CONCORD EXTENDED CARE
Facility I.D. Number: 0026914
Date of Survey: 12/02/02
Incident Report Investigation of 11/05/02
A VIOLATION (S):
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.
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.
This REQUIREMENT is not met met as evidenced by:
Based on record review, observations, and staff interviews, the facility failed to provide adequate supervision to one resident (R1) with the diagnosis of Dementia (Alzheimer's type). R1 has made frequent attempts to leave the facility and has been identified by the facility as an elopement risk. R1 eloped on 11/5/02 while wearing an electronic monitoring device and was found approximately 1/2 a mile from the facility by a staff member who was leaving a neighboring long term care facility.
R1 is a 72 year old male with diagnoses that include Dementia (Alzheimer's type), Parkinsons disease, Hypertension, Glaucoma, Anemia and Schizoaffective disorder. Review of the clinical record revealed a physicians order dated 4/25/02: "May wear [electronic monitoring device]", and 5/26/02: "Alarm in chair and while in bed."
Further review of the clinical record revealed that R1 has a history of attempting to leave the facility. Dates include: 9/2/02 at 4:00p.m., "Resident seen attempting to leave facility. Alert but confused. Residents [electronic monitoring device] applied to leg with residents cooperation." 10/2/02 at 5:00p.m., "Resident combative, anxious, trying to leave facility, Lorazepam given as ordered." 10/6/02 at 2:00p.m., "Resident up ad lib (at liberty) with steady gait, attempted to elope times one this shift." 11/3/02 at 12:40p.m., "Observed patient on the ground in the courtyard with abrasion of forehead and right knee." On 11/5/02, R1 eloped from the facility sometime after 4:45p.m.
Interviews of E2, E3, E6, E7, E9 and E10 (CNA'S-certified nurses aides) E5 (DON-director of nursing), E8 (LPN-licensed practical nurse) on 11/25/02 and 11/26/02 revealed to the surveyor that R1 was alert but confused, anxious, and had to be watched frequently and monitored every two hours because of multiple attempts to leave the facility. R1 wore an electronic monitoring device to let staff know when he was trying to leave. The surveyor was further informed that R1's behavior of being anxious would cause staff to put R1 in bed, sit with him or medicate him to calm him down. Continued interview revealed, on the evening of 11/05/02 when R1 eloped, staff searched the facility room to room because sometimes he would get so confused he would go lay down in another room. On 11/5/02 staff put R1 down to bed at approximately 4:45p.m. When staff went to bring R1 to dinner, at approximately 5:30p.m., he was not in his room. After looking for R1 for 5-10 minutes that evening, a call came in from a neighboring long term care facility that he was there. Staff do not know how R1 got out without the alarm being heard.
Staff informed the surveyor that R1 went out the North or Southeast door (called the back doors) because those doors are closest to the neighboring facility. The electronic device monitoring doors are identified as follows; Front door, West wing, elevator door and short North door. Other audible alarmed doors are as follows: Southeast, Northeast, Northwest, north side hallway to basement and basement door behind the dietary department.
Interview with E1 (assistant director of nursing) revealed that the electronic devices are checked by E1 monthly, but no log book is available for review. E4 (maintenance director) revealed that the alarmed doors are checked every Friday, but during the testing of the West door on 11/25/02 at approximately 4:35p.m. with E1 and E11 (administrator) revealed that alarmed door only had a very low (buzz) sound making it difficult to hear unless you stand right at the door. On 11/26/02 the same (West) door was tested after a new battery had been installed on 11/25/02. The sound/voice alarm was loud but could not be heard over the activities going on in the activity room where staff and residents were with the television playing. This was verified by E4 and due to the inadequate muffled low sound of the voice alarm; E4 informed the surveyor that he may need to put a speaker in the activity area.
Further interview with E4 revealed that when R1 eloped on 11/5/02 he was called in and asked to check the alarm for the North door only that night, per request of E5. E4 continued that no other doors were checked.
Interview with Z2 (admissions director at the other facility) at 10:53a.m. on 11/27/02 revealed, "I want to say between 5:00a.m. and 5:15p.m. one of our staff and her husband found R1 on 95th street; calm not agitated, disoriented, walking with a shuffling gait in slippers, shirt and pants when he arrived here."
Interview with Z1 (LPN-licensed practical nurse at the other facility) at 11:00a.m. on 11/27/02 revealed, "I was just picked up by my husband at around 5:00p.m. going North on the street East of the facility located on 94th street. I saw R1 walking on 91st street. He had on terry cloth slippers a pajama type pants and shirt with no coat. We drove along and followed him. It was cold he was walking real fast. You could see that he was a runaway. I asked him if he wanted some coffee? He said "I don't have a police record." It was cold and wet outside. My husband helped me put him the car. We brought him back to my place (the other facility) where I work. They called R1's facility."
The surveyor asked the facility for an elopement assessment for R1 and was presented an "elopement profile for at-risk residents" with the date of the incident 11/5/02.
The facilities at Risk for Elopement Policy revised on 2/2/02 reveals; Elopement precautions may include: 1) Monitor during activities and mealtimes; or 2) Monitor resident's whereabouts every two (2) hours; or 3) Monitor resident's whereabouts every 1/2 hour. Appropriate monitoring to be determined on an individual basis.
The facility failed to provide adequate supervision for R1 on 11/5/02 on a more frequent basis because of to R1's behaviors that day of anxiety and agitation, and his recent (4) attempts to leave the facility. The facility did not know that R1 was missing even though he was to be kept on close monitoring.