ODD FELLOW-REBEKAH HOME Facility I.D. Number: 0010223 Date of Survey: 10/02/2002 Incident Investigation of September 20, 2002 “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. General nursing care shall include at a minimum the following and shall be practiced on a 24-hour, seven-day-a-week basis: 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. These regulations are not met as evidenced by: Based on observation, record review, and interviews, the facility failed to supervise R1 with his many attempts to elope which resulted in an unnoticed absence from the facility; failed to monitor R1's electronic monitoring device more than one time a day when a known behavior of R1 was to cut off the device; failed to follow their policy and procedure for Wandering Resident/Elopement; failed to assess and increase supervision of R1 after R1's wife was admitted to the hospital on 9-19-02 as she was R1's roommate and helped supervised R1; and failed to supervise R1 to prevent an injury from a fall resulting in a laceration and abrasions to the face. R1 is 1 of 14 residents in the facility assessed with wandering behavior who are not on the Harmony Unit (a locked Alzheimers Unit.) Findings include: 1. R1 was admitted to the facility on 7-30-02 with diagnoses of Alzheimer Dementia, Parkinson's Disease, Melanoma of Arm, Osteoporosis, and Organic Mental Syndrome with Associated Psychotic Behavior. The assessment of 8-8-02 describes R1 as having short and long term memory problems, moderate impairment to decision making, behaviors of being easily distracted, altered perception of awareness, episodes of disorganized speech, mental function varies, and wandering. The assessment also describes R1 as independent with transfer and ambulation and needing minimal assistance with dressing, bathing, eating and is continent of bowel and bladder. The Care Plan of 8-8-02 describes R1's concerns as confused behavior, disorganized speech, short attention span, wandering from facility unattended, behavior of cutting off his electronic monitoring bracelet, potential for weight loss, potential for Tardive Dyskinesia related to the use of Zyprexa, potential for falls due to antipsychotic and anti-depressant medications. The approaches to the wandering behavior are to divert attention when R1 becomes insistent on leaving facility, check promptly when alarm system goes off to insure R1's safety, redirect attention, and test batteries and apply electronic monitoring bracelet. The assessment to Psychotropic Drug Use of 8-8-02 for R1 states, "Is confused and disoriented but follows simple commands well. Does have a tendency to wander from subject to subject at times. Does recognize wife." The assessment to Behavioral Symptoms of 8-8-02 for R1 states, "Staff report that (R1) has problems finding his room, gets lost, wanders in the hallways looking for his room and wife." The assessment of Falls of 8-8-02 for R1 states, "(R1) does show some rigidity and slow gait and balance disturbances, however (R1) can ambulate without assistance." A Physical Therapy Evaluation done on 9-24-01 for R1 states, R1" is combative and confused and is to use a wheeled walker to improve safety with gait." The Admissions Care Plan note of 8-8-02 for R1 states, "Does have tendency to wander at times and is considered an elopement risk. Electronic Monitoring Device ordered." Observation on 9-30-02 at 11:10 A.M. of R1 on the Harmony Unit, a locked unit for Dementia Residents, showed R1 ambulating with a walker. R1 agreed to talk and the interview was held in the small dining room. R1 could tell his name but had no recall of the recent fall, did not know the name of the nursing home, did not know the day of the week, and thought the year was 1999. Further interview showed that R1 did not have any safety awareness. Question was asked to R1 if he were walking and he came to the corner and the light was red, would he cross the road. R1 replied, "I don't know." Surveyor asked what did the red light mean and R1 replied that it meant "caution." R1 was asked again about the red light at the intersection and if he would cross the street and R1 replied that he didn't know. Observation also showed that R1 had an electronic monitoring bracelet on his left wrist and when asked what it was, R1 said that he didn't know what it was and he said that he thinks he will take it off. 2. The Incident Report from the facility states, "Elopement, was noted by 2 nurses ambulating indept.