Alden Heather Rehab & HCC Date of Survey: 12/12/02 Complaint Investigation "A" VIOLATION(S): 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 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. Personal care shall be provided on a 24-hour a day, seven day-a-week basis. All necessary precautions shall be taken to assure that the resident’s 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. AN OWNER, LICENSEE, ADMINISTRATOR, EMPLOYEE OR AGENT OF A FACILITY SHALL NOT NEGLECT A RESIDENT. These regulations are not met as evidenced by: Based on record reviews, incident report, elopement policy and interviews, the facility failed to provide supervision for one resident (R1), who was identified as a high elopement risk by the facility. As a result of R1's elopement, R1 was found dead frozen to the ground in the alley on 12/03/2002, behind the nursing facility. The facility staff was unaware of R1's elopement. Findings include: R1 is a 66 year-old female with diagnosis of undifferentiated and paranoid schizophrenia and hypertension. R1 is cognitively impaired and in need of constant supervision. Review of facility’s incident report dated 12/03/2002 reveals R1 was not in her room for a 6:00 a.m. blood pressure at the time of arrival. This was rechecked with a cardiac heart monitor machine which revealed a systole, no heart activity. During phone interview with Z3, (medical examiner), on 12/06/2002, at 8:00 a.m., Z3 told surveyor the initial cause of R1's death was cold exposure which caused hypertension and resulted in a heart attack; and accident death. Z3 further went on to say there were bruises on R1's knees. Z3 also told surveyor R1's body temperature was 84 degrees Fahrenheit at the time of death. Z3 told surveyor the last entry made in R1's chart was on 12/03/02, at 1:00 a.m. R1's body was found on 12/03/02, at 6:30 a.m. During phone interview with Z10 and Z11, (medical examiners) on 12/12/02 at 11:15 a.m., Z10 told surveyor, generally speaking it would have taken over two hours for someone to have a body temperature of 84 degrees with the weather temperature between 17 and 19 degrees Fahrenheit. Z11 told surveyor the over two hour time frame given by Z10 was very, very conservative. Z11 further told surveyor that it could have taken up to five hours for someone to decline to such a low body temperature after death under the same weather conditions. Review of the local police department supplementary death investigation report dated 12/03/02 reveals R1 was found outside behind the facility at about 6:30 a.m. This report reveals there were photos taken of the victim and her route of travel before death. This report states: the victim’s route of travel was started from the main entrance, then R1 traveled south along the east side of the building. R1 then traveled west along the south side of the building. R1 then traveled north along the west side of the building. R1's dead body was found near the rear kitchen door which is located on the west side of the building. During interview with Z7, (local police officer), on 12/04/02 at 9:00 a.m. in the local police station, Z7 told surveyor that Z6 (local police officer), took photos of R1's dead body which was located on the ground and the areas around the building. Z7 further told surveyor it seems to him from the photos that R1 started walking around the building and then began to crawl around the building to find an open door. There were snow tracks on the east, south and west sides of the building leading to R1's body. During a phone interview with Z3 on 12/06/02 at 8:00 a.m., Z3 told surveyor R1 had bruises on her knees. The photos taken by the local police department reveals snow stuck to R1's sweat pants at the knees. Z12, (local hospital), clinical notes dated 12/03/02 states R1 had bruising on her knees and was dead on arrival. Observations of the nine photos taken by the Z6 reveals R1 laying on the ground outside with a t-shirt and sweat pants on. There were tracks in the snow around the east, west, and south sides of the building showing R1's travel just prior to her death. During a phone interview with Z4, (paramedic) on 12/05/02 at 4:00 p.m., Z4 told surveyor she observed R1 laying on the ground in a fetal position on 12/03/02 at 6:33 a.m. R1 had no pulses and skin was cold to the touch. R1's attire was a thin tee shirt, sweat pants, and house slippers. Z4 further went on to say that when they tried to pick