THE WATERFORD NURSING & REHAB
Facility I.D. Number: 0038612
Date of Survey: 12/13/2002
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.
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 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.
These REQUIREMENTS are not met as evidenced by:
Based upon observation, interview and record review, the facility failed to supervise, observe and monitor a resident's behavior to prevent an elopement of one resident (R1) from a locked unit.
This failure resulted in an Immediate Jeopardy.
The findings include:
R1 is a 76 year old male with diagnoses of Organic Delusional Disorder and Senile Dementia. R1 is cognitively impaired and in need of constant monitoring. R1 was first observed missing from the bed and the locked unit at 11:10P.M. on 11/01/02. R1 was found outside the facility and brought back to the nursing facility at 12:15A.M., 11/11/02, by a neighbor (Z1). Z1 had observed R1 to fall twice in the alley near the nursing home. The facility's investigation report of 11/13/02 states R1 sustained scratches and abrasions to the right hand, right elbow, left elbow and the middle of the back. On 12/06/02, R1 had a slightly reddened, healing scratch/bruise on the right elbow area.
E1 (administrator) was interviewed on 12/06/02 at 3P.M.. E1 stated "R1 resides on 3rd floor, a coded locked unit. A code has to be entered for the elevator to open if one is exiting from the third floor. That code has to be reentered before getting on the elevator in order to lock the elevator when leaving the unit. If a resident, staff or visitor comes to the 3rd floor on the elevator, the door will open to allow the passenger to get off at the 3rd floor." E1 was not able to state which neighbor brought R1 back to the facility, nor which exit was possibly taken by the resident. E1 does state "the front exterior door does not have an alarm to alert the staff if a resident leaves the facility." All ground floor and 3rd floor doors are alarmed and locked with the exception of the front entrance/exterior door. The front door is monitored after 5:30P.M. by the 1st floor charge nurse and two certified nurse assistants (CNA) on duty for the 3-11 and 11-7 shift. E1and E2 (assistant director of nurses) state "the last observation of R1 in the facility is not known."
E9, 3-11 certified nurse assistant (CNA) was interviewed by phone on 12/11/02 at 10:58P.M.. E9 stated "I left the 3rd floor around 11:05P.M. on 11/10/02. R1 was in his room. R1 had been taking his gown on and off. R1 was walking up and down. R1 would sit and then get up to walk again all the afternoon shift. R1 did not make an attempt to leave the unit during the shift. When I left the floor, there was suppose to be a CNA on the floor, but as I left, I saw the CNA on the 1st floor. Actually, there wasn't a CNA on the 3rd floor and the 3-charge nurse had left the facility already. E8 (11-7, CNA) was assigned to the 3rd floor but was standing talking on the 1st floor." E9 said that E8 saw her leave. E9 said they did not speak as she left the facility.
E8 was interviewed on 12/11/02 at 10:40A.M.. E8 stated "when I went to the floor I made my rounds on each resident and discovered that R1 was not present on the unit. Based upon time card review, E8 clocked in at 11:07P.M. on 11/10/02. The nurse's progress note states R1 was found missing at 11:10P.M. on 11/10/02.
Z2 (attending physician) was interviewed on 12/11/02 at 10A.M. regarding R1's treatment plan. Z2 stated "R1 has a diagnosis of Organic Delusional Disorder and Senile Dementia which explains his wandering behavior. R1 is on a locked unit as well."
Based upon observation and interview with E4, E5, E7, and E8, residents are able to leave the 3rd floor if they are able to put in the code. A resident standing at the elevator is able to enter the elevator and go from the 3rd floor to 2nd floor to 1st floor to the basement area. If the CNA is busy in another resident's room the CNA may not have seen R1 enter the elevator.
E2 states "staffing patterns for 3-11 and 11-7 shift is for one licensed staff and 2 CNA 's on each floor. However on 11/10/02 one licensed nurse covered the 1st floor and the 3rd floor." Based upon time card review, E6 (11-7 charge nurse for 1st and 3rd floor) clocked in at 11:06P.M.. E6 stated "I started rounds on 1st floor on 11/10/02 and by the time I got upstairs about 1:10P.M., E8 was stating to me that R1 was not on the floor." E6 stated "we checked each floor and R1 was not in the facility. R1 was returned to the facility at 12:10A.M., 11/11/02 by a neighbor. R1 was in the neighbor's car. We took a wheelchair to Z1's car to get R1 and R1 was dressed only in a pair of pants and a t-shirt. E6 further stated "I didn't hear an alarm ringing from the back doors and the front door did not have an alarm to alert us when someone leaves."
The nurse's progress notes dated 9/28/02 indicate that R1 had an episode of continually going to the elevator to try to get off the floor. While there is no further mention of this behavior in the documentation for 10/2002, the problem was put on the care plan and elopement high risk alert was initiated on 9/28/02. The care plan approach states to observe/monitor resident behavior and make sure all doors/exits in the unit are locked. These approaches were not implemented on this day of elopement.
The facility's elopement policy states that all residents that wander are to be placed on the 3rd floor locked unit and that a tracking sheet will be utilized if a resident makes attempts to leave the unit. However, E2 stated a behavior monitoring sheet and location tracking sheet was not utilized to monitor R1's behavior and location as stated in the elopement policy.
The monthly summary for 9/21/02 describes R1 as disoriented x3 with impaired memory. The MDS of 10/11/02 assesses R1 to have moderate impaired cognition with mood indicators present that are alterable, alert, no falls, no gait issues.
E3 stated in interview on 12/06/02 at 1P.M. on the 3rd floor, that R1 does try to leave the unit. "The floor is basically a locked unit, but if another resident gets on the elevator or gets off the elevator, R1 could get on it." E2 was interviewed on 12/06/02 at 1:15P.M.. E2 stated "we don't know where outside he fell, but R1 always goes to the East back exit. We try to redirect. He tries to open the door and we redirect."
Although the facility was aware that R1 was an elopement risk and required constant monitoring, R1 was left on the floor without a CNA nor licensed nurse present at 11:05 P.M. on 11/10/02 and was found missing from the facility at 11:10P.M.