Challenge Scenario. Featured TAG TOPIC SCENARIO NOTES F323

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1 TAG TOPIC Make sure that the nursing home area is free from accident hazards and risks and provides supervision to prevent avoidable accidents. SCENARIO In this scenario, the facility failed to ensure the adequate provision of safety measures to prevent elopement of a cognitively impaired and independently mobile resident. Could this happen at your facility? For additional details related to this scenario, see page 2 What actions would you and your staff members take to prevent this from occurring in your facility? NOTES

2 Based on a complaint from the general public, facility self-report, record review and staff interview, it was determined the facility failed to ensure the adequate provision of safety measures to prevent elopement of a cognitively impaired and independently mobile resident (Resident #1) who left the facility unobserved and unattended and received multiple facial fractures and injuries after falling on a public road. The facility failed to: 1. Involve the resident s Interdisciplinary Team (IDT) in making the decision to remove a Wander-guard alarm from the resident. 2. Document the rational for removing the Wander-guard. 3. Update the Care Plan to include needed monitoring and interventions after the Wander-guard was removed. 4. Notify staff, who were responsible for the resident s monitoring and care, when the Wander-guard alarm was discontinued. 5. Ensure the front door was adequately monitored/alarmed to prevent the resident from exiting the building unnoticed. These failed practices resulted in serious physical harm, and placed the resident at risk for death, constituting immediate jeopardy. The facility s failed practice also had the potential to place other residents at risk who were cognitively impaired, independently mobile and had the ability to exit the building without assistance or the staff s knowledge. The failed practice was brought to the attention of the Administrator and the ADON on 12/16/09 at 6:00 p.m. They were provided with specific details of the failure to ensure the safety of Resident #1 as well as other vulnerable residents. On 12/17/09 at 11:00 a.m., the facility provided an acceptable plan of correction and the immediate jeopardy was abated. The findings include: Resident #1 was admitted with facial fractures, multiple lacerations and contusions and an intraparenchymal hemorrhage/ contusion. The resident was readmitted to the facility after a five-day hospital stay. A Behavioral Symptoms RAP Worksheet, completed in conjunction with the resident s annual MDS assessment, dated 2/23/09, documented, Wandering Contributing problems and risk factors include...mental disorder, repetitive questions, sad pained worried facial expressions, repetitive physical movements, reduced social interaction and mood persistence and depressive disorder. The resident s quarterly MDS assessment, dated 11/11/09, documented: Short and long term memory problems. Recalls location of own room and staff s name and faces, does not recall current season or that he/she is in a nursing home Moderately impaired cognitive skills for daily decision making Independently walks in room but requires supervision when walking in corridor and with locomotion on/off unit Unsteady balance while standing, but able to rebalance self without physical support Falls within the past days Wandering behavior in the last 7 days, occurred on 4-6 days, but less than daily.

3 Resident #1 s comprehensive Care Plan, signed 2/25/09 and documented as reviewed on 5/26/09 and 8/19/09, identified the problem, At risk for Elopement AEB [as evidenced by] wanders and gets lost. The onset date was 12/18/08. The approaches included: Re-orient resident as needed to person, place and time. If [resident] is looking to go outside offer diversion techniques. Observe for safety and make frequent visual checks. If resident looks lost, walk and talk with her and offer to walk her home. Wears a Wander-guard bracelet to prevent elopement. A Plan of Care: Elopement Prevention form, dated 9/23/09, documented, Minimize the risk of resident/patient elopement, with a goal date of 12/23/09, contained the following interventions: Initiate wander alert system; Describe system used: Wander-guard Re-direct resident/patient Offer reassurance if resident feels lost or abandoned Place wander/elopement risk and picture in book Note: The box with the intervention, Initiate the wander alert system contained a handwritten note that documented, Wander-guard d/c [discontinued] 12/4/09. Note: The comprehensive Care Plan and the Plan of Care: Elopement Prevention were not updated or otherwise revised to include increased monitoring and/or other needed approaches once the Wander-guard was discontinued on 12/4/09. An Elopement Risk Alert form, not dated, contained a picture of the resident and a description that included height, race, hair color, glasses, mobility mode and visible distinguishing marks. The Elopement Risk Alert form also contained a section for Areas/Places to Focus Search, which documented the following handwritten comments: 9/11/07, Outside exit doors parking lots, streets. Wander-guard bracelet on leftwrist. 12/10/07, Continues to wander halls need redirection. Wander-guard appropriate. 12/2/08, No attempts [illegible] [illegible] wanders. 3/1/09, No attempts at elopement. No changes. 5/26/09, No attempts at elopement this quarter. Note: The Elopement Risk Alert form was not updated or otherwise revised to alert staff that the resident s Wander-guard was discontinued on 12/4/09. On 12/16/09 at 11:52 a.m., the ADON informed the survey team that Elopement Risk Alerts were kept at the nurses station and up front.

