indication that facility policy for search protocol was not appropriately followed when the facility staff failed to search outside proximity of the building including the street after hearing the alarm. Review of R9's care plan showed that R9 had made several attempts to elope on the following dates: 02/15/03, 04/02/03 and 05/20/03. R9 finally succeeded to eloped out of the facility on 06/06/03. Further review of the care plan showed that facility was aware of R9's continued attempts at elopement and that R9 was a chronic risk to leave, but there was no revision of interventions to address R9's issues with elopement attempts. This care plan was only revised on 06/09/03, after the fact that R9 had already successfully eloped on 06/06/03. |