Flora Pavilion Nursing Home Center
Facility I.D. Number: 0038760
Date of Survey: 12/18/03
Annual Inspection and Incident Report of 12/03/03
The facility shall provide a Resident Services Director who is assigned responsibility for the coordination and monitoring of the residents overall plan of care. The Director of Nurses or an individual on the professional staff of the facility may fill this assignment to assure that residents' plans of care are individualized, written in terms of short and long range goals, understandable and utilized; their needs are met through appropriate staff interventions and community resources; and residents are involved, whenever possible, in the preparation of their plan of care.
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.
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 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.
Based on record review, observations, and interviews, the facility failed to provide adequate supervision to prevent the elopement of one resident, R6, from the 4 residents assessed at high risk for elopement. R6, who is cognitively impaired, left the facility on the late afternoon of 12/03/03 without staff knowledge.
The findings include:
R6 is a 95 year old resident who was admitted to the facility at 2:40p.m. on 12/3/03. R6 was admitted from a local hospital with the following diagnoses: Cholecystectomy (11/30/03), Hypertension, History of coronary disease with a stent placement 10/03,
History of hysterectomy, Cerebrovascular accident, Seizure disorder, Mild aortic aneurysm and mild confusion. R6's admission assessment 12/3/03 indicated alert to person, some confusion. No formal elopement assessment had been completed at the time of admission and a partially completed Assessment Data Set indicates R6's current cognitive status as moderately impaired with short and long term memory problems. R6 had been appointed with a temporary guardian on 12/1/03 prior to her admission in order to place her in a residential facility.
Upon admission to the facility at 2:40p.m. on 12/3/03 the admission assessment was implemented but not completed by E5 (RN). E5 stated in an interview at the nurses station at 4:30p.m. on 12/17/03 that she added the following after the incident: wanders, unsteady gait and 1 person assist for transfers and ambulation. Interview of E6 (Social Service Director) at approximately 9:30a.m. on 12/17/03 at the North nurses station found she was informed by the hospital staff that R6 had not walked after her surgery of 11/30/03. E6 further stated at that time that R6 was admitted for therapy including ambulation. R6 was admitted to the facility in a wheelchair.
R6's record and a 12/5/03 elopement follow-up report indicated R6 was propelling herself in the hallway at 4:30p.m. asking for the lady who had brought her to the facility. She was also asking to place a call to Z1 at work. According to interview with E4 (Activity Director) in the administrator's office at 10:55a.m. on 12/16/03, R6 was last seen by him at the North hall nurses station at approximately 4:35 to 4:40p.m. E4 indicated R6 was upset about nursing home placement and did not want to stay in the wheelchair or at the facility. E4 indicated he tried to comfort her and continued to work at the nurses station in the charts. E4 indicated when he turned around R6's wheelchair was empty. A nurse's aide in the hallway also noticed the empty chair.
Per the facility records, the staff began an in-house search and a search of the facility grounds. The Administrator and Director of Nursing were notified. The facility search continued on foot and in vehicles to surrounding areas. The facility was notified by the Flora Police Department at approximately 5:30p.m. that a woman had brought R6 to the police department and would be returning R6 to the facility. E2 (DON) indicated during an interview on the afternoon of 12/16/03 in the Administrator's office that the facility had not contacted the police department prior to the police calling the facility.
Interview with Z2 in the doctor's office on 12/16/03 at 10:25a.m. found she was in her home on the corners of 8th and Rider Streets, .8 mile from the facility (per surveyors odometer) on the late afternoon of 12/3/03. Z2 indicated she heard something outside her home and investigated. Z2 asked her stepson to accompany her outside to check. Z2 indicated there was an individual stumbling in the drainage ditch at the corner and she feared it was a drunk person. Z2 stated the individual was wearing a hooded sweatshirt with the hood up and the persons face was not visible. Z2 stated the person stumbled, caught themselves on their hands and then fell on their chest into the stop sign. The individual came out of the ditch and held on to a truck parked there. Z2 found the person was R6 and was familiar with her from her work at a local bank. Z2 assisted R6 to her truck and planned to take her home. Z2 stated R6 was cold and held her hand throughout the ride. R6 commented to Z2 that her chest hurt. Z2 wanted to go home or to Z1's home but indicated she did not have keys. Z2 realized there was a problem and took R6 to the local police station to report the event. Once there R6 wanted to call Z1 at work. Calls were placed but Z1 could not be located. R6 indicated to the police she had come from a home but could not state the correct name. The police and Z2 stated the name of a facility near where she was located but R6 said it was on the other side of town. The police contacted the facility and Z2 returned R6 to the facility at approximately 5:45p.m. Z2 stayed with R6 at the facility upon her return. Z2 said R6 held on to her and she helped her to her room.
Observation of the location where R6 was found was on the corner of Rider and Eighth Street. Rider Street ends at the corner of 8th Street, .8 mile from the facility. The ditch R6 was stumbling in was approximately 2.5 to 3 feet deep with slopes to the street and to Z2's yard. The ditch is gravel covered and has exposed tree roots. There are no sidewalks available for use in this area. A metal post with a stop sign was also at the corner. Z2 indicated it was dark and cool at the time she found R6. The incident report indicated it was 40 degrees Fahrenheit and clear. This weather information was obtained from the Flora water treatment plant per interview with E1 and E2 on the afternoon of 12/17/03.
Upon return to the facility, the records indicated R6 was escorted to her room and a full body assessment was conducted with no negative results. Z2 stated she had made the facility aware of R6's complaint of chest pain. However, there is no documentation or reference to this in R6's record or the incident report. The record indicates that an alarm bracelet was applied to R6 and her picture was taken for the record. All of R6's outer wear was removed from her room. The facility initiated 15 minute visual checks for R6 at this time. A bed alarm was also applied to R6 at this time.
Telephone interview with Z3 on the morning of 12/16/03 at approximately 10:00a.m. indicated that recently R6's mental and physical function had declined and she was no longer able to care for herself. Z3 also indicated that she wanted R6 removed from Z1. Z3 received guardianship of R6 on 12/01/03 to admit R6 to the facility. When asked Z3 indicated she had told the facility that R6 may try to leave. Z3 was unaware of the elopement until R6 was returned to the facility. When asked about R6's ability to ambulate Z3 indicated R6 was ambulating well prior to her recent hospitalization.
Interview with R6 throughout the survey found R6 to be alert to person but not to time and place. Staff and family interview confirm R6's mental and physical condition has declined since admission. R6 could not answer questions regarding her elopement on 12/3/03.
An environmental tour of the facility on 12/15/03 found all door alarms in working order when tested. The facility's front door is alarmed with a chime alarm. Interview with evening staff indicated that the front door chimes even after the front office staff leave for the day. During the daily status meeting of 12/17/03 E1, E2 and E3 (corporate representative) stated the front door alarm was changed to instant alarm when the evening supervisor leaves for the day. They stated this time varies .
A second interview with Z3 on the afternoon of 12/17/03 at 2:00p.m. in the doctor's office found that Z4 had worked with Z3 to obtain guardianship of R6, due to R6's decline in mental health and inability to make appropriate choices. Z3 indicated she did not feel R6 was safe to be negotiating outside the facility alone on the evening of 12/3/03. Z3 was never informed of the location where R6 was found during her elopement.
This facility is located at 701 Shadwell Avenue, Flora, approximately 1/4 of a mile from State Route 45. There are no sidewalks on any of the local streets including those between the location of the facility and where R6 was found. R6 would have crossed 2 main North/South streets leading to the town's business area.