THE IMPERIAL GROVE PAVILION
Facility I.D. Number 0037754
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.
Objective observations of changes in a residents condition, including mental and emotional changes, as a means for analyzing and determining care required and the need for further medical evaluation and treatment shall be made by nursing staff and recorded in the residents medical record.
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.
The DON shall oversee the nursing services of the facility including:
Planning an up-to-date resident care plan for each resident based on the residents individual needs and goals to be accomplished, physicians orders, and personal care and nursing needs. Personnel representing other services such as nursing, activities, dietary, and such other modalities as are ordered by the physician, shall be involved in the preparation of the resident care plan. The plan shall be in writing and shall be reviewed and modified in keeping with the care needed as indicated by the residents condition. The plan shall be reviewed at least every three months.
These REQUIREMENTS are not met as evidenced by:
Based on observations, record review and interviews, the facility failed to assess and identify R3 as being at risk for elopement. The facility failed to implement a plan of care and supervise R3 who had made previous attempts to elope, and this resulted in R3 falling down a flight of stairs in a wheelchair causing her to be hospitalized on 8/19/02. R3 was admitted to the hospital with blunt head trauma, nasal fracture, mandible fracture, first metacarpal fracture, multiple lacerations and multiple blunt trauma caused by falling down a flight of 9 stairs. R3 is confined to a wheelchair and when she fell, the wheelchair was found at the top of the landing and resident apparently fell striking her head first.
R3 is a 73 year old female with multiple diagnoses that includes Parkinson's disease, Dementia, Arthritis and Manic Depressive disorder.
Review of the incident report and nurses' notes dated 8/19/02 revealed that R3 was found at the bottom of the first flight of stairs in a left side lying position surrounded by a large area of blood to the head area. R3 sustained lacerations to the bridge of the nose, left side of the head, right side of the forehead, right eye, right lower leg, right foot, and between the right thumb and forefinger. Fire Department brought R3 to the hospital emergency room. R3 was admitted to the hospital with diagnoses of blunt head trauma, nasal fracture, mandible fracture, first metacarpal fracture, multiple lacerations and multiple blunt trauma.
On an interview on 8/26/02 at 1:15 PM, E9 (6th floor nurse) stated that she worked on 8/19/02 from 7-3 shift, stayed over for 3- 11 shift and admitted that she was the only nurse on the 6th floor at 3:30 PM when the fall incident of R3 occurred. E9 told surveyor that there were three CNA's working with her for the 3-11 shift. E9 further stated that at 3:30 PM she was at the middle of the north hallway (in front of room 617) and was heading towards the end of the north hallway when the alarm on the north exit stairway went off. E9 added that she immediately ran towards the north exit stairway and found R3 on the bottom of the 9 stairs. E9 stated that she did not see R3 pass by the north hallway prior to the incident and the last time she saw R3 was at 2:50 PM in the 6th floor dining room. Surveyor asked E9 on 8/28/02 at 4:25 PM how loud the north exit door alarm was on the day of R3's incident. E9 responded that it was loud enough to be heard in front of room 617 where she was at that time, but not loud enough to be heard at the nursing station. E9 further stated that the volume of the alarm has increased recently after the incident. During the tour of the 6th floor on 8/26/02 at 11:30 AM with E1 and E2, surveyor observed that there was no other way to go to the north exit stairway without passing through the north hall which E9 stated was her location during the incident. It was also observed that the flight of stairs that R3 had fallen from had an alarmed exit door (North hallway exit 6th floor) that is very audible and there was a foyer before reaching the nine stairs. This door alarm has a loud audible ring that is heard at the site of the door. It has to be turned off manually with a key pad. On 8/27/02 at 1:30 PM surveyors with E1, E12 and E11 measured the distance from room 617 (which was E9's location at the time of incident) to the north exit door to be 64 feet. The distance from the north exit door to the stairs is 12 feet. This indicates that the resident had to travel a distance by wheelchair until reaching the door.
Interview with E5 (Social Service Director) on 8/26/02 at 2:45 PM revealed that R3 manifested anxiety with agitated behavior and was always anxiously "looking for her children". E5 further stated, that these behaviors were observed for almost a week prior to the above incident. E5 also stated that he is not aware of R3's elopement risk.
Interview with E4 (Director of the third floor Dementia/Alzheimers Unit) on 8/26/02 at 12:20 PM revealed that R3 was previously on the third floor dementia unit (secured unit) but was transferred to another floor due to skilled care needs (gastrostomy tube insertion) "some time ago." R3 did not have a gastrostomy tube in place and was on the 6th floor prior to the 8/19/02 incident. E4 further stated that R3 was not reassessed if she needed to be placed back to the third floor secured unit after the removal of the gastrostomy tube. E4 added that obviously R3 was an elopement risk since she went down the stairs. E4 also stated that she was not informed of R3's previous attempts to leave the floor, otherwise she would have done an elopement assessment , and R3 would have been placed back to the third floor secured Dementia/Alzheimers unit.
On an interview on 8/26/02 at 3:35 PM, E6 (3-11CNA) stated that R3 is confused and uses wheelchair to move around the unit. Per E6, R3's behavior has changed a few days before the fall incident on 8/19/02. R3 became very agitated and was seen several times near the elevator, attempting to get out of the floor. E6 also stated that E8 (3-11 shift/6th floor nurse) and every staff in the 6th floor was aware of R3's behavior of trying
to get off of the floor. E6 added that another CNA informed her that on one occasion R3 had set off the alarm. E6 further stated that on the day of the incident on 8/19/02 she reported to the 6th floor at 3:05 PM and did not see R3 until the time of the incident.
Interview with E8 on 8/27/02 at 11:10 AM revealed that R3 is confused, able to wheel herself, mumbles words and anxiously and repeatedly goes looking for her husband. In addition, E8 told surveyor that R3 has no self direction and no safety awareness. E8 further stated that R3 had attempted to leave the floor, and this behavior has been on going for "a while." E8 also stated that R3 attempted to leave the floor by the elevator at least once a month. E8 admitted to the surveyor that he did not notify E5 about R3's above behavior.
Review of the progress notes written by Z1 on 8/14/02 showed that R3 remained agitated and was trying to leave the floor by the stairwell. On an interview on 8/27/02 at 11:20 AM, Z1 stated that the facility staff requested her to see R3 due to agitation, combativeness and was told that R3 was trying to leave the floor by the stairwell. Z1 further stated that per facility staff, R3 tried to leave the floor by the stairwell between Wednesday and Friday (8/14 - 8/16/02).
R3 returned to the facility on the third floor secured dementia/Alzheimers unit on 8/23/02 after this incident.
Based upon the above evidence, the facility was aware of R3's elopement risk because of her previous attempts to leave the 6th floor that was noted by several staff. The facility failed to reassess R3 as she began wandering for a possible need to be placed back on a secured Dementia unit. The facility also failed to implement interventions, to include supervision and monitoring of R3. There was no evident care plan addressing R3's wandering and several attempts to leave the unit. R3 had been originally assessed by this facility to benefit from the Alzheimers program on the 3rd floor and the facility failed to reassess her behavior after the medical condition that sent her to the 6th floor was no longer a priority.
There was no indication that any staff were assigned or were aware of the need to more closely monitor and supervise this resident even after elopement attempts were recognized.