Washington Heights Nursing Home
Facility I.D. Number: 0042044
Date of Survey: 07/24/2003
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.
Personal care shall be provided on a 24-hour, 7-day-a-week basis.
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.
AN OWNER, LICENSEE, ADMINISTRATOR, EMPLOYEE OR AGENT OF A FACILITY SHALL NOT ABUSE OR NEGLECT A RESIDENT. (Section 2-107 of the Act)
This REQUIREMENT is not met as evidenced by:
Based on observation, interviews of staff, family and residents and records and policy review, the facility failed to supervise and prevent one resident (R1) from going through the West exit stairs of the third floor on July 21, 2003. R1was found at 8:45 P.M. after falling down a flight of stairs while in a wheelchair. The west exit door alarm was off at the time. R1 suffered scrapes, bruises and severe swelling to her entire face and scalp. Resident was sent to the hospital.
R1 is an 83-year-old resident with dementia with psychosis, congestive heart failure, hypertension, transient ischemic attacks. She was admitted July 22, 2001. The most recent care plans of June 19, 2003 identify R1 as verbally abusive, wandering into other resident rooms and rummaging. Care Plan also indicates that this resident should have a soft belt restraint when up in a wheelchair, release every two hours. Minimum Data Set identifies R1 as confused, wandering, and needing constant redirection.
On July 21, 2003, R1 was last observed coming out of the dining room/activity at 7:05P.M. E3 (LPN and Supervisor for that day covering the 3rd floor) was interviewed and confirmed that the last time R1 was seen was at 7:05P.M... The Incident Report states that R1 was discovered by Z1(security guard) at approximately 8:45P.M.. Z1 was interviewed and stated that he starts his rounds at 8P.M. and makes rounds on the first two floors, then checks the stairs north side then proceeds to the third floor. From the north wing third floor he proceeded to the west wing stairs. Z1 told the surveyor that at the west door, he heard no alarm going off. Z1 pushed the buttons on the access panel to go through the door so it would not sound. When Z1 opened the door, he saw R1 on the middle part of the landing which is concrete with R1's head facing the wall and calling for help. The wheelchair was found upside down next to the resident. Z1 backed out of the door and went to look for a nurse. Z1 found E6 (LPN nurse) at the nursing station. Z1 discovered the alarm panel turned off at the time for the west door. Z1 asked E6 why was the alarm turned off? E6 instructed Z1 to call 911 and call E3.
E6 stated that she was in the nursing station watching the elevators and another resident who was wandering. Z1 approached her to inform her that a resident had fallen in the stairwell. E6 looked at the door alarm panel behind her and discovered that the light for the west wing door was turned off.
E6 did this because she had heard no alarm to indicate that the door had been opened. E6 stated that she went to the resident and she was joined by E4 (CNA), E8 (LPN) and E9 (LPN). Together they put the resident back into the wheelchair and carried R1 sitting in the wheelchair up to the floor and into her room. R1 was moved without being stabilized and assessed for injuries (even with the obvious trauma from a fall with obvious injuries to the head). The paramedics then came and treated the resident in the room before transferring out to the emergency room. E6 stated that resident was conscious asking for help and wanted to be put back into her wheelchair so the full assessment was done in the room. E6 identified bleeding and abrasions on left forehead and applied a pressure dressing.
Per interview of Z1 and E6 confirmed that they did not see a seatbelt attached to the wheelchair immediately after the fall. They also denied seeing soft belt during transfer of the resident back up to her bed. R1 was observed up in a chair on July 23, 2003, in the dining room with no soft belt applied.
E4 (CNA) was interviewed and stated that she was on the north wing helping residents and did not hear any alarm. E4 did not supervise the west section because she thought the CNA in charge of that section was doing it and was not at dinner.
E3 interviewed and stated that she was covering the third floor because a nurse called in. E3 denied seeing R1 prior to the fall. E3 was called off the floor at 7:45P.M. to the second floor and did not let E6 know she was called off the floor. Surveyor also found out through an interview with E2 that of the four CNAs on the floor, three went to dinner at approximately 8P.M..
On July 22, 2003 at 10:00A.M., tour of facility was made by surveyor to observe alarmed doors with E10 (Ast. Director of Nursing). The west door alarm exit was working but the sound was weak and almost inaudible at the nurses station. The north door emitted a strong beeping sound at the nurses station panel indicating the exit door had been opened. This sound did not occur with the west wing door. All the exit doors on the 2nd and 3rd floors are alarmed and should sound both at the door and at the nurses station. The staff has to go to the door with a key to turn off the alarm and reset it. Surveyor reviewed alarm check sheets with E11 who stated that the alarm on that door had been working by indicating it was "OK" on the sheet for July 21, 2003, the day of the accident and then on July 22, 2003 after he heard about R1's fall. The surveyor had tested this alarm on July 22, 2003 after reviewing the alarm sheet and found that it was not working as indicated on the sheet. The alarm was checked again on July 23, 2003 and still was not working properly on the nursing station panel.
Because of the facility layout and staffing, the beeping at the nursing station is important in order to alert staff on other parts of the floor to respond. The sound at the door could not be heard on the other wings.