Pleasant Hill Village
Facility I.D. Number: 0021014
Date of Survey: 07/16/2003
Incident Investigation of 07/03/03
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.
Objective observations of changes in a residents condition, including mental and emotional changes, as a means for analyzing and determining care required and the need for further medical evaluation and treatment shall be made by nursing staff and recorded in the residentss medical record.
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.
The DON shall supervise and oversee the nursing services of the facility, including:
Overseeing the comprehensive assessment of the residents needs, which include medically defined conditions and medical functional status, sensory and physical impairments, nutritional status and requirements, psychosocial status, discharge potential, dental condition, activities potential, rehabilitation potential, cognitive status, and drug therapy.
Developing an up-to-date resident care plan for each resident based on the residents comprehensive assessment, individual needs and goals to be accomplished, physicians orders, and personal care and nursing needs. Personnel representing other services such as nursing, activities, dietary, and such other modalities as are ordered by the physician shall be involved in the
preparation of the resident care plan. The plan shall be in writing and shall be reviewed and modified in keeping with the care needed as indicated by the residents condition. The plan shall be reviewed at least every three months.
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:
R12 is an 82-year-old individual admitted to the facility on 10/19/02 with diagnoses that include Alzheimer's with impaired cognitive status, chronic obstructive pulmonary disease, and transient ischemic attacks.
Review of R12's assessment completed on 04/29/03 indicated the following: R12 has short and long-term memory problems, is cognitively impaired at a moderate level (decisions poor, cues/supervision required), can move off her unit with limited assist of one person physically helping her and had fallen in the 31-180 days prior to the current assessment being completed.
R12's care plan identifies R12 as "... independent to ambulate in room, supervision with ambulation...confused at times, wears [an electronic monitoring device], wanders inside, may attempt to go out at times, packs belongings, states she wants to leave [the facility]..." .
R12's care plan notes that R12 is on behavior tracking to decrease episodes of "packing belongings" to 22 times in the next 30 days, this is down from 24 times on March 2003. April 2003 behavior tracking sheets document five times that R12 expressed the behavior of packing her belongings, May 2003-6 times, June 2003-0 times and July 2003-1 (the time of the above elopement).
Entry made in nurses notes on 07/03/03 at 2000 p.m. indicates that neighbors of the facility came to ask staff if we had a resident missing with a description of what resident was wearing. CNA was able to determine R12 had eloped from the facility. When CNA from the facility went to pick up resident to return to the facility R12 had fallen. CNA was sent to the facility to explain to writer that resident had fallen and neighbors had phoned "911". E42 (R.N.) phoned E2 (Administrator) and E42 was told to get resident chart to be at the scene when the police/rescue arrived. Upon the scene R12 was lying beside the road, on R12's left side, in the rocks. R12 had a hematoma with abrasions noted to the left side of R12's head. When E42 arrived R12 was alert, responsive and able to follow directions. Neuro checks "WNR [within normal range] per verbal stimuli, ROM [range of motion] done per resident with complaints of pain when raising right arm." R12 requested to sit up to wait for help. E42, CNA from the facility and neighbors at the scene.
2030 p.m. police arrived at the scene and assessed the situation.... ambulance dispatched and arrived at the scene and took over care.
2040 p.m. ambulance at scene and assessed resident.
2050 p.m. R12 was transferred to ... hospital emergency room for evaluation. R12 restated, " I was walking to intersection to use payphone for my grand babies and I fell in the rocks."
2054 p.m. "POA" notified.
2100 p.m. Z5 (R12's physician) was paged.
2005 p.m. (backnote) resident has [electronic monitoring device] in place as ordered and was still in place when writer arrived at scene, but due to resident had a sweater on, apparently did not set off alarms due to long heavy sleeves covering bracelet.
On 07/04/03 at 0330 a.m., R12 was returned to the facility from the hospital with a right humerus fracture and left finger fracture.
R12 was interviewed by surveyor on 07/09/03, at the facility and when asked how she got abrasions to her face and greenish- yellow discolored area around left eye. R2 replied that she was playing softball and she threw the ball and when they threw the ball back to her she missed (catching) it. R12 did not recall leaving the facility on 07/03/03 and falling down along the roadside.
Interview with Z5 via telephone indicates that R12 should not be walking alone outside and that R12 does not recognize safety routine hazards as R12 is confused.
A hand-written statement dated 07/11/03 by E35 (CNA) identifies that when E35 came to work on 07/04/03 at about 5:30 a.m., she found out that R12 had eloped so she and another employee E39 (Medical records secretary) immediately went around to make sure the door alarms were working properly. They also checked to see that the electronic monitoring device bracelets worked. They found out that if an individual had a sweater on that the alarm only sounded 50% of the time (the alarm sounded for four of eight attempts). The alarms have about a 10-second reset time before the alarm will sound after being reset. E35 notes that she reported this to E1 (Administrator).
Interview with E1 via telephone indicates that the nurses check their bracelet-lock door system each shift by taking each resident with a safety bracelet on to a door with the locking system to see if the bracelet actually locks the door to outside. This is documented for each resident with a safety bracelet on the medication administration record.