Park Haven Care Center
Date of Survey: 10/10/02
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 residents.
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 to prevent accidents.
Staffing shall be based on the needs of the residents, and shall be determined by figuring the number of hours of nursing time each resident needs on each shift of the day. This determination shall be made separately for both licensed and non-licensed nursing personnel.
These REQUIREMENTS are not met as evidenced by:
Based on record review and interviews, the facility failed to ensure that 1 (R10) of 10 residents in the facility who have been assessed to be at high risk for elopement, was adequately supervised. R10 left the facility without the knowledge of facility staff.
R10 was originally admitted to the facility on 09/04/02, with diagnoses, in part, of Inter-cranial injury with Psychotic Symptoms, Status Post increased Inter-cranial Pressure with Multiple Contusions of the Brain. The facility assessed R10 on 10/03/02 as having severely impaired cognitive skills and short and long term memory problems. R10 has a history of falls, communication and vision problems. R10's assessment dated 09/27/02, for falls states that R10 ambulates with a shuffled gait, is blind in one eye, has had at least one fall in the past 30 days, receives psych meds daily therefore resident is at risk for additional falls. The behavior assessment states resident has been combative in recent past, has attempted self-injury and has attempted elopement. Resident has profound mental impairment due to head trauma, has difficulty understanding others, has difficulty communicating accurately, and shows evidence of delusional thinking. Resident is typically friendly and cooperative, but remains completely confused. The communication assessment states speech is tangential, flights of ideas and nonsensical, has difficulty with decision making requiring much prompting and assist related to her not being able to stay on task. The visual assessment states Resident is unable to see out of right eye, both eyes dilated with little reaction to right eye when pupils checked and no movement from left eye. Resident vision is highly impaired, although when ambulating successfully moves through obstacles without impact.
During the initial tour of the facility, staff told the survey that R10 had eloped from the facility on the previous day, 10/06/02. The facility Verification of Investigation states At 12:55 p.m. nurse and aide checking door alarm at west end 300 hall, also checked residents room and noted resident not in room. Nurse went around facility and two staff members went to look for resident in cars. 12:58 Resident returned to facility without incident. Body check done upon return. No noted redness, bruising or open areas. Interview of E4, the Certified Nurses Aide (CNA) who initially noted the R10 was missing and was the employee who located R10 gave the surveyor the following account: I was working Sunday and I was the one who realized that R10 was gone. I last saw her at 12:45 as she was getting up and leaving the table in the dining room after finishing her lunch. About 10 minutes later I walked down to the 300 hall to get another resident for lunch. I heard the door alarm at the 300 hallway west door sounding. The only staff member down there was the nurse who was sitting at the nurses station talking ont he telephone. I said to the nurse, that alarm down there is going off. She (E5) said I thought it was the alarm for the sliding door out to the employee smoking patio.
She (E5) and I walked down the hallway toward the 300 west door and I looked in R10's room shes gotten out before. We started calling out R10's name and we didnt see her standing outside. E5 went one way around the outside of the building and I went the other. We both came back to the building and neither one of us saw her it took about 5 minutes. I came into the building and asked the other CNAs if they had seen her.
No one had. I and E8 got in my van and E9 got into her van and we drove around looking for her. I drove past the mini-mart and happened to look back and see R10 standing next to a gas pump talking to a man. We got her in the van and brought her back. She looked O.K. The surveyor asked E4 how long the alarm had been going off and she stated that she had no idea. E5 was unable to be reached by telephone and did not show up for work on 10/09/02.
The nurses notes state that on 09/09/02 at 11:30 a.m. Pt had gotten more agitated and walked out the door. Staff followed pt. out of building and tried to redirect her. Tried calming pt. with reassurance and TLC. Did not succeed. Ativan given 1 mg tab. Pt. talked into coming back in the building by staff. Pt. agitated still Haldol ordered 5 mg. tab.
R10 was found approximately 4/10ths of a mile southeast of the facility at a convenience store/gas station located on State Highway 159. R10 would have had to travel through a residential area which has chip and oil streets, across State Highway 159 to the convenience store.
The posted speed limit on Highway 159 in this location is 35 miles per hour. This is a well-traveled, centrally located road. Local businesses are located along 159. It took the surveyor approximately 9 minutes, traveling at a moderate pace, to walk a direct route from the facility to the convenience store.
Z3, a convenience store employee, stated during a telephone interview on 10/08/02, that she had seen a woman resembling R10's description standing across the street next to Highway 159 at approximately 12:45 p.m. on 10/06/02. Z3 stated that R10 seemed somewhat confused. Z3 said that a few moments later a local policeman entered the convenience store and asked if she had seen a woman resembling R10's description. She then told him about the woman she had seen across the street.
The Chief of Police, Z6 stated that the facility had telephoned the police department when they realized that a resident was missing and they dispatched an officer. Z6 said that the facility called back shortly after they had dispatched the officer stating that the facility had found the missing resident.
The surveyor obtained a copy of the Case Report from the police department. The Case Report stated On October 6, 2002 at approximately 11:10 a.m., R/O Z7 was dispatched to Facility (address), in reference to a report of a missing person. While R/O was in route to (Facility), Cencom advised R/O to disregard, that (Facility) employees had located the missing person and did not need R/Os assistance. R/O then cleared with nothing further.
E2 told the surveyor that the police must have written the time down incorrectly and the facility disputed the time which was recorded by the dispatcher.
On 10/07/02, R10 approached the surveyor while walking down the 300 hallway. R10 stated will you take care of me today? The surveyor attempted to talk to R10 and R10's speech became very nonsensical. A short time later, the surveyor went to R10's room and once again attempted to interview her. Most of R10's speech was gibberish the only think that the surveyor could understand is when R10 asked for a cookie. R10 was unable to respond to surveyors questions concerning the elopement which occurred on 10/06/02.
On 10/08/02, the surveyor noted that the door alarm panel, which is located at each of the two nurses stations, lights up when an exterior door is opened. There is a corresponding light for each exterior door. One 10/08/02, the surveyor noted that the lights which correspond to the doors were not labeled with the location of the door it was simply two rows of four lights. An audible alarm sounds at each door when an exterior door is opened. On 10/08/02, E2 told the surveyor that the facility was in the process of identifying and labeling which light corresponds with which exterior door.
On 10/08/02 at 2:45 p.m., the surveyor spoke with Z2, R10's physician, on the telephone. Z2 stated that the had seen R10 at the hospital earlier that day.
When the surveyor asked Z2 if R10 would be capable of identifying hazards in her environment, Z2 stated Ill make this simple for you, she had a severe closed head injury three months ago! She doesnt even know that her husband died in the motorcycle accident. Theres no awareness whatsoever of what danger is or what non-danger is, so No!
Review of the nursing schedule for 10/06/02 noted that there were only three certified nurse assistants on duty for the 7-3 shift. This does not meet the minimum staffing requirement for certified nurse assistants. The minimum requirement is for nurse assistants. There were no extra licensed staff on duty to make up the fourth person. Once licensed staff and one registered nurse were on duty as required for the minimum staffing. This scheduled was confirmed by E2, Director of Nursing.