Facility I.D. Number: 0038653
Date of Survey: 09/16/2003
Incident Report Investigation of August 5, 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.
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.
This REQUIREMENT is not met as evidenced by:
Based on observation, record review, staff and resident interview the facility failed to supervise a confused resident (R1) who wanders by:
The findings include:
1) R1 was admitted to the facility on 6/24/03 with diagnosis of Dementia according to R1's face sheet. R1's Physician Order Sheet (POS) dated 9/1/03 through 9/30/03 documents diagnoses of Altered mental status and Alzheimer's Dementia with agitation. R1's assessment dated 7/7/03 assessed her as having moderately impaired cognitive skills for daily decision making, short and long-term memory problems, being unable to recall current season, location of room, or that she is in a nursing home, and being was identified as a wanderer.
2) R1's comprehensive plan of care dated 7/7/03 under physical and psycho social needs documents "... resident is a wanderer and at times tries to leave the building; the resident demonstrates movement behavior that may be interpreted as wandering, pacing or roaming related to diagnosis of Alzheimer's disease, and problems understanding immediate environment. Symptoms are manifested by attempting to leave the facility without a responsible escort, the resident is new admission and not familiar with her environment ...resident is very confused and needs frequent redirection ...". The approaches include "Provide resident with plenty of group/items to keep her (from) attempting to leave facility." Since admission R1 has had an approach to use electronic monitoring device to notify staff of any attempts to elope from facility.
3) A review of R1's nurses' notes documents that R1 had at least thirteen attempts to elope from the facility between 6/24/03 and 7/30/03. The nurses notes further documents that R1 would pack her clothes and would attempt to leave the facility. The nurses notes dated 8/5/03 - 7:15a.m. documents "Resident left the building, and got off the grounds, she was returned to the building by staff member. Resident was not harmed. Body check done. No injury noted. Blood pressure 130/66, temperature 98, pulse 74, respiration 20."
4a) Physician's progress note dated 7/3/03 "The patient is very anxious and wanting to come out of the facility ... will continue current management and watch closely ..."
b) Psychiatric evaluation dated 7/12/03 documents "... Current symptoms: confusion, wandering, periods of agitation, wants to go home - trying to leave the facility, difficult to redirect, increased agitation and paranoid." The evaluation further documents that R1 is oriented to self, disoriented to place and time; R1 has impaired short and long-term memory; R1 has impaired judgment.
c) A review of R1's Assessment of wandering behavior dated 6/26/03 documents "Diagnosis: Dementia; Character of wandering behavior: wanders about the floor, attempts to go off floor, looking for something/something, unaware of safety concerns, attempts to leave building , looking for exit, trying to go home; ... Potential causes: elopement - leaving facility grounds; ... Possible environment risk factors: busy highway in front of facility ..."
d) A review of R1's Cognitive Resident Assessment Protocol (RAP) dated 7/7/03 documents "... Resident has severely impaired cognitive abilities related to Alzheimer's disease. Resident has short-term and long-term memory loss with impaired decision making. ... She has periods of altered perception where she often thinks she is elsewhere or believes her son is her husband. Resident also has periods of restlessness, and frequently paces up and down hallways ..."
e) A review of R1's assessment dated 7/7/03 documents "... Resident has diagnosis of Alzheimer's disease. Resident does have short-term and long-term memory loss ... Resident does display restless behavior as she will pace/wander through out the building ... Resident also at times will think she is some where else ..."
f) The facility's investigation report dated 8/11/03 and signed by E3 (DON) documents that E3 was informed by E5 (the night nurse) on 8/5/03 between 7 and 7:30a.m. that R1 had eloped off the facility grounds. The report further documents "Nurses stated that at this time of day they are passing medications and the aides are in resident's rooms getting people up for the day."
5a) E5 was interviewed on 9/3/03 at 1:46 p.m.. E5 stated that she last saw R1 at 4:00a.m.. E5 stated that she heard the door alarm after 5:30a.m. and when she reached the front door, the other nurse (E10) was already at the door looking out and that they did not did not see anyone. E5 also stated that she opened the front door and looked around but did not walk the grounds. E5 also stated that she did not do the head count, as she was caught up with R2's fall and the medication pass. E5 further stated that E4 (Rehab CNA) brought R1 back at around 7:00a.m.. E5 also stated that she was unaware that R1 was missing.
b) E10 (night nurse) was interviewed on 9/3/03 at 3:00p.m.. E10 stated that around 6:00 or 6:30a.m. she heard the front door alarm going off and she went to the door and looked outside but did not check the
outside of the building. E10 also stated it was still relatively dark and the sun was not up and she did a headcount of residents residing in the 100 and 200 wing. E10 stated that she was not aware that R1 was missing.