4 Nurses Notes, dated 1/15/09 through 12/10/09, Quarterly Care Conference notes, dated 7/13/09 and 9/22/09, and a Care Management Summary, dated 11/19/09, did not contain documentation regarding the Wander-guard alarm, nor any team discussion or rationale for discontinuing the Wander-guard. Monthly Behavior Monitors for October, November, and December 2009, revealed documentation of only one episode of wandering, on 12/10/09, the date of the incident. Note: During an interview on 12/16/09 at 11:55 a.m., the ADON and Administrator defined wandering as attempts to leave the building and were associated with the resident s Wander- guard alarming at the front door and/or staff observing overt attempts to leave the building. Any aimless walking, or confused wandering would not be documented on the Behavior Monitors. An Incident/Accident Report (I&A), dated 12/10/09, documented Resident was outside of facility near Highway 7 and fell. Witnesses reported to facility, staff went to help resident, ambulance called, resident transported to local hospital. The I&A documented under location of injury, Broken nose, broken orbital, big laceration, several head bleeds. The corresponding Administrator s investigation, dated 12/15/09, documented, On December 10 at 1:30 p.m., the resident was taken to her room by a CNA to sit in her chair. At approximately 1:40 p.m., the facility administrator was at the door of the facility and was informed by a volunteer that had just left the building that an elderly lady was on the road. The administrator and another staff member went to the resident, who was approximately 250 feet from the facility, lying on the ground. 911 was called. The ambulance arrived within minutes, and transported her to the hospital emergency room. It was determined that the resident was out of the building approximately 5-10 minutes. The associated emergency room note, dated 12/10/09, documented the resident arrived in the emergency room at 2:05 p.m. and was admitted to the hospital at 5:00 p.m. The hospital Admission History and Physical (H&P), dated 12/10/09, documented, CT [X-ray Computed Tomography] of the head shows an intraparenchymal hemorrhage/contusion on the left parietal hippocampal region, 9 millimeters, and a contrecoup [injury produced at a site by a blow on the opposite side] injury on the right, 13 mm. An orbital [eye socket] fracture with blood and air fluid levels in the left maxillary [upper jaw] sinus, and a depressed, comminuted [broken into small fragments] nasal fracture. The Plan listed on the H&P included, Will further assess her abrasions and lacerations to see if any need to be repaired, and do so if able. We will watch her and do neurological checks, use morphine and Zofran to help with nausea and pain. She has vomited multiple times in the emergency department and has been suctioned well. Certainly, she is at risk for aspiration pneumonia. She may require transfusion depending on the amount of blood loss from the lacerations and epistaxis. The resident remained in the hospital until 12/15/09, when she was readmitted to the facility. A Care Management Summary, dated 12/15/09, documented that a Wander-guard was placed on Resident #1 when she was readmitted. Surveyors entered the facility on 12/15/09 at 4:00 p.m. During the initial tour, four exit doors in the building were observed and tested. Three of the four exit doors were locked and/or alarmed with a key pad. The main door to the facility had no locking apparatus but was equipped with a Wander-guard alarm system that alarmed if a resident, with a Wander-guard in place, approached the door. The front door opened into a small lobby. The front door was visible to the receptionist s desk which was located nearby, behind a glass window. A glass window also ran between the lobby and the main dining room. However, a large Christmas tree stood in front of the window which prevented a full view of the front door.

