STERLING PAVILION Facility I.d. Number: 0040436 Date of Survey: 12/04/2002 Incident Report Investigation of October 26, 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. All nursing personnel shall evaluate residents to see that each resident receives adequate supervision and assistance to prevent accidents. These requirements are not met as evidenced by: Based on observations, record review and interviews, the facility failed to supervise R1, a known wanderer with end-stage dementia, by not: a) Having a specific monitoring plan to supervise R1 to prevent an elopement from the facility. b) Analyzing the time, location, and the correlation of family visits and outings related to the attempted elopement. c) Following the care plan to document the whereabouts of R1. This resulted in R1 successfully eloping from the facility on 10/26/02, crossing a nearby state highway and being absent from the facility for approximately 45 minutes. This was for one (R1) of four identified wanderers in the facility. The findings include: A) The November 2002 Physician Order Sheet (POS) listed R1's diagnoses as End-Stage Dementia, Hypertension, Anxiety, Degenerative Joint Disease, Weight Loss and Insomnia. The Quarterly Resident Assessment Instrument (RAI) assessed R1 to have short and long term memory problems and to be severely impaired in cognitive skills for daily decision making. R1 was assessed as being easily distracted, having periods of altered perception or awareness of surroundings, periods of disorganized speech, periods of lethargy and mental function that varies over the course of the day. R1's behaviors were assessed as wandering daily, being socially inappropriate, physically abusive, and resisting care. R1 was assessed as requiring the supervision of one for ambulation, dressing, eating, and bathing. On 11/26/02 and 12/02/02, R1 was observed ambulating independently and needing to be redirected by staff. On 11/26/02 at 1:30 P.M., R1 was observed wandering around the central nursing station, E5 (RN) escorted R1 back to the activity room on the Alzheimer's unit. E4 (Activity Aide) attempted to keep R1 occupied. R1 kept getting up and walking to the Southeast exit door. E4 walked with R1 and kept trying to redirect him. During an interview on 11/26/02 at 9:25 A.M. in the dining room, R1 was able to give his name, name of the town, where he had been employed, and his wife's name. He was unable to identify the season or that Thanksgiving was in two days. Review of the nursing notes between 09/24/02 and 10/26/02 documented that R1 had set off the exit door alarms and attempted to elope 20 times. The Episodic Behavior Intervention Charting documented that R1 had attempted to leave on 6 days between 10/01/02 and 10/26/02. The care plan dated 11/14/02 has an approach: "Charge nurse will document resident's whereabouts at the beginning and end of their shift in the clinical record." There is no documentation in the nursing notes from 10/09/02 to 10/14/02 and from 10/16/02 to 10/26/02 nor any documentation of the whereabouts of R1 at the beginning and end of each shift in the clinical record. B) The nursing note of 10/26/02 (5 P.M.) documented, "Resident tried to elope out of C-wing door. Nurse redirected after getting him inside the building." An Incident Report of 10/26/02 documented that at 5:30 P.M. resident left the building via the West exit A-wing. During a phone interview on 11/27/02 at 8:45 A.M., E13 (CNA) was asked about the incident. E13 stated, "E9 (CNA) and I were down at the East end of the hall when we heard the alarm. I looked out the door of the room and then went to the A-West wing door. It rang 10-15 seconds before I got there. I looked out the exit door and went outside and looked but didn't see anyone. I'm not sure of the time. It was some time during the first feeding (starts at 5:30 P.M.)." During an interview on 11/26/02 at 9:50 A.M., E8 (Director of Nursing) stated, "It was reported to me that the alarm went off at 5:30 P.M. at the A-wing West door. E13 (CNA) responded to the alarm. He looked and didn't see anyone but he knew that R1 had been redirected earlier. He asked, 'Where is R1?' They looked around A-wing and near R1's room (B-wing). When they couldn't find R1, the announced a 'Code Violet' for a missing resident. I wasn't here when R1 left but E11 (LPN) called me between 6:00 - 7:00 A.M.. About that time E14 (off-duty CNA) returned R1 to the facility." On 11/27/02 at 9:00 A.M. during a phone interview about R1's elopement on 10/26/02, E14 stated, "I stopped at a video store and my daughter came out to the car and said that she had seen R1 in the store. This was around 6:15 P.M. on 10/26/02. I went in and R1 came with me and got into my vehicle and I returned him to the facility around 6:30 P.M.. R1 was not wearing a coat. He was wearing sweatpants and a long sleeved shirt." During an interview on 11/26/02 at 3:30 P.M., E12 (RN) stated, "We try our best to keep an eye on R1. It makes it worse when he goes out with his wife. There seems to be a correlation with an increase in behavior after he has been out. He looks for his car, his wife, or his daughter. He thinks that his relatives are outside so he can go out. When he gets out the door you have to run to get him. He is very quick." E12 indicated that R1's family visits often and his wife comes a couple times a week and takes him on car rides." C) Weather information found at Wunderground.com documents the temperature for Sterling on 10/26/02 at 17:55 to be 46.40 degrees Fahrenheit, 66% humidity, no precipitation with scattered clouds. The distance from the facility to the video store is two-tenths of a mile. To get to the video store, R1 had to cross a highway (speed limit 30 mph) at an intersection with a gas station on one corner, a food store on another corner and the video store on another corner. D) From 11/01/02 to 11/26/02, the Episodic Behavior Intervention Charting documented that R1 had made 92 attempts to elope from the facility. During a phone interview on 11/26/02 at 10:30 A.M., Z1 (R1's physician) stated, "R1 is not at all safe outside. He has end-stage Alzheimer's and is primarily confused. He is always on the move and pacing constantly. He is not safe to cross the street. He keeps doing this and he will go out again. He needs a locked down unit. His medications are hard to control." |