The McAllister Nursing Home
Facility I.D. Number: 0026989
Survey Date : 05/16/03
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 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 observations, interviews, and record reviews, the facility failed to supervise and protect 1 of 9 residents, (R2), who was a known flight risk and wore an electronic monitoring device. R2 successfully eloped on 5/2/03 between the hours of 3:15 a.m. and 4:00 a.m.
The facility was not aware that this resident had left the facility. The facility failed to ensure that all the alarms were reset after the evening staff left. The facility failed to watch R2 even after being warned by staff that she should be watched closely that night. The facility failed to have staff at an unalarmed door.
According to clinical records, R2, was admitted to the facility on 3/24/03 with a diagnosis which included Alzheimers Disease. While at the facility, R2, made multiple elopement attempts according to the nursing notes as follows, 3/29/03, 3/31/03, 4/2/03, 4/4/03, 4/7/03, 4/19/03. R2 successfully got out of the facility on 5/2/03 between 3:15 a.m. and 4:00 a.m.
No one at the facility knew where R2 was until she was returned by the local police even though she was known to be a wanderer and had made 6 previously documented attempts to elope and therefore being a flight risk.
E3, (R2's RN), stated during interview on 5/13/03, that on 5/2/03 she did not hear any alarms go off that night, she stated she was at the other end of the building from 3:00 a.m. until she let the police in when they were returning R2 around 4:00 a.m. She further stated that when R2 entered the building with the police, the electronic device the resident was wearing went off. E3 stated that she did not hear an alarm go off that night prior to that time.
E4 (R2's CNA that night), stated during interview on 5/13/03, that she last saw R2 around 3:00 a.m. when she put her to bed and left to care for other residents. She stated we looked for her. There is no record that the police were notified by the facility.
E1 (Asst. Adm.) stated that someone failed to reset the alarm to the front door. E7 (DON) stated that it is nursing responsibility to put on the alarms to the front door when someone leaves out of the door during night change of shift.
On 4/14/03, R2's resident assessment identified behavior problems and indicated that R2 had a decline in behavior as evidenced by wandering and trying to get out of (the) building. R2 was assessed as an elopement risk by the facility on 4/21/03. R2's assessment stated that R2 did not have an existing careplan targeting elopement and recommended that she should be placed on the elopement protocol. This assessment further noted that the resident is at risk for elopement at this time.
On 5/1/03, nursing notes indicate that at 11:00 p.m., prior to R2's elopement, she was very aggressive and warned that staff must keep a close watch on her. E3 noted that R2 was noted to be wandering the hallways at 12:30 a.m. and again at 2:00 a.m. that night prior to eloping. At 3:15 a.m., R2 was returned to her room by staff and left alone according to the nursing notes by E3. E4 verified that she did return R2 to her room and left her alone to care for other residents.
On 5/2/03 around 3:55 a.m., the police called the facility after they observed R2 outside and down the street from the facility. She was disorientated, according to the police report. The resident was returned to the facility by the police around 4:00 a.m., according to the police report.
Review of the weather on 5/2/03 between 3:05 a.m. and 4:05 a.m. showed that the temperature outside that night was 44 degrees and misty. E4 stated that R2 was returned in a gown and no shoes or stockings. The facility was not aware that this resident had left the facility.
The facility failed to ensure that the alarm was reset after the evening staff left. The facility failed to watch R2 even after being warned by staff that she should be watched closely.
R2 was observed by the surveyor on 5/9/03 to be up in the dining area with waist restraints on in a wheelchair, being fed lunch. During interview with R2, she stated that the President is Carter. She had no idea what time it was, where she was, or who she was. She could not state how old she was. Record review of R2's admission assessment indicated that R2's cognition is moderately impaired and required supervision.