Provena Villa Franciscan
Facility I.D. Number: 0042861
Date of Survey: 08/05/2003
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 resident's 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.
Each facility shall maintain all signaling systems in safe and functioning condition. This shall include regular inspections of these systems.
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.
These requirements are not met as evidenced by:
Based on observations made of the secured dementia unit (Damiano), residents records, incident reports and policies reviewed and staff interviews, the facility failed to provide adequate supervision to one resident (R1), with a diagnosis to include altered mental status and vascular dementia with psychosis. R1 had a history of making multiple attempts to elope from the facility and was assessed by facility as being a high risk for elopements. On 07/19/03 at approximately 6:15p.m., R1 eloped from the facilitys secured dementia unit unnoticed and was found at approximately 6:45p.m. about four blocks from the facility on a
heavy traffic street, on "Glenwood Ave.", approximately ½ block west of another very heavily traffic street with four lanes of traffic "Larkin Ave". R1 told Z2 (agency nurse) that he was going home 07/19/03, when Z2 found him. R1's home is approximately three miles away from facility.
On 07/30/03, surveyor observed a total of 29 high risk for elopement resident photographs in a album labeled elopement risks at the front receptionist desk (R1, R5, R6 and R7 through R32).
R1 is a 74-year-old who was newly admitted to facility on 06/12/03, related to behavioral and cognitive changes. On 06/17/03, R1 was transferred to the hospital for psychiatric evaluation related to combative and aggressive behaviors toward staff and other residents. R1 was readmitted to facility on 06/24/03 with an interim care plan stating "on occasion, looks for a way out". During individual interviews on 07/30/03, E2 (Director of nurses), Z2 (Agency Nurse) and Z7 (Agency nurses aide) stated that they were all aware that R1 was a high risk for elopement prior to 07/19/03.
R1's 06/24/03, 06/25/03, and 06/26/03, nurses notes included documentation of multiple attempts to leave the Damiano unit. R1's medical record included nurses notes, 06/30/03 care plans, minimum data set assessments (MDS) and resident assessment protocol (RAPs) of which included the following assessments and needs of R1: R1 wanders daily - not easily altered, has severe cognitive deficits, impaired long and short-term memory, requires staff supervision and direction to ensure safe and appropriate decision making, paces on the unit, attempts to leave through the exit doors and stating he is going home, resists medications, care and meals and is not easily redirectable with his behaviors. R1 is on psychotropic medications and is noted to be at risk for possible falls and injury.
R1's 06/30/03 care plan interventions for his wandering behavior and elopement risk problem include the following:
8) "Know his where abouts at all times",
12) "Place in areas where constant observation is possible",
13) "Attempt to divert his attention from the exit doors" and
17) "Respond to exit door alarms promptly."
Nurses notes and Incident report of 07/19/03 indicate that at 6p.m., R1 was upset with his supper meal, refused to eat, got up from his chair and walked out of the dining room by himself. At 6:15p.m., Z2 went out of the dining room to check on R1 but was unable to locate him on the unit or anywhere in the facility. Z2 notified the nursing supervisor and called a code green at 6:30p.m. and then left the facility and drove around the area in her car and at 6:45p.m., Z2 found R1 walking down Glenwood Ave. R1 was guided into Z2's vehicle and driven back to the facility. When Z2 found R1, he told Z2 that he was going home. Z2 told surveyor during 07/30/03 interview that R1 was found 1/2 a block west of Larkin Ave. on Glenwood, by the school athletic field.
Z1 (R1's physician) stated during 08/05/03 phone interview that R1 required placement on the "Alzheimer" unit due to his cognitive deficits, I'm not sure how how got out of the facility but R1 is pretty clever and may appear to others as a visitor rather than a resident. If R1 had gotten out he would not be able to find his way home and he would not know where to go."
