Stephenson Nursing Center
Facility I.D. Number: 0004259
Date of Survey: 9/29/03
Incident Report Investigation Of 08/30/03
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.
Personal care shall be provided on a 24-hour, seven 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.
These regulations are not met as evidenced by:
Based on observation, record review, and interviews, the facility failed to supervise R1, a known wanderer with severe Alzheimer's disease by not:
a) Maintaining 1:1 supervision at 8:30 p.m. on 08/30/03.
b) Having an audible alarm system on the exit doors to the outside enclosed yard that can be heard in all locations on the unit.
c)Having staff on the unit to supervise residents both inside the building and out.
d)Having knowledge of R1's elopement from the facility.
On 08/30/03 around 8:45 p.m., R1 walked along a country road (speed limit 55 miles per hour), and was absent from the facility for approximately 1 hour. This was for 1 of 22 residents on the Dementia Unit (R1).
The findings include:
1) The September 2003 Physician Order Sheet (POS) listed R1's diagnosis as Dementia - Alzheimer's. The nursing notes documented that R1 was admitted to the Birchwood unit on 08/25/03. R1 was transferred to the Willow's unit (Dementia unit) on 08/28/03 at 9:40 a.m. for closer supervision due to wandering and confusion.
Review of the nursing notes on 08/28/03 (3:45 p.m.) documented, "Went out and jumped fence. Very agitated and hitting doors." The Incident Report Form of 08/28/03 documented, "Staff observed resident go outside to the Alzheimer's Unit fenced in area and jump fence. Resident was redirected and assisted back in building. About 15 minutes later, staff observed resident go outside into fenced area and staff followed after him. Resident began to jump fence and staff assisted him back down and into building. Resident very fast and staff unable to reach him in time to prevent him from reaching fence."
The Investigative Report of the 09/02/03 incident documented, "On 08/30/03, at 9:20 p.m., (E9) (Evening Supervisor) received a call from the race track (less than 1 mile from the nursing center), asking if we had a resident, (R1). They informed (E9) that a man by this name was at the racetrack, having been observed by a wrecker driver. After (E9) confirmed that this was our resident, the caller stated that the resident would be brought back by the Sheriff's Deputy, that we did not need to come and get him."
2) During an interview on 09/22/03 at 3:15 p.m., E4 (Certified Nurse Aide - CNA) stated, "(E10,CNA) and I were the only 2 aides working on the unit. (E10) left a little before 9:00 p.m. The other unit called and said that (E11, CNA) hadn't had a break yet. She didn't come to the unit until after the South nurse had come down and asked us where (R1) was (9:20 p.m.). I last saw (R1) at 8:30 p.m. I brought him inside and sat him down in the room with the television. There were still 6 people up at that time. Later, (R2) was beginning to remove his clothes and I presumed that (R1) had gone to bed. I was busy with (R2) and (R3). They were in the last two rooms. I could not hear the door bell. (E2, Registered Nurse -RN) was out of the main room at this time." The surveyor asked about staffing on the unit. E4 replied, "Two aides are not enough. For 40 minutes that night there was only 1 aide and the nurse for 22 residents."
During an interview on 09/23/03 at 8:30 a.m., E2 stated, "I was here with 2 aides. We used to frequently only have 2 aides. All three of the men came about the same time (R1, R2 and R3). All of the men were acting up. They are all elopement risks. (E10) left at 8:45 p.m. (R1) went out the door around 8:30 p.m. (it was dark outside). (E4) stayed with him and then he settled down in front of the television. (E4) started putting residents to bed and I was giving out bedtime medications and I noticed around 8:45 p.m. that (R1) was not in front of the television. I saw his door closed and thought that (E10) had put him to bed. Around 9:30 p.m. the South nurse came and asked where (R1) was and said that they found him at the race track. I probably could not hear the door bell when I am in a resident's room. It is just one ding."
During interviews on 09/22/03, E1(Director of Nursing) and E5 (Unit Manager - RN) indicated that prior to 08/30/03 there were usually either 2 or 3 aides on during the evening shift. From observations made during the survey and review of R1, R2, and R3's care plans, they required 1-1 supervision to prevent them from eloping.
During a telephone interview on 09/29/03 at 9:33 a.m., E5 stated, "I don't know if (R1) was on 1-1's on 08/30/03 because I wasn't working that weekend. It is our policy to that one staff person stay with the resident at all times when the resident is on 1-1's." E5 presented evidence that 15 minute checks had not been started on R1 until he returned to the facility at 9:40 p.m. on 08/30/03.
During a telephone interview on 09/23/03 at 9:12 a.m., Z1 (R1's physician), Z1 stated, "(R1) has Severe Alzheimer's Disease that has been coming on gradually over the last 2 years. (R1) is absolutely not safe outside by himself."
3) The facility has designated the Willow's unit for residents with dementia. On 09/22/03 there were 22 residents on the unit. R1, R2 and R3's clinical records were reviewed. R1, R2, and R3 are residents that were all admitted in July and late August 2003. All three residents have made successful attempts to go over the fence in the enclosed yard. The yard is enclosed with a 4 foot cyclone fence with three alarmed gates. They alarm at the nurse's station on the Willow's unit. The door to the unit has an alarm that must be manually turned off. On 08/30/03, the side and back door, both open into the fenced area and have a door bell that dings once when the door is opened and then shuts off.
On 09/22/03 at 11:00 a.m. surveyor went into the bathroom in room 115. E8 (CNA) opened the side door with the door alarm and surveyor was unable to hear the bell.
R1 was observed on 09/22/03 and 09/23/03 constantly moving around. R1 would go outside in the yard and go to the fence and have to be redirected and returned to the unit. Ten minutes later he would go outside and have to be redirected. After 3:00 p.m. on 09/22/03, R1 was even more mobile and needed staff to be with him constantly. R1 walked very fast. R1 was asked his name and R1 stated, "I fell in." On 09/23/03 at 9:30 a.m., E12 (CNA) stated in reference to R1's agility, "(R1) goes across the fence like a deer. He just vaulted over."
4) Weather information documents the temperature for the town on 08/30/03 at 9:00 p.m. to be 62.5 degrees Fahrenheit, 68% humidity, clear skies and no precipitation.
5) Review of the facility's investigation of the elopement documents that R1 went out the door into the enclosed yard and over the fence. The surveyor drove the distance from the nursing home to the race track. It is eight-tenths of a mile. It is thought that R1 crossed through the employee parking lot and followed the driveway to the main road. The speed limit on the stretch of road between the nursing home and the race track is 55 miles per hour. The shoulder on this country road is very narrow. There were street lights on this road. There was a stock car race at the race track with a lot of lights and noise. At 9:00 p.m. the races had already started and the races are generally over by 10:30 - 11:00 p.m.
Between the nursing home and the race track on the left there is a large business parking lot, the County fair grounds, and a creek with water. On the right, R1 would have passed the County Landfill entrance.