(independently) past nurses station at 1325 (1:30 P.M.) Res. wife was recently admitted to hosp. and apparently res. left the building to find her." Interview with E1 (ADM) on 9-30-02 at 2:30 P.M. states that on the date of the incident the front door of the facility opened automatically with an electronic eye and no alarm system was present except for the electronic monitoring device (bracelet) system on 9-20-02. Interview with Z1 (Police Dept) on 9-30-02 at 9:30 A.M. states that a call was logged at 1:09 P.M. at the Police station regarding a man that fell in a yard at the corner of Logan and Wabash. Z1 states that an officer was dispatched at that time to that location. Interview with E3 (ADON) on 9-30-02 at 8:30 A.M states that R1 was seen by her on the east wing by the nurses station at 1:25 P.M. Interview with E4 (Nurse) on 9-30-02 at 10:45 A.M states that she also saw R1 at the nurses station on the east hall at 1:30 P.M. E4 also stated that R1 usually wore an electronic monitoring bracelet but R1 cuts his bracelet off at times. E4 also stated that R1 has tried to leave the facility but the staff would stop him before that happened. Interview with E5 (CNA) on 9-30-02 at 10:55 A.M. states that she (E5) had been asked by E4 (Nurse) to change R1's clothes as R1 was wet and thought it was between 12:00 noon and 1:00 P.M. E5 was busy with another resident and told E4 that she would finish and be right with R1. When she went to find R1, he was not there. E5 states that R1 is confused but she was unaware that R1 needed an electronic monitoring bracelet. Interview with E1(ADM) on 9-30-02 at 10:15 A.M., E1 stated that she was aware of R1's elopement when the Police Officer arrived at the facility at 1:30 P.M. to tell them about the man they had just found about 1 and ½ blocks away. E1 stated that a neighbor or a passerby found him and that R1 did not have his electronic monitoring bracelet on at that time. E1 stated that the Police told her that R1 had been sent to the Hospital for injuries to the face in his fall. E1 also stated that the nurse on the east unit was immediately told of the elopement and a search was done of R1's room and scissors were found in the room. E1 stated that R1 was looking for his wife who had been admitted to the hospital recently. E1 stated that R1's wife, who is also a resident at the facility, helps to look after R1 as they are roommates and his wife helps supervise R1. E1 stated that R1 was looking for his wife when he left on 9-20-02. E1 further states the family of R1 had been approached about separating R1 and his wife but the son felt they were so close and R1 depended on his wife so much, it would be upsetting to them. E1 stated that R1 and his wife were kept together on the east wing. The location that R1 was found by the Police is about 1 and ½ blocks from the front door of the facility. R1 would have had to walk the length of the front yard of the facility which is approximately 100 plus yards, would cross Lafayette Avenue which is the road is front of the facility, walk to Logan Street which is the next road west, and walk to Wabash which is 1 block north of Lafayette. The corner of Wabash and Logan is located 1 block south of Route 16. Route 16 is a very heavily traveled 4 lane highway and there is a stop light at this intersection. The facility policy for Wandering Resident/Elopement states on part 3d: Resident's wandering episodes will be tracked and resident specific approaches/interventions added to the care plan as determined effective by the interdisciplinary team. Part 3e: If the resident attempts to leave more than one time in a 24 hour period, he/she will be placed on every 30 minutes Visual check for 48 hours. Part 3f: If exacerbation of the behavior, 1:1 supervision will be considered until the physician can assess the resident for cause. No evidence of behavior tracking, no Visual Check sheets, no 1:1 supervision was seen. Also no evidence was seen regarding further assessment or increase in supervision after R1's wife was admitted to the Hospital on 9-19-02 which is the day before R1 eloped. The facility investigation report stated that time unaccounted for R1 was less than 10 minutes, that R1 was found 1 block from the facility and R1 eloped out the front door and that no alarm sounded. The description of the accident states, "(R1) had cut off his electronic monitoring device. (R1) intended to leave facility to find his wife, also a resident, but had been taken to hospital." The History and Physical dated 9-20-02 states, "(R1) was found on the road, not responding, and with abrasions to the face. There was a superficial laceration across the bridge of the nose about a half a cm. in length and abrasions on the face, forehead, and nose." |