Facility I.d. Number: 0038364
Date of Survey: 10/23/02
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.
These REQUIREMENTS are not met as evidenced by:
Based on record review, interviews and observation, the facility failed to implement the care plan for one (R1) of thirteen residents identified by the facility as an elopement risk. R1 was found off the facility property without staff knowledge.
On 9/18/02 at 5:00 p.m., R1 2 was off facility grounds without knowledge of facility staff as verified through interview with E1 ( Office Worker) at 10:10 a.m. on 10/16/02. E1 stated that on the date of 9/18/02, A local reverend brought (R1) back. The reverend said he found (R1) by Route 251. It was around 5:00p.m. or a little later.
The facility sits on the corner of two intersecting roads. When crossing the road to the east of the facility, there is a four lane highway (Route 251) approximately one block away with posted speed limit of 45 miles per hour (mph).
E2 was the nurse assigned to East Wing on 9/18/02 at the time of the incident. In interview with E2 (Registered Nurse-License Pending) on 10/17/02 at 9:40 a.m. she stated, I last saw (R1) around 4:15 p.m. in his room. (Z2-son, of R1) was getting ready to leave and (R1) was anxious. He was brought back around 5:00 p.m. or so. I didnt know he was gone.
The Care Plan for R1 dated 7/31/02 identifies elopement risk. Approaches include:
During interviews conducted on 10/16/02, E1, E2, E3 (Administrator), E4 (Assistant Director of Nursing/ADON), E7 (Registered Nurse) verified that R1 tries to exit the facility, often wanting to go home.
In interviews on 10/17/02, E5(CNA), E9(CNA), E11(CNA) and E13(CNA) verified R1 attempts to exit the facility quite a bit and needs to be redirected.
Z1 (spouse of R1) was interviewed on 10/17/02 at 9:30 a.m. Z1 stated, (R1) always wants to leave when my son visits. (R1) could get hurt.
Z2 (son of R1) was interviewed on 10/17/02 at 9:35 a.m. Z2 stated, I visit my dad after work around 3:30 p.m. and stay until 4:00 or 4:15 p.m. at the latest about once a week. Dad had been very restless especially the past few visits (prior to eloping) and wanted to leave with me. When I left that day, Dad was in his room.
In interviews with E3 and E4 on 10/16/02 at 3:00 p.m., both stated they believed R1 exited through the West Wing door. These doors are located approximately 200 feet west of R1's room. Facility incident dated 9/18/02 at 1700 concluded that R1 left the facility unattended and was brought back by a visitor.
R1 is an 88 year old male resident. Physicians orders dated 9/5/02 identify diagnoses including Alzheimers. There is an order for code alert at all times in relation to elopement risk written initially on 11/21/01 and
remains a current order.
R1 was interviewed on 10/16/02 at 9:30 a.m., 10/17/02 at 11:00 a.m. and 10/17/02 at 12:30 p.m. During these interviews, R1 was unable to state his full name, age, marital status, where he was or if he had children. He was unable to tell what to do if he needed to cross a street by stating, I dont know. Facility incident report dated 9/18/02 at 1700 identifies R1 as alert to person, confused to time and place.