WARREN BARR PAVILION
Facility I.D. Number: 0046003
Date of Survey: 01/24/2003
Incident Report Investigation of December 25, 2002
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 resident.
Each facility shall maintain all electrical, signaling, mechanical, water supply, heating, fire protection, and sewage disposal systems in safe, clean and functioning condition. This shall include regular inspections of these systems.
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 are not met as evidenced by:
Based upon observation, staff interview and record review, the facility failed to provide supervision of a resident by failing to:
A) a confused resident did leave the facility unsupervised and without a coat. The resident did sustain an injury to the right arm during the elopement.(R1)
The findings include:
R1 is a 77-year-old female with a diagnosis of Alzheimers Disease. R1 is assessed per Minimum Data Set (mds) of 12/06/2002, to have a memory problem, modified cognitive independence and may have difficulty in new situations, but is able to ambulate independently off the unit. R1 is also care planned on 12/10/2002, to have a problem of potential elopement with approaches to closely supervise R1.
R1 was found wandering in the street on 12/25/02, at 8:40P.M. by the police and was taken to the hospital. The facility investigatory report states R1 sustained a bruise and abrasion on the right arm as a result of the fall. Z2 states during interview on 01/22/03, at 2:30P.M. "the right arm after the elopement had a mild superficial abrasion."
The facility reports last seeing R1 at approximately 7:30P.M. on 12/25/02. Z3 called the facility at 8:45P.M. to make the facility aware that R1 was at the hospital. E5 states in her report of 12/27/02, at 3P.M. that "after a through search of the facility at approximately 8:45P.M., it was determined that R1 was missing."
R1 was interviewed on 01/21/03, at 3:30P.M. and stated, "The family is near-by. I remember going out and couldn't find my way back. There was a policeman and he brought me back. That was some place else. I never did it here. I'm able to go downstairs here. I've never had to go out the front door by myself. I'm sure I would have to ask someone. I'm sure I musta taken another door, but it was someplace else, not here."
E2 stated during interview on 01/21/03, at 1:55P.M.. "We believe R1 exited the facility after 7:45P.M. on 12/25/02. Her room is near the freight elevator and a back exit door is near the elevator. The rear exit door is not frequented by residents. It is used for food delivery and to take trash out of the facility. The door is alarmed continuously. The door is suppose to alarm to the front desk area on the monitor and screen 24 hours a day. However, there was a problem with the door and the alarm did not go off as it should have done. We did not know it was a problem until this time. R1 was not an elopement risk. The only wandering incident that we are aware of occurred last summer. At that time,R1's sister dropped her off in the car on the corner and said "go back to the facility", but she got lost and wandered the neighborhood. She does not exhibit exit-seeking behavior. She does get turned around, and she does go down for the newspaper. The maintenance check is done monthly, and there was no check of the exit doors daily prior to this incident. There is no locked unit specific for the Alzheimer's resident."
E1 was interviewed on 01/21/03, at 4:45P.M.. E1 stated "we have a 24-hour security at the front door with a camera that covers the back door, and the garage area. This camera system is more inclusive than before the incident of 12/25/02." After the incident we made sure that none of our employees cards could open the back door. All employee cards were deactivated"
E6 was interviewed on 01/22/03, at 12 noon per telephone. E6 stated "R1 has tried to get out of the facility frequently during the past three months. The events were reported to the charge nurse on the floor. We have a picture of her as one of the high risk patients. She has been attempting to exit the front door. She would come up to the desk and say I'm going out. If a group of people were here in the lobby, she would try to blend and go out the front door. We would tell her no and call the nurse on her floor. we did have difficulty with viewing the rear exit door. The camera didn't give a complete view, only the back of the person leaving could be viewed. We have gotten the camera lens corrected.
E5 was interviewed on 01/21/03, at 4:45P.M.. E5 stated I was working the date of 12/25/02, from 3P.M. to 11P.M. but I was not aware of a resident leaving the facility. When the incident involving R1 happened , the door was not working on that day. The nurses and employees were going in and out of the rear exit door to smoke or to go the store. I would on occasion go to the rear exit door and find it open, then close the door. When the staff use their badges, if you're not sitting right at the desk , you're not aware of who is using the door. So a resident could go downstairs on first floor and if the door is ajar, then no alarm was present and a resident could just walk out the door. Security was aware of the door condition. So after the incident, they had to come in to fix the door. Now I can tell who is going out the rear exit door. No employees are going out the rear exit door and we have a photo album of all residents that we have to keep an eye on."
E4 was interviewed on 01/21/03, at 3:45P.M.. E4 stated "one of my staff came in after the incident, checked the door and found the door not closing nor alarming ."
E7 was interviewed on 01/21/03, at 4P.M.. E7 stated "on 12/25/02, I took care of the resident. I was assigned to do 1:1 with R1 after R1 returned to the facility. There is a place to sit so we can make sure R1 doesn't leave the room and get on the elevator. I did not take care of R1 in the morning. They switch people around on the fourth floor and we may start off with an assignment and the assignment may change during the shift."
Based upon the care plan of 12/10/02, and staff interviews the facility was aware that R1 was an elopement risk prior to the incident as well as R1 could become confused and exit the rear door as other staff exited the facility and independently in the absence of a functional alarm system. Although R1 had made several attempts to exit the facility, the facility failed to complete an elopement risk assessment prior to 12/25/02, and to make operational the Safety, Elopement, risk for elopement protocol as follows:
the current mds was not reviewed to determine any changes in condition that indicate at risk residents.
specific interventions to prevent further elopement were not added to the care plan
frequency of monitoring within the eight hour shift was not identified on the care plan nor on the monitoring sheet.