Victorian Manor Healthcare & Rehab Facility I.D. Number: 0044982 Date of Survey: 04/03/2003 Complaint Investigation "A" VIOLATION(S): 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 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 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 requirements were not met as evidenced by: Based on observation, interviews, record reviews and policy reviews, the facility failed to supervise and prevent one resident from leaving the facility unnoticed on 01-25-03, at approximately 2:29 p.m. after the resident was left unsupervised in the TV area and wandered into the receptionist/front entrance area which was also left unsupervised. These failures placed R2 and seven (7) other residents assessed for elopement at risk. Findings include: Based on observation, clinical record review, facility incident report and surveyor interviews with E1, E2 (licensed nurses), E4 (activity aide), E5 (administrator) and E6 (receptionist), the facility failed to provide supervision resulting in R2 eloping and sustaining a fractured nasal bone. On 04-02-03, during tour of the facilities third floor, R2 was observed and noted to be cognitively impaired. R2 is a 70-year-old female with diagnoses including Dementia, CVA, COPD, and Alcohol abuse. Per MDS dated 03-13-03, R2's cognition level was assessed as moderately impaired. On 04-02-03, surveyor reviewed R2's clinical record and the facility incident report dated 01-25-03. Per documentation R2 was last seen in the facility's 1st floor television room area at approximate 2:25 p.m. by E4 (activity aide). Per documentation and surveyor interviews with E1, E2, E4 and E5, E4 went to the dining room at approximately 2:30 p.m. to escort R2 to the activity at which time R2 was no longer noted in the dining room area. E4 stated that she was in the process of taking other residents out of the first floor television room area to another activity when R4 wandered out of the area. E4 further stated that there was no other staff in the TV area to supervise the residents at the time that the incident occurred. E4 stated that she went to the reception desk located at the front entrance of the facility and noted two other residents who told her that a resident had left the facility without a coat on. Per interview, E1, E2, E4 and E5 stated that the front door is the only door in the facility without an alarm. E1, E2, E4 and E5 stated that the receptionist reported to them that she walked away from the front desk briefly to go to the mail room. E6 stated on 04-03-03, via phone that she left the front desk to go place the mail inside the slots in the mail room. E6 further stated that she returned to the front desk 10-15 minutes later and overheard R13 and R8 say that a woman had left the facility without a coat on. E6 stated "My job was to monitor who came in and out. I was inserviced to get relief before ever leaving the front desk." Per incident and hospital report. R2 was found by police outside of the facility approximate four blocks away by the railroad tracks. When found, R2 had a laceration to the lip and bruising to both sides of her nose. R2 was escorted by the police to the hospital. Per emergency room documentation, R2 arrived at the emergency room at 3:05 p.m. and sustained a nasal bone fracture. |