Review of 07/19/03 staffing schedules and interviews of E1 (Administrator), E2, Z2 and Z7 revealed that on 07/19/03 evening shift, the Damiano (secured dementia unit), was staffed with one agency nurse (Z2) and three agency nurses aides (Z7, Z8 and Z9). Z2 and Z7 both told surveyor that on 07/19/03, all four of the assigned staff were in the dining room assisting residents with the supper meal when R1 walked out at 6p.m. and that no exit door alarms or code green was heard. Z2 and Z7 both stated that it is unknown how R1 eloped from the facility but it is thought that he walked out the front door, possibly with exiting visitors because his physical appearance was not that of a typical resident.
Facilities 8/2002 updated Elopement Risk policy states the following: Residents are screened using the Elopement Assessment Tool prior to admission and those noted to have potential of eloping will be assessed for and admitted to the Damiano unit if they have a Dementia diagnosis. If the resident is not admitted to the Damiano unit the nurse on the unit admitting the resident will be notified that the resident is a high risk for elopement. If the high risk resident is in a wheelchair or is ambulatory, their picture will be placed in an album at the nurses station and at the front receptionist desk. All stairway doors are alarmed, if an alarm sounds during the hours of 8AM - 8p.m. the receptionist will call a code green with the location of the breached stairway or exit door over the intercom and repeat the call every 30 seconds until an all-clear is called, meaning, that the cause of the alarming exit door was resolved. The facilities environmental service department will make daily rounds to verify proper operation of each stairway/exit alarm.
E5 (evening receptionist), stated during 07/30/03 phone interview, " R1's photo was not included in the elopement risk photo album on 07/19/03, E5 was not aware of R1 being a high risk for eloping and that E5 does not remember seeing R1 leaving through the front entrance on 07/19/03." During 07/30/03 investigation surveyor, E2, E8 (maintenance mechanic) and E11(Nurse) opened the Damiano unit East and Center court corridor exit doors, setting off the alarms and observing no code green being called by the receptionist. E12 (Day receptionist) stated that when these alarms went off on the unit it did not show up that the exit doors had been opened on the receptionist panel board. E3 stated during 07/31/03 phone interview that the Damiano East and Center court exit doors are not wired into the receptionist panel board due to the panel board already being to full. These corridor exit doors have a 15-second delay panic bar on them and they lead into a hallway that leads to an exterior exit door that is wired to the receptionist panel. E2 also stated that the Damiano East corridor outer exit door required realignment on 07/31/03 due to the fact that the door would not close and seal shut when released.
E2 (Maintenance Director) 07/30/03 interview and review of facilities door alarm test and drill forms revealed that exit door alarms are not assessed daily as per policy but instead only checked once a month by the environmental service department.
On 08/01/03, facility had an outside alarm company come evaluate the Damiano exit door alarm system in response to surveyor findings and R1's elopement. The outside alarm companies letter of recommendation stated, "Damiano Wing: To address the issues regarding the door alarms: It has been generally agreed upon by your staff that the local alarm on the inner doors which have the 15-second delayed egress can not be heard when one is at the opposite end of the unit. We propose therefore to install a remote annunciator near each door that would not only emit a louder audible but would also incorporate a flashing strobe to more easily recognize the breached opening."
Review of R1's Elopement Investigation Tool and E2 and Z2's 07/30/03 interviews revealed that the exit door alarms of the Damiano East corridor exit door were not functioning appropriately on 07/19/03 evening shift. E2 stated sometimes they went off when the doors were opened and sometimes the alarms did not set off.
During the initial tour of the Damiano unit with E2, surveyor observed an unlocked and unsupervised door in the dining room that leads to an outside unsupervised patio. The patio is surrounded by a six foot wooden fence and the fence has a swing open gate that was observed to be unlocked, unlatched and jarred open. E2 and E8 during separate interviews on 07/30/03, stated that the gate was left open and unlocked by an outside landscaping company that was there earlier that day. E2 also stated that the gate was jarred open and unable to be closed due to the landscapers having backed their trucks into the fence. E2 notified the surveyor on 07/31/03 that the fence was currently under repair. E8 stated that this was not the first time the landscapers have left that gate unlocked when they finished their work and would leave.