ALDEN PARK STRATHMOOR
Facility I.D. Number: 0044909
Date of Survey: 12/09/02
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.
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.
The DON shall supervise and oversee the nursing services of the facility, including:
Developing an up-to-date resident care plan for each resident based on the residents comprehensive assessment, individual needs and goals to be accomplished, physicians orders, and personal care and nursing needs. Personnel representing other services such as nursing, activities, dietary, and such other modalities as are ordered by the physician shall be involved in the preparation of the resident care plan. The plan shall be in writing and shall be reviewed and modified in keeping with the care needed as indicated by the residents condition. The plan shall be reviewed at least every three months.
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 requirements are not met as evidenced by:
Based on observation record review and interview the facility failed to:
a) Prevent R1 from eloping from a secured unit.
b) Prevent R1 from being outside for approximately 1 hour when the temperature was 32 degrees Fahrenheit with a wind chill factor of 24 degrees.
c) Have a specific monitoring plan for R1 and R2 to prevent elopement from a secured unit.
d)Have a plan to monitor residents on the secured unit when staff turns the alarm off to the back door of D wing during their breaks.
The examples include:
1) Review of R1's cumulative dagnosis sheet since admission on 08/03/98 documents the following diagnoses, Dementia and Memory Loss.
R1's care plan dated 06/17/02 documents, "R1 attempts to leave the unit (secured Alzheimer Unit) and does open alarmed doors."
Review of R1's Minimum Data Set of 09/12/02 documents R1 as having long and short term memory problems. R1 also has severely impaired cognitive skills for daily decision making.
Review of the facility incident report dated 12/01/02 documents, "R1 was found in a wheelchair at the end of the north gate. R1's hand and feet were dark pink and cold to touch. R1's oral temperature was 95.7 degrees."
The National Weather Service recorded the temperature for 12/01/02 between 8:00 p.m. to 9:00 p.m. as 32 degrees Fahrenheit with a wind chill factor of 24 degrees Fahrenheit.
E8 (CNA) was interviewed by telephone on 12/03/02 at 3:45 p.m. E8 stated," On 12/01/02 at approximately 8:00 p.m. a code yellow (missing resident) was announced on the intercom. E12 (LPN) and I ran over to D Unit (Alzheimer Unit). E9 (CNA) commented that she had not seen R1 since 5:30 p.m. E12 and I went to the D unit and checked on the unit. R1 was not found. We went out the back door of the D unit and no alarm sounded. The alarm system was off. R1was out in the enclosed (fenced) yard. R1 was wearing a thin house dress no shoes no socks. E1 (Asst. Admin) took statements from everyone but me (E8) and I found her." (There is a discrepancy in the description of what R1 was wearing between E8 and E12.)
E12 was interviewed by telephone on 12/04/02 at 1:45 p.m. E12 stated, "E2 (CNA) and E9 came and said to call a code yellow. R1 was missing. After that I went to D wing with E2. R1 wasn't there. I went through the alarmed door to the fenced area of D Wing. I did not hear the alarm sound. R1 was all the way by the gate (approximately 150 feet from the door). I brought R1 back inside. She was wearing a jogging suit, blue slippers (thin terry cloth) with rubber soles. R1 had pulled her pants over her feet and shirt sleeves over her hands. R1 had taken her slippers off her feet and put them on her hands. E1 did not ask me to write a statement."
E9 (CNA) was interviewed on 12/04/02 at 0950. E9 stated, "I saw R1 in the dining room at dinner between 5:30 p.m. to 6:00 p.m. When E2 came in from outside ( E2 was outside the D wing back door) after her cigarette break at 6:30 p.m. R1was still sitting at the same table. I (E9) noticed R1 was gone at 7:30 p.m. when I was counting people to go to bed. I asked E11 (LPN)
and E2 if they had seen her. We (E8, E2, and E11) started looking for R1. No one had heard the alarm go off."
E11 was interviewed on 12/04/02 at 9:15 a.m. E11 stated, " E12 found R1 at the north end of the gate in the fenced yard. I did not hear the alarm go off that night." E11 was interviewed again on 12/04/02 at 1:00 p.m. E11 stated. " No I didn't talk with Z2 (MD on call). A triage nurse called back. I don't know her name. "
Review of the nurses note dated 12/01/02 8:30 p.m documents, "R1 found at the end of the north gate. Attempts to leave unit. Slippers on hands and feet. Night care given and put to bed. MD and family notified"
Z1 was interviewed on 12/04/02 at 10:25 a.m. Z1 stated, "R1 has no safety skills. I am concerned about the length of time R1 was outside. I'm also concerned that she wasn't sent to emergency room for evaluation on 12/01/02. Our pager logs reveal there weren't any calls for any doctor from this nursing home from 2:00 p.m. to 11:00 p.m. on Sunday 12/01/02."
A review of R1's behavior monitoring sheets for November and December of 2002 do not address wandering or attempting to leave the secured unit.
During a body check on 12/04/02 at 1:10 p.m. R1's left foot was observed to be reddened with a dark area at the arch of the foot. The toes of the left foot were bright red and edematous.
Review of the emergency room transfer sheet dated 12/02/02 documents, "Left foot, cold exposure yesterday."