Hearthstone Manor Facility I.D. Number: 0027664 Date of Survey: 09/15/03 Incident Report Investigation of 8/30/03 "A" VIOLATION(S): Have each exterior door equipped with a signal that will alert personnel in the area if a resident leaves the building. Any exterior door that is supervised during certain periods during the day or night 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. Based on observation, interview and record review, the facility failed to 1) comprehensively assess R 19 for elopement risk after attempting to leave the building on 2 separate occasions 2) supervise the front entrance door on 8/30/03 allowing R 19 to leave the facility without staff knowledge 3) immediately reassess R 19 after readmission to the facility and other sheltered care residents for elopement risk and inservice all staff regarding R 19's elopement risk/ front door monitoring. The findings include: Review of R 19's Incident/Accident Report, dated 8/30/03, notes that at 2:15 p.m., the facility received a call from the police stating that they had found R 19 and he had a cut on his forehead. Review of the facility's investigation, presented on 9/9/03, noted that interview with E 10 (staff nurse on R 19's unit) showed that E 10 did not know R 19 was gone until she received a call from the police department. "No staff recalls seeing (R 19) leave building." Several staff were interviewed and the last time R 19 was seen was noted at lunchtime, eating his meal at 12 noon. The distance from the facility entrance door to the location R 19 was found was approximately 1.3 miles. R 19 crossed 3 streets and multiple business driveways. The temperature that day was approximately 84 degrees. R 19 was admitted to the sheltered unit at facility on 7/1/02 with diagnoses including Alzheimer's Disease, Atrial Fibrillation, anxiety and agitation, per Profile Face Sheet dated 1/02 and POS (physician order sheet) dated August 2003. Review of R 19's last behavioral/psychological assessment, dated 8/15/03, notes R 19 as continuing to "experience memory problems and cognitive confusion". Review of R 19's Mood Behavior Tracking sheets from 3/03 to 8/03 notes include behaviors of wandering, confusion and being anxious. Observation of R 19, on 9/8/03 at 11:30 a.m., noted a well dressed elderly resident on the nursing care unit, electronic monitoring device intact. R 19 was observed playing ball toss with both hands with no visible problems with his fingers with healed abrasions noted to his head and hands. Interview with R 19 noted a pleasant but confused resident. Review of Social Services Progress Notes, dated 4/29/03, notes R 19 disoriented and "left building." R 19 was redirected. On 7/29/03, R 19 was noted "left building after supper." E 4 (Activity Director) was called and she "intercepted" him and brought him "back in." On 8/30/03, R 19 was noted as "eloped. Found by woman on Birch Street. He was in her yard. Had fallen and had head wound, fractured finger" and was taken to the emergency room. Review of a hospital x-ray report, dated 8/30/03, confirmed R 19 did not fracture his finger. Interviews with E 4 (Director of Activities)and E 7 (Social Services Director), on 9/8/03 at 2:25 p.m., showed that R 19 was allowed to the leave the facility but staff would watch him once he would go out the front door to make sure he came back. "Usually gives an indication of wanting to leave by pacing, putting his jacket on and sitting by the entrance. E 19 (Receptionist), per interview on 9/10/03 at 9:45 a.m., confirmed that R 19, prior to the 8/30/03 incident, was able to go out of the facility and for walks or sit on the bench and did not have to sign out or be "watched" by staff. E 19 stated that residents residing on the sheltered unit were allowed to leave the facility without staff. E 3 (ADON), per interview on 9/10/03 at 2:48 p.m., disclosed that R 19 was wearing his jacket on 8/30/03 and often did so during lunch because he complained of being cold. Interview with E 9 (Receptionist) per facility on 9/2/03, noted that a visitor activated a door alarm at the top of the stairs. "She left her desk to deactivate the alarm. Resident (R 19) was standing by group of visitors before she left the desk and she didn't see him after that." E 9, per interview on 9/9/03 at 10:10 a.m., disclosed that at approximately 12:30 p.m. on 8/30/03, residents were starting to come out of the lunch room. An alarm was set off in lounge area. E 9 stated she had a set of keys so she ran around the corner and into the stairwell to shut the alarm. The last time she saw R 19 was in the lunch room. E 9 stated she went to her desk and about 1/2 hour later she had to use the bathroom. E 9 confirmed that she was allowed to leave the reception desk as necessary. She looked down the hallways, nobody was around so she quickly went to the bathroom. At approximately 2:15 p.m., she received a call from the police regarding R 19 being found and transferred the call to E 10. E 9 stated that she was informed by E 8 (Director of Admissions) months prior that R 19 would try and go out to go to his house. E 9 stated that she would normally have someone go out with R 19, even to sit with him. E 9 informed surveyor that the front door is not alarmed and is to be supervised 24 hours a day by the receptionist. E 9 stated that residents on the sheltered unit are allowed to leave the facility premises but required to sign out. E 9 confirmed that R 19 did not sign out to leave the facility on 8/30/03. Interview with E 8 (Admissions Director), on 9/10/03 at 2:00 p.m., noted that she was unsure if R19 would leave the building and was not aware of R 19 having any attempts of leaving the building prior to his elopement. R 19 stated that once someone does activate the stairwell alarm, it would take approximately 2 minutes for the receptionist to deactivate the alarm. Review of a facility's Security and Elopement Policy Update for the receptionists , dated 4/23/03 and received on 9/9/03 by E 1, states that "your physical presence at the desk is essential in supervising the folks entering and leaving. Please remember to only leave the desk area if necessary as you are so needed to monitor the security beep." Review of the facility's receptionist policy, dated 3/03, states that "keeps an eye on the monitors to see who is coming and going, and generally watches building procedures." Review of a Shelter Care Assessment, dated 9/4/03, assessed R 19 to have a memory deficit, not easily redirected, moderate impairment with cognition/decision making-"unable, noticed more confusion and disoriented. Gets agitated when checked often. Concerned for resident's safety, may attempt to leave." R 19 was temporarily transferred to nursing care with an electronic monitoring device, 1/2 hour checks and a plan for permanent placement to a secured unit, per interview with E 1(Administrator) and E 2 (DON) on 9/8/03. |