ASPENWOOD HEALTH CARE CENTER
Facility I.D. Number: 0043737
Date of Survey:12/13/2002
AN OWNER, LICENSEE, ADMINISTRATOR, EMPLOYER OR AGENT OF A FACILITY SHALL NOT ABUSE OR NEGLECT A RESIDENT.
All treatments and procedures shall be administered as ordered by the physician.
The facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psycho social 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.
The regulations are not met as evidenced by:
Based on record review, interviews and observations, the facility staff failed to provide supervision to prevent R15 from leaving the facility unnoticed. The facility staff failed to respond to the door alarm allowing R15 to exit the building without staff knowledge.
1. R15 was admitted to this facility on 05/04/99. The current physician's order sheet found on R15's medical record lists diagnoses of Dementia, Alzheimer's Disease, Hypotension, Congestive Heart Failure and Osteoporosis.
According to the resident's current MDS (Minimum Data Set) dated 11/07/02, R15 has short and long term memory loss, and is disoriented to the season and nursing home placement. R15's mentation varies over the period of the day. R15 needs limited assist for most ADL's (Activities of Daily Living) and wheels herself about in her wheelchair. An "Elopement Risk Assessment" dated 11/08/02 identifies R15 to be at risk due to diagnosis, the use of mood altering medication, a history of past attempts to leave the facility, and her current behavior of wandering. R15's care plan dated 11/21/02 identifies R15 to be "at risk for falls" and that she "wanders out exit door."
During random observations of R15 on 12/04/02 and 12/06/02, R15 wandered independently in her wheelchair throughout the facility. During interviews with R15 on 12/06/02 at 9:45 A.M., and again at
11:30 A.M., R15 could not answer questions appropriately, and could not verbalize any knowledge of safety awareness.
R15's medical record has a physician's order dated 11/13/02 that states "Arrange for transfer to locked Alzheimer's unit." E19 (Social Services)and E18 (Social Services) interviewed on 12/04/02 at 10:40 A.M., stated that they were aware of the order and had talked about it in their team meetings, but had not acted on the order until today (12/04/02). Both stated that they do not have the authority to act on the physician's order, and that the directive would have to come from E1 (Administrator) or E2 (Director of Nurses).
E1 and E2 were interviewed 12/04/02 at 11:45 A.M. and stated that they as a group didn't think R15 needed to leave, stating, "We thought that we could handle her." E2 stated that Z5 (R15's physician) was not informed that the staff had decided to disregard his order to transfer R15 to a locked unit.
Z5 was contacted on 12/06/02 at 10 A.M.. Z5 verified that he had been told of the incident on 12/01/02, but that he had not been informed of the staff's decision to keep R15 at the facility even though he had written an order for R15 to be placed in a locked Alzheimer's unit. Z5 stated that he wrote the order because of R15's agitation and wandering. He did not feel that the facility had the staff to deal with her and that they were unable to assure her safety. Z5 stated, "They just don't have the manpower to deal with that kind of resident." Z5 also stated that he needs to be informed if the facility is not going to carry out his orders for his residents. Z5 stated that the staff should have told him of their decision not to transfer R15.
Z4 (neighbor to the facility) was interviewed on 12/05/02 at 9 P.M.. Z4 stated that on 12/01/02 at around
9:30 A.M., from the window of his home, Z4 saw R15 in the field beyond the trees behind the nursing home, approximately 50 yards from the facility. R15 was lying on the ground with wheelchair overturned. Z4 placed R15 back into the wheelchair, placed a blanket around her and wheeled her backwards to the facility. Z4 stated that due to the rough terrain he had to pull the wheelchair backwards through the field. Z4 stated that R15 was cold and shivering. It took him about 5 minutes from the time he saw the resident from his window to get her into her chair and take her back to the facility. As Z4 approached the building R15 began to scream that she did not want to go back to the facility. Z4 knocked on the sliding door window next to the nurses station, and E15 (Staff Nurse) then came out and retrieved the resident. Once inside the resident stated "I'm cold. My hands are cold. Will they ever get warm again?"
R15 is identified as a wanderer and according to E2 (Director of Nurses) interviewed on 12/04/02, staff are to record R15's location, with their initials, every 30 minutes on the facility's "Resident Hourly Check" form. Records show no entries for 12/01/02, 12/02/02, and 12/03/02 between 6 A.M. and 10 P.M.
There were four CNA's (certified nurse aides) E17, E5, E6, and E16 that were working at the time of the incident on the morning of 12/01/02. E17 was interviewed on 12/04/02 at 11:55 A.M.. E5 was interviewed on 12/04/02 at 11:45 A.M..
E16 was interviewed on 12/06/02 at 9 A.M., and E6 was interviewed on 12/06/02 at 2:10 P.M.. All stated that they did not know that R15 had left the building until after she had returned. All stated that they did not hear the alarm and did not check the door. E5, E6, and E16 all stated that they could not say when they last saw R15 prior to her elopement. E17 stated that she saw R15 around 9:00-9:10 A.M., after breakfast, "hanging around the nurses station."
According to E2, interviewed on 12/04/02, the nurses are responsible for silencing and resetting the door alarms. E17 stated that she has seen E15 turn off the alarm without checking the door or determining the cause for it sounding. E15, LPN (Licensed Practical Nurse) was the only nurse working on 12/01/02, at the time of the incident. She stated that she did not know R15 had left the building, until she saw her outside the patio door with Z4. E15 stated that she does not always check the doors when an alarm goes off, as she counts on the aides to do that. E15 stated that when the alarm went off that morning , she did not personally check the door that R15 used to leave the building. E15 stated that the alarms were being set off frequently that morning.
E5 states that when she checks a door alarm, she looks out the window but does not go outside. E6 stated that she looks down the hallway to see if there are any residents in the area, but does not go to the door when checking for the door alarm.
According to the Midwestern Regional Climate Center, the temperature outside at 10 A.M. on 12/01/02 was 28 degrees F (Farenheit), with winds at 16 miles per hour and a wind chill of 16.5 degrees F. Z4 and E15 both state that R15 was wearing only a sweatshirt, jogging pants and shoes, and when returned to the facility R15's hands and face were cold. According to E15, R15's vital signs were acceptable. Nurses notes dated 12/01/02 indicate that R15's vital signs were 97.8 Axillary temperature, 110/62 blood pressure, 86 heart rate, 25 respirations when R15 as brought back into the facility at 9:50 A.M..
This facility is located in a residential area. There are fields between the houses and the facility on three sides of the building, and a field between the facility and a service road on the fourth side. Just beyond the service road is a busy four lane highway with a posted speed limit of 55 miles per hour. Although there is a high fence, the highway is accessible within a mile of the facility. The fields are grassy with various slopes and inclines and uneven terrain.
Facility policy at the time that R15 left the building without staff knowledge states that "When a door alarm does sound, the alarm is not to be silenced until the reason for the activation of the alarm is determined. Staff must: *Go directly to the door where the alarm is sounding. *Check outside the door, do not assume anything, find the cause of the alarm sounding. If no residents or visitors are found initiate a search of the immediate area. Account for all facility residents immediately." The facility staff did not follow their own protocol on 12/01/02 when R15 left the building without staff knowledge.
The facility investigation of the incident dated 12/06/02, and signed by E1 (Administrator) states that the opinion of the facility is that the door alarm sounded, and that the staff checked the hallway and then silenced the alarm.