LA HARPE-DAVIER HEALTH CARE CENTER
Facility I.D. Number: 0035741
Date of Survey: 10/07/2002
Incident Investigation of 09/20/2002
The facility shall provide a Resident Services Director who is assigned responsibility for the coordination and monitoring of the residents overall plan of care. The Director of Nurses or an individual on the professional staff of the facility may fill this assignment to assure that residents plans of care are individualized, written in terms of short and long range goals, understandable and utilized; their needs are met through appropriate staff interventions and community resources; and residents are involved, whenever possible, in the preparation of their plan of care.
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.
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.
Based on observation, record review, and interviews, the facility failed to account for all residents with electronic monitoring devices after door alarm was activated, and failed to conduct an exterior perimeter search of the building after the door alarm was activated.
R1 was admitted to the facility 04/26/01. Among her diagnoses listed on the current admit face sheet is Mild Infarct Dementia, Hypertension with a history of electrolyte imbalance.
R1's current assessment dated 09/08/02 identifies R1 as being severely impaired for Cognitive Skills for Daily Decision Making. The assessment also indicates that R1 has a behavior of wandering, wears a personalized alarm triggering device. The assessment also indicates that resident is independently ambulatory, requiring only supervision from facility staff. R1's current care plan dated 09/11/02 identifies that R1 has a behavior of wandering, and a cognitive deficit with short and long term memory loss and impaired decision making ability. R1's Behavior Observation Monthly Flow Charts from June 2002 through September 2002 identified five incidents of R1 attempting to leave the building.
R1 was observed on 09/30/02 at 11:00 A.M. walking independently, wearing a personalized alarm triggering device. During interviews with E2 (director of nurses) on 09/30/02 at 10:15 A.M. and E1 (administrator) on 09/30/02 at 10:45 A.M. and E3 (certified nurse aide) on 09/30/02 at 10 :45 A.M. all stated that R1 keeps busy through out the day cleaning and dusting fixtures and furniture and, on occasion, does so next to the front door where her personalized alarm triggering device sets off the exit signal. All stated that R1 is confused and would not be aware of her own safety outside the facility.
An interview attempted with R1 on 09/30/02 at 1:00 P.M. verifies that R1 is not oriented and could not answer simple questions appropriately. R1 stated that she enjoyed working here (at the facility) but it was a never ending job. R1 also said that she was going to feed her horses in the back pasture the afternoon of the elopement.
In an interview with E3 on 09/30/02 at 10:45 A.M., E3 stated that on 09/20/02 around 3:15 P.M. she observed R1 between the nurses station and the south hall. E3 stated that later the same day at approximately 3:30 P.M. she heard the exit alarm sound. E3 proceeded to the nurses station and questioned Z3 (agency Licensed Practical Nurse) as to who exited this door. E3 said that Z3 told her that it was only the Z1 (clergy person) who had been visiting the facility and was now leaving. From the nurses station E3 observed only Z1 outside the building. E3 verified that neither she nor E4 went outside the building to check for residents. E3 stated that the alarm stopped sounding while they were at the nurses station. R2 was near the door on the inside of the building. E3 stated that they thought the personalized alarm was sounding because R2 was at that location. They assisted her away from the door and resumed their duties.
Interview by telephone on 09/30/02 at 12:45 P.M., with E4 supported E3's account of the events of 09/20/02. Both E3 and E4 said that they did not know who turned off either of the alarms that were sounding at the time. During an interview with Z3 on 10/02/02 at 10:50 A.M. Z3 stated that she was busy doing paper work at the time, heard the alarm sounding, looked up and saw Z1 and the back of another person going out the door. Z3 further indicated that she did not think the other person was a resident. Z3 indicated that she had been briefed by E2 on the alarm system, how to shut it off once it was sounding and the code to turn it off at the key pad located at the individual doors. Z3 also stated that she had not been made aware of the identity of the individual residents who had wandering behaviors. Interviews with E3, E4 and Z3 verified that they did not think that a resident had left the building, therefore the facility's Missing Resident Protocols were not initiated. These include an in house check of residents who are known wanderers and an outside search of the building and facility property.
A review of the facility's report related to the 09/20/02 incident and interviews with E1 and E2 in the A.M. of 09/30/02 indicated that on 09/20/02 at 3:45 P.M. E2, who was on duty and running an errand called the facility to inform them that she observed R1 lying on the ground, near the sidewalk, approximately three blocks from the facility. E2 also informed them that E2 had called an ambulance. The Emergency Medical Services report dated 09/20/02 indicated that R1 had a contusion on the right side of face, scrapes on her right arm, and was complaining of her cheek and wrist hurting at the time of response. Interviews with E1, E2, E3, E4 and Z3 verified that none of the staff were aware that R1 had left the building in the P.M. of 09/20/02 prior to the call by E2.
This facility is located in the downtown area. The building has city streets with sidewalks on three sides, one of which is state highway which has a constant flow of traffic. The speed limit on this street located on the south side of the building is thirty- five miles per hour. On the entire south side of the building between it and the street there is a fenced yard area that has gates on the south east corner and the north east corners of the fence. Observation at 11:10 A. M. on 09/30/02, revealed that both of these gates were not locked. The alarm systems were turned off at the exit doors to the fenced yard from the South Hall and at the center of the unit near the nurses station. There was no staff in the immediate area for periods of time up to five minutes.
Observations on 09/30/02 between 11:00 A.M. and 11:40 A.M. revealed that all of the exit doors have an alarm system that sounds instantly when the door is opened and continues sounding until the alarm is reset by entering a code at a key pad, on the wall, next to the door location, or at the nurses station. The function of these alarms can be turned on or off at the nurses station. Observation also revealed that at the front exit door, across the hall and to the west of the nurses station, there is an axillary alarm system that is activated by an ankle bracelet worn by certain residents. E2 indicated that there are currently nine residents including R1 who wear the alarm activating ankle bracelets. This alarm system is activated when a resident wearing a personalized alarm ankle bracelet approaches the door, sounding when they come to within approximately ten feet of the door. When this occurs the door automatically locks with an electronic locking system. If the door is already open when a person wearing the personalized alarm bracelet approaches the it, the alarm sounds but the locking system does not activate, even when the door closes. The personalized alarm system, once activated can only be shut off by entering a code at the key pad on the wall next to the door. The above alarm systems were checked in the A.M. of 09/30/02 and found to be functioning properly.
A review of the facility's policy for Missing Residents verified that immediately following the alarm signal, staff shall check the alarm panel and respond to the door indicated. If a resident is found to be missing and unable to be located, a thorough search of the facility and immediate grounds shall be initiated by facility staff, a head count shall be conducted if necessary. Interviews with E3, E4, and Z3 indicated that this was not followed in the afternoon of 09/20/02. E3 stated that she only came
as far as the nurses station, looked out the front door from that location, did not see any residents and did not proceed further. E3 further stated that since she saw R2 in the vicinity of the door she believed it was R2's ankle bracelet that triggered the alarm. E3 also stated that Z3 told her that no residents exited the building with Z1.