c) Z4 from national weather service was interviewed on 9/16/03 at 8:40a.m.. Z4 stated that the sunrise on 8/5/03 was at 5:53a.m..
d) E6 Certified Nurses' Assistant (CNA), E7 (CNA), and E8 (CNA) who worked on 8/5/03 at the time of R1's elopement were interviewed on 9/3/03 between 3:20p.m. and 3:53 p.m.. They stated that they did not hear the door alarm and were not aware that R1 was missing from the facility. E7, who worked 300/400 wing stated that she saw R1 at around 3:30a.m. during the rounds.
e) E4 (Morning CNA) was interviewed on 9/3/03 at 12:39p.m.. E4 stated that at around 7:00a.m. on 8/5/03 when she was coming to work she saw R1 standing at the corner of a major intersection adjacent to the facility. E4 stated that she stopped her car and asked R1 what she was doing, R1 stated to E4 "Honey, I have to go to work". E4 stated to R1 "I will take you to work". R1 then got into E4's car and was brought back to the facility.
6) On 9/4/03 at 12:51p.m. R1 was observed at another facility. R1 was interviewed. R1 was oriented to self, she was disoriented to time and place. R1 was wearing an electronic monitoring device on her right wrist and she resides in a secured unit. During the interview R1 stated that three weeks ago she went to McDonald's with her husband and that her husband was hurt at the job. She stated that she had three kids. An interview with Z3 on 9/4/03 at 1:12p.m. indicated that R1's husband passed away in 1965 and that she has only one child. Z3 also stated that "(R1) is very, very confused and I have seen her up dressed and walking at 3:00a.m.." Z3 stated that R1 is oriented to person at times and disoriented to place and time and that the facility has an electronic monitoring system, R1 is in a secured unit.
7a) Z2 was interviewed on 9/3/03 at 11:59a.m.. Z2 stated that R1 should not be outside unsupervised. When asked about R1's ability regarding recognizing safety hazards, Z2 stated "resident could recognize danger due to the basic instinct, but I would not trust her."
b) E3 and E2 (Assistant Administrator) were interviewed on 9/3/03 between 9:21a.m. and 9:31a.m.. Both stated that R1 was admitted to the facility on 6/24/03 because R1's son realized that R1 needed close supervision. R1 would take the train to the city but would get lost coming home. E2 stated that R1 was disoriented to time and place. E2 stated that R1 could not recognize the facility staff. Both stated that R1 would go to the door wanting to go home, or looking for her son or the dog. Both also stated that R1 was wearing the electronic monitoring device. E3 also stated that E5 told her that the front door alarm went off and that E5 and E10 looked out of the front door and they did not see anybody.
c) E4 when interviewed on 9/3/03 at 12:39p.m. stated that R1 wandered a lot, she was little confused, would say "I have to go to work, I have to find the baby".
d) E14 (Morning Nurse), E2, E12 (Morning CNA), and E3 were interviewed on 9/3/03 between 9:21a.m. and 1:40 p.m.. All stated that R1 could not recognize safety hazards.
8) A review of facility statement regarding electronic monitoring device documents "Any resident who display a need for a electronic monitoring device - i.e., makes attempts to leave the facility unattended and is confused and not aware of safety needs - will have a physician order obtained for the use of an electronic monitoring device ...". When interviewed on 9/4/03 at 8:30a.m., E2 stated that the electronic monitoring device is applied if the family or the hospital indicates that resident has wandering potential, if the resident wanders towards the front door and is confused and has diagnosis of Dementia.
9) The policy and procedure for Resident elopement was reviewed. It documents the following:
" ... WHEN A DOOR ALARM SOUNDS STAFF SHALL IMMEDIATELY RESPOND TO AND DETERMINE THE CAUSE OF THE ALARM.
10a) The Physician Order Sheet (POS) of R1, R6, and R8 was reviewed. R1, R6, R8 were assessed by the facility as wanderers. The POS of R1, R6, and R8 indicated no Physician's order for the use of electronic monitoring device, this was confirmed by E1 (Administrator) on 9/11/03 between 9:20 a.m. and 1:30 p.m..
b) A review of facility statement regarding electronic monitoring device documents "Any resident who display a need for a electronic monitoring device - i.e., makes attempts to leave the facility unattended and is confused and not aware of safety needs - will have a physician order obtained for the use of a electronic monitoring device ..."
11a) The red folder which contained the pictures of all identified wanderers at the reception desk was reviewed. The pictures of R7, R10, and R11 were missing and this was confirmed by E2 on 9/3/03 at
1:35p.m.. An interview with E3 on 9/3/03 at 2:05p.m. indicated that an electronic monitoring device was applied to R7 on 8/17/03, R10 on 8/28/03, and R11 on 3/5/02.
b) A review of the facility's policy on wandering- high risk documents "... a picture will be taken and ... given to the receptionist ... "