R1 up off the ground and lay her a stretcher, R1's body was frozen to the ground. They paramedics had to tug at the ice several times before they could put the body on the stretcher. There was also an imprint of snow surrounding R1's body. The above statement was also confirmed by the second paramedic on the scene, Z5. The information received from the Internet indicates the range of weather on 12/03/02 was between 19.40 and 17.60 degrees Fahrenheit. The wind speed ranged from one to nine miles per hour. Review of R1's clinical records reveals, R1 is a 66 year-old female and was admitted on 06/25/99 and has diagnoses which include undifferentiated and paranoid schizophrenia and hypertension. Review of R1's assessment dated 9/18/02 states R1 is severely cognitively impaired and needs supervision with all activities of daily living. Progress note dated 9/18/02 indicates R1 has arthritic discomfort in mobility. Nursing notes dated 10/06/02, 10/24/02, 10/25/02, 10/26/02 and 11/12/02 reveal R1 had discomfort in ambulation and an unsteady gait. Nursing notes dated 9/28/02, 10/03/03 and 10/15/02 reveal R1 would wander during the night. Nursing notes dated 10/06/02 and 10/24/02 reveal R1 attempted to leave through the exit doors. During a phone interview with Z1 (psychiatric physician) on 12/04/02 at 10:00 a.m., Z1 told surveyor R1 has a long history of chronic schizophrenia. R1 has variable and inappropriate behavior, and needs constant redirection. Z1 further told surveyor, R1 probably was unable to follow through on any train of thought because of psychotic thinking R1 could experience at any given time. During a phone interview with Z2 (attending medical physician) on 12/04/02 at 11:00 a.m., Z2 told surveyor R1 needed constant supervision and needed help with all care. In Z2's opinion, R1 probably locked herself out and did not know how to get back into the building. During a phone interview with E4 (nurse’s aide, night shift) on 12/04/02 at 10:00 a.m., E4 told surveyor the last time she saw R1 was about 2:30 a.m. on 12/03/02 wandering around the unit. At 5:45 a.m., E6 (charge nurse) informed her R1 could not be found. We started a search for R1. E4 told survey she searched the entire inside of the facility and then the outside of the building. R1 was not found by E4. E4 told surveyor she went home at 6:20 a.m. E4 was aware that R1 required a check every two hours because of high risk for elopement. During phone interview with E5 (nurse’s aide, night shift), on 12/04/02 at 10:20 a.m., E5 told surveyor she last saw R1 at 1:00 a.m. on 12/03/02 wandering around the unit. E5 is also aware of R1's every two-hour check because of elopement risk. During a phone interview with E6 (charge nurse), E6 told surveyor the last time she R1 was about 3:00 a.m., just before she took her lunch. E6 also told surveyor R1 was wandering the unit alone. E6 is aware of R1's frequent monitoring because of several attempts to elope from the facility. Observations on 12/03/02 at 4:00 p.m., with the administrator in the main lobby of the facility, surveyor observed two glass doors leading to the outside with no alarms or signals to alert the staff when the doors open. During an interview with the administrator on 12/03/02 at 4:15 p.m. in main lobby, administrator told surveyor that there are no alarms or signals on the front doors. Administrator also told surveyor that the only time supervision is on the front door is between the hours of 8:00 a.m. to 8:00 p.m. This is supervision for only 12 hours per day. The administrator admitted there is no supervision at night after 8:00 p.m. During an interview with Z7, (corp. Sanitarian) on 12/04/02 at 10:55 p.m. in social service office, Z7 told surveyor there has never been an alarm or signal on the front door for as long as she has been with the company. This has been at least five years. Review of facility’s incident report on 12/03/02 reveals R1 eloped from the facility on 12/03/02, unknown of the exact time or what door but between the hours of 8:00 p.m. and 8:00 a.m. During a phone interview with Z8 (floor cleaner) on 12/10/02 at 3:15 p.m., Z8 told surveyor he shut off the alarms on the second floor to have access to the stairwell. Z8 also further went on to tell surveyor he set the alarm back to the previous setting and announced to the nursing staff to check the alarms. Z8 was unsure of which nurse he spoke to but it was at 10:00 p.m. to 6:00 a.m. nurse. |