Facility I.D. Number: 0039859
Date of Survey: 10/27/2003
Past Visit to Annual of 7/2/03, Incident Report Investigation of 10/7/03, Incident Report Investigation of 10/21/03
There shall be evidence of training and habilitation services activities designed to meet the training and habilitation objectives set for every resident.
An appropriate, effective and individualized program that manages residents behaviors shall be developed and implemented for residents with aggressive or self-abusive behavior. Adequate, properly trained and supervised staff shall be available to administer these programs.
Appropriate records shall be maintained for each resident functioning in these programs. These shall show appropriateness of the program for the individual, residents response to the program and any other pertinent observations and shall become a part of the residents record.
Appropriately qualified staff shall be provided in sufficient numbers to meet the training and habilitation needs of the residents. At a minimum, staffing shall be provided as described in Section 350.810(b) of this Part.
These Regulations were not met as evidenced by the following:
A) Based on interview and record verification, the facility failed to ensure safety and welfare for R6 who eloped from the facility and day training with the potential to impact all residents in the facility.
1) Per facility roster, R6 is a 19 year old male who functions at the moderate level of mental retardation with an additional diagnosis of Autism and an adaptive behavioral score of 2 years, 4 months. R6 was admitted to the facility 10/18/02.
Per review of facilitys incident reports, R6 eloped from the residential facility on 9/27/03 and 10/07/03 without staffs knowledge of R6s whereabouts. In addition, R6 also eloped from the day training site on 9/19/03 and 10/21/03 without staff having been aware that he left the building.
Per interview with E3 on 10/22/03 at 3:30 p.m., E3 confirmed that no additional staff had been added to monitor E6 after the above elopements and that 1:1 staff coverage for R6 had not been implemented until 10/21/03.
Per interview with E3 on 10/22/03 at 2:00 p.m., E3 said that he assumed the duties of QMRP (Qualified Mental Retardation Professional) and acting administrator around the first of August (2002). E3 stated that he had prior experience as an administrator in a long term care nursing facility, but had let his license lapse in 1997. E3 also stated that he did not have prior experience in an ICF/MR (intermediate care facility for the mentally retarded).
B) Based on interview and record verification, the facility failed to develop objectives to address the community safety needs for R6.
1) According to the incident report, dated 9/27/03, R6 was noticed missing at approximately 5:50 a.m. and was gone for approximately 20 minutes before staff found R6 and returned to the facility. Per incident report of 10/7/03, R6 eloped from (facility) at 10:10 PM and was gone from facility for approx. 17 minutes.
Per interview with E4, DSP (Director Support Person), on 10/21/03 at 1:40 p.m., E4 stated that she was on duty the evening of 10/7/03 and confirmed that R6 had left the facility without staffs knowledge. E4 said that R6 was later found by road on left before the levee by the river.
In addition, per incident reports, R6 eloped from the day training site on 9/19/03 without staff having been aware
that he left the building.
Per interview with Z1, Assistant QMRP (Qualified Mental Retardation Professional) on 10/22/03 at 9:30 a.m., Z1 stated that when R6 left the building, he crossed the adjacent road, went down the alley and took a bicycle from a neighbors utility shed. At some point, R6 then crossed to the opposite side of the main highway which, per surveyors observation, is heavily traveled by large trucks. According to Z1, R6 stole a soft drink at a convenience store, approximately ¼ mile from the day training site.
Per review of R6s current behavior plan, dated 10/8/03, R6 has demonstrated a history of eloping, defined as
running away from the facility wheeling a bicycle or on foot. The plan states that at R6s prior placement, the grounds were larger and (R6) had places to go to and from with a bike. The plan also states that R6s current residential facility is smaller with more stringent perimeters which has made it harder for (R6) to experience some freedom.
Interviews with both E3, Acting Administrator/QMRP (Qualified Mental Retardation Professional), and E7, Assistant QMRP, on 10/22/03 at 3:30 p.m. confirmed that R6s prior placement consisted of a large campus and R6 sometimes left his living unit and went to different buildings, but R6 was still on the facilitys campus.
According to R6s current ICAP, dated 10/18/02, R6 is unable to stay in an unfenced yard without wandering away , cannot cross nearby residential streets, roads, and unmarked intersections alone and does not respond to common signs such as STOP, DANGER, etc. Per review of R6s current IPP (individual program plan), dated 12/20/03, the Interdisciplinary Team (IDT) determined that R6 cannot access the community alone.
However, per review of the facilitys program book, R6 is currently working only on the following objectives:
Speech/Language-to identify a choice of activity from two pictured items. Personal Living Skills-bathing. Independent Living-attention to task. Behavior-to reduce incidents of elopement.
Per interview with E7 on 10/22/03 at 3:30 p.m., E7 confirmed that the facility has not developed objective(s) to a assist R6 to acquire community safety skills.
C) Based on interview and record verification, the facility failed to document incidents of elopement, or attempted elopement from the facility for R6.
1) Review of doctors progress notes, dated 1/14/03, indicated that R6 is having some problems. He wakes up in the middle of the night and takes off out of the facility in his stocking feet. Physician documentation on 8/6/03 again references R6 wandering at nighttime.
Per review of the facilitys Human Rights Committee/Behavior Program/Rights Review, dated 4/29/03, an ankle bracelet was recommended for R6 and approved by the Committee. The only information on the document states that R6 is on Ambien and with an additional comment that the ankle bracelet would be a rights restriction. The document does not specify what the Ambien is being used for, why the ankle bracelet was recommended, or whether R6 had eloped, or attempted to elope from the facility.
Per review R6s chart, a behavior plan was approved and implemented on 8/26/03 to address R6s History of Eloping, defined as Running away from the facility wheeling a bicycle or on foot. However, surveyor could find no information, such as number of incidents of elopement or attempted elopement in R6s chart.
Per interview with E4, DSP (Director Support Person), on 10/21/03 at 1:40p.m., E4 stated that when she first started working at the facility on 10/28/02, R6 eloped a lot, then the incidents of elopement slowed down for a while, then increased again. E4 said that everyone knew that R6 tried to take off frequently, but is not sure if all the incidents were documented.
Per interview with E7, Assistant QMRP (Qualified Mental Retardation Professional), on 10/22/03 at 2:35p.m. confirmed that the former QMRP (E1) didnt do much documentation. E7 said she couldnt find any information of elopements, or attempted elopements from the time R6 was admitted to the facility on 10/18/02 to the time she assumed the duties of Assistant QMRP in 9/03.
Facility was unable to provide surveyor with documentation pertaining to R6s prior elopements, or attempted elopements at the time of the survey.