ASTA CARE CENTER OF PONTIAC
Facility I.D. Number: 0040436
Date of Survey: 08/13/2002
Incident Report Investigation of August 4, 2002
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.
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.
AN OWNER, LICENSEE, ADMINISTRATOR, EMPLOYEE OR AGENT OF A FACILITY SHALL NOT ABUSE OR NEGLECT A RESIDENT. (Section 2-107 of the Act)
This REQUIREMENT is not met as evidenced by:
Based on observation, interview, and record review the facility failed to prevent one resident (R1), with impaired safety awareness and impaired cognition, out of six sampled residents R1, R2, R3, R4, R5, and R6, (at identified risk for wandering and elopement), from leaving the facility without the facility's knowledge. R1 experienced an unwitnessed fall that resulted in a fractured right arm necessitating surgical repair. R1 also suffered several lacerations to the right hand, right ankle, and right elbow.
Review of R1's clinical record show R1 was admitted to the facility on 5/6/99 and has diagnoses of Alzheimers, Confusion with Sundown syndrome, and Parkinson Disease. Review of R1's most recent minimum data set (MDS) dated 5/23/02, indicate R1 is cognitively impaired and has periods of altered perception or awareness of surroundings. The MDS also shows R1 has a full range of physical motion. Review of a document titled "Initial Wandering Assessment Guide" dated 6/14/01 indicates R1 "wanders" and is in need of having her whereabouts checked every thirty minutes.
Review of R1's most recent care plan dated 6/14/02 show R1 to be independent with ambulation and also indicates R1 is confused. The care plan states, "Resident is sometimes disoriented, as evidenced by residents' statements that she 'is going on home now' or trying to get out the door." Further review of the care plan shows R1 has behaviors that include wandering. The care plan states, "Ms. (R1) wanders @ (at) times related to .....wanting to go home, becomes easily agitated. The care plan also shows R1 "oblivious to safety needs/awareness" and at risk for falls. The care plan states, "(resident) is at risk for falls related to Hx Falls (a history of falls)."
Review of a document titled "Psychiatric Exam" dated 2/06/02, and signed by R1's psychiatrist confirm R1 has short and long term memory loss and impaired judgment. The report states, "Her judgment is impaired; she does not know what to do if there is a fire in a movie theatre."
Record review of a document titled, "Resident Incident Report" dated 8/4/02 at 7:15 P.M. show the resident left the facility on 8/4/02. The report states, "Resident left the facility unattended. Resident brought back to the facility by a family that stated they found her (R1) lying by the curb by the prison. Resident transferred from their van to a w/c (wheelchair). 911 was called.... (right arm) dislocated, alert and responsive."
Review of a nurses note dated 8/5/02 states, "ER at (hospital) called for a report. Res (resident) has a fx (fracture) R (right) humerus [sic]....several lacerations to R (right) hand, R (right) ankle, R (right) elbow".
Record review of a hospital radiology (x-ray) result for R1 dated 8/5/02 show R1 sustained a broken right arm. The report states, "1. Complete mid shaft fracture of the right humerus with one bone with lateral displacement 1 cm overriding."
Record review of an intraoperative (x-ray while surgery is going on) hospital radiology result for R1 dated 8/6/02 show the fracture was realigned during surgery. The report states, "...operative reduction and internal fixation of a mid shaft fracture of the right humerus..."
Review of an activity note dated 7/28/02 confirm the facility was aware of R1's specific elopement behaviors and the need for hands-on redirection for R1. The note states, "Res (resident) very confused (and) determined to leave, took her (R1) with me .... then outside between rain showers to feed fish and check flowers."
Interview with E5, CNA, on 8/8/02 at approximately 2:20 P.M. confirm R1 requires hands-on redirection. E5 states, "I caught her (R1) trying to put the code in one night and redirected her to her room. The nurse had to come and help - I had to hold the door closed while she (R1) tried to get out."
Interview with E4, certified nurses assistant (CNA), on 8/8/02 at approximately 2:00 P.M., confirm the resident was last seen on 8/4/02 at approximately 7:00 P.M.. The CNA states, "I saw (R1) at approximately 7:00 P.M.. She went into her room, got her purse, and told me she was going to the doctor. I tried to redirect her but then I got busy and went to do a (mechanical lift transfer of two other residents). After we finished putting the other two residents in bed, they (other staff) came and got us. (R1) had been found outside on the curb. We have to bring her back to her room often from the front door, especially after supper....."
Observations made on 8/9/02 at approximately 11:00 A.M. confirm the description of the area immediately north and west of the facility, where the resident was reported found by passer-byes. The area between the facility and the location where R1 was reportedly found is approximately two city blocks from the facility, and is described as a residential, blacktop and gravel street, with a speed limit of 20 miles per hour. According to the Facility Administrator, and based on the location where R1 was reportedly found; the resident most probably traveled west from the facility and crossed an intersecting street, also with a posted speed limit of 20 miles per hour. This would be R1's most probable path in order to be found immediately on the west side of the State Prison. The residential street west from the facility toward the prison has no sidewalks and the grass lawns give way to gravel gullies that directly abut the pavement of the street. The outside ambient temperature at a nearby monitoring facility according to Midwestern Climate Center, on August 4, 2002, reached a high temperature of 92 degrees F. and a low of 62 degrees F.
Observation of the facilities entrance and exit doors on 8/8/02 at approximately 10:00 A.M., show 9 alarmed entry and exit doors. All doors leading to the exterior with the exception of the doors (2) leading to the courtyard are alarmed with an audible alarm that sounds at the nurses station and an indicator light that flashes on a board at the nurses station. All exterior doors, including courtyard doors, are also armed with remote audible alarms that are supposed to sound a loud audible alarm at the location when the door is opened. The front door and all other fire exits are also equipped with 15 second delay magnetic locks. The front door has a key pad (with the code posted and visible to all) that is designed to defeat the alarm system when the proper code is entered. This allows visitors and staff to go out the front door without the alarm sounding. All alarms were working at the time of observation, with the exception of the remote alarm at the central wing solarium door; this alarm did not sound when activated. The other alarm on that door, the central alarm system, that sounds and flashes a light at the nurses station was working. Also, there are security cameras in place that monitor, on a screen at the nurses station, all exterior doors and walkways with the exception of the front door. There was no other monitoring system in place at the facility at the time these observations were made.
Observations and interview made on 8/9/02 at approximately 11:00 A.M. confirm all staff are not familiar with the new split screen monitors at the nurses stations and how to determine which door in the facility they are looking at when they view a particular picture on the monitor. Opening the central solarium door activated the alarm at the nurses station. When questioned about which door was opened and whether there appeared a view of that door on the monitor, E6, CNA, could not identify the picture on the monitor that showed the central solarium door.
Record review of R2, R3, R4, R5, and R6 confirm these residents are assessed by the facility and care planned for wandering behaviors and are assessed by the facility at risk for injury due to a risk for leaving the facility without the facility's knowledge.