Red Bud Nursing Home
Facility I.D. Number: 0045476
Date of Survey: 3/18/03
Type of Survey: Incident of 1/28/03
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 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 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 there 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.
A.) Based on interview, record review and observation, the facility failed to prevent 1 of 13 residents (R8) identified as a wandering risk from leaving the facility without staff's knowledge. Findings include:
R8 was admitted to the facility on 1/11/03 from the hospital. She had been living at home prior to the hospital admission and had a history of wandering. R8 has diagnoses, in part, of Alzheimer's Dementia and Psychosis. An electronic monitoring device was placed on R8 upon admission to the facility. R8's Minimum Data Set, dated 1/24/03, indicates that she has severely impaired cognitive skills for daily decision making, and short and long term memory loss. The facility did not develop a Plan of Care for R8 until 1/21/03. The surveyor noted that throughout all days of the survey, R8 was continuously moving. As soon as R8 sits down, she gets up again immediately and starts walking. While eating the noon meal on 3/3/03, R8 kept getting up and staff repeatedly attempted to get her to sit back down and eat her meal. The surveyor observed R8 repeatedly approaching exit doors and opening the doors.
On 1/28/03, at approximately 2:15 P.M., E4, staff nurse, stated that she received a telephone call from a woman, Z1, who lives two houses to the north of the facility stating that one of the residents was walking down the street in front of her house. E4 stated that she then left the facility and proceeded up Rock Street, which runs North and South. This street crosses State Highway 3 and ends at a strip mall, The Plaza, located on the North side of Highway 3. E4 stated that she found R8 on the North side of Highway 3, in front of The Plaza, and immediately returned her to the facility. ( This is approximately 2 blocks from the facility.)
State Highway 3 is a well-traveled, chip and asphalt road. The speed limit in this area is 30 mph. There are numerous businesses located in the immediate area - gas stations, restaurants, etc. The United States Weather Bureau website lists the following temperatures for 1/28/03: Maximum, 56; Minimum 27; Average 42. E4 stated that when she found R8 she was wearing slacks, shirt and shoes. R8 was not wearing a coat. R8 had no apparent injuries.
Nurses notes state that on 1/14/03, "Res went out Door #16 without supervision. Instructed res that she needs to have someone with her when she goes outside. Res redirected without any problems, will cont. to monitor".
R8's Resident Assessment Protocol for Cognitive Loss, dated 1/24/03, states "(R8) has significant cognitive losses. Her family took care of her at home as long as they could. She is in need of frequent reorientation and cuing during the day as she is unable to understand what is going on around her. Will proceed to care plan with frequent orientation and cuing as often as needed. No plan for long lasting reteaching as her losses are irreversible".
During an interview of E1, facility Administrator, on 3/4/03, E1 stated that E6, Certified Nurses Aide (CNA), had seen R8 just 5 minutes before Z1 telephoned the facility stating that R8 was walking down the road. All door alarms and electronic monitoring devices were tested and found to be in proper working order.
The surveyor interviewed E4 on 3/4/03 at 12:30 P.M. E4 stated that she was the floor nurse assigned to the wing on which R8 resides, on 1/28/03. E4 stated that whenever an exit door is opened, there is an audible alarm at the panel on the East Wing. At this time, the East Wing Nurse pages staff to check the door at the location specified on the alarm panel. The established procedure is for staff to check the specified door then call the East Wing Nurse and give them an "all clear" signal. At this time the alarm panel is reset. E4 states that she was busy on 1/28/03 and did not hear any page for the door alarms.
The surveyor attempted to interview R8 on 3/3/03. R8 did not respond to the surveyors questions and began to speak nonsensically. R8 rose from the chair she was sitting in and rapidly walked away from the surveyor. The surveyor again attempted conversation on 3/4/03. R8 did not respond to the surveyors questions.
During an interview with Z2, R8's physician, on 3/5/02 at 2:55 P.M, the surveyor asked Z2 if R8 would be aware of dangers in her environment. Z2 stated "No, she has advanced Alzheimer's - she doesn't even know that she has an environment".