5 The nurses station was located down a walled corridor, approximately 30 feet from the lobby. The nurses station was centered at the start of three halls where the residents resided, attended activities, and spent most of their day. Neither the front door nor the lobby were visible from the nurses station. The main door led outside the facility to a small fenced patio with a loosely latched gate. The gate opened onto a parking lot with two driveways. Both driveways sloped down to a public gravel road which, if taken to the right, continued to another graveled road that led to a State Highway. There was a large open ditch at the intersection of the public road the State highway. A steep sloping hill was directly across the State highway. A railroad track was at the bottom of the hill and a fast-moving river was just beyond the railroad track. During an interview on 12/15/09 at 6:00 p.m., Resident #1 s primary physician was interviewed. During the interview, the resident s physician was asked about the risk the resident s elopement and fall put the resident at. Her physician stated, She could have died because she did not have the where-with all to get out of the road or back to the facility. The physician said the resident could have been hit by a car as well as died from exposure. Regarding the resident s injuries, the physician stated, It looks like most of the force was to her face. He stated she had nasal and left orbital fractures, a laceration over the left eyebrow, and bruising on her forearms and knees. The resident s physician stated, however, he was not sure the intraparenchymal hemorrhage was caused by the fall, or occurred before the fall and caused the elopement behavior, which he felt was out of character for her. The physician said Resident #1 was previously placed on Plavix because she had TIAs (transient ischemic attacks or mini strokes). He indicated the Plavix could have possibly contributed to a spontaneous intraparenchymal bleed. Note: Physician Recapitulation Orders for December 2009 included an order, with an initial date of 11/26/08, for Plavix 75 milligrams daily by mouth. Further, the resident s physician stated it would be unusual for a fall to produce an intraparenchymal hemorrhage because of the location of the bleed in the center of the parietal lobe. He stated a fall typically resulted in other types of bleeds, such as subdural and epidural hemorrhages. On 12/16/09 at 10:00 a.m., the Administrator was interviewed regarding the 12/10/09 elopement of Resident #1. The Administrator stated that on 12/10/09 the husband of a staff member was driving to the facility, at shift change, when he saw a resident walking down the gravel road toward the main highway. The Administrator stated by the time the man turned his vehicle around and went back to the resident, the resident had fallen face first onto the road. The Administrator stated the man yelled to a volunteer who was just leaving the facility and the volunteer yelled to the Administrator who was standing at the front door of the facility with the Social Services designee (SSD). Both the Administrator and the SSD went to the resident. The Administrator said the resident was dressed in Normal clothing she wears here in the building. She normally carries a purse and she had that with her. She had not put a coat on or anything. He said an ambulance was called and the resident was quickly taken to the emergency room at the local hospital. The Administrator confirmed the information reported on the 12/10/09 I&A and in his 12/15/09 investigation report. During the interview, the Administrator was also asked about Resident #1 s Wander-guard, including when the decision was made to discontinue the Wander-guard and the rationale behind the decision to discontinue it. The Administrator stated that on or around 12/2/09, the ADON, the Social Worker, Activities Director, a CNA and he were in a Patients at Risk (PAR) meeting. The Administrator stated that during the meeting the Wander-guard alarm at the front door kept going off because Resident #1 would continually sit on the front couch. The couch was in the lobby by the front door and the resident s proximity to the front door caused the alarm to go off. The Administrator indicated this stimulated a conversation in the PAR meeting regarding why Resident #1 wore a Wander-guard and if she still needed it. The Administrator stated the facility s intent was to decrease the use of loud alarms because of the disruption and wanting to make the facility more homelike. During the meeting, PAR members were told that Resident #1 had not exhibited

6 exit-seeking behavior for at least a year. Note: This was an informal conversation and did not include review of the resident s record or data regarding exit seeking behaviors]. The Administrator stated based on the verbal report of those present in the meeting, the decision was made to remove the Wander-guard. The Administrator was asked if the decision to remove the Wander-guard was documented. The Administrator stated he did not know, but the ADON would know. On 12/16/09 at 10:20 a.m., the two surveyors and the Administrator walked from the facility to the incident site. The Administrator stated the resident was found in the road about 7-10 feet from the intersection with the State Highway. The location appeared approximately 250 feet from the facility. The Administrator stated the roads were dry on 12/10/09 but that it was very cold that day. He reported the temperature was around 15 degrees Fahrenheit. During the walk to the incident site, the surveyors observed the large open ditch which was at least 10 feet wide by 12 feet long by 6 feet deep. There was no fence or barrier around the ditch to deter a person from falling or climbing into it. On 12/16/09 at 10:40 a.m., the facility s receptionist was interviewed. The receptionist stated an unofficial function of her job was to monitor the front door and redirect residents, with Wander-guards, away from the door when the alarm sounded. The receptionist stated she worked 8:00 a.m. to 5:00 p.m., Monday thru Friday, with a one hour lunch break. The receptionist stated other front office staff monitored the front door when she was on break. The receptionist said the other office staff did not always visibly monitor the front entrance but would continue working in their own offices and listen for the Wander-guard alarm. The receptionist stated the other office staff would come to the lobby and redirect the resident if the alarm went off. She stated, We all just try to hear the door. The receptionist stated she was taking her lunch break at the time of the incident on 12/10/09 and as far as she was aware, Resident #1 was not observed exiting the building. On 12/16/09 at 11:50 a.m., in response to questions regarding Resident #1 s Wander-guard and the rationale to discontinue it, the ADON stated, I ve been here over a year. I ve never seen her exit seek. The ADON added, I m thinking it was a PAR meeting. The resident was sitting up front and we couldn t get her to move. She was totally not responding that day to attempts to get her to move and the alarm was going off. The ADON was asked who removed the Wander-guard and she stated, I removed the Wander-guard. The ADON said the decision to discontinue the Wander-guard was based on reports from people at the PAR meeting, including herself, who said they did not know of any attempts to elope for at least two years. The ADON shook her head no when asked if any PAR member reviewed Resident #1 s record regarding past behavior monitors and why the resident was originally placed on the Wander guard prior to the decision to discontinue the Wander-guard. When asked if there was documentation that the Wander-guard was discontinued, the ADON said, I did not. She added that a change was made to the Elopement Plan of Care but she did not think it was put in the 24-Hour Report. The Administrator named CNA-1 as the last staff to see Resident #1 before the elopement on 12/10/09. On 12/16/09 at 2:30 p.m., CNA-1 was interviewed regarding Resident #1 s behavior and Wander-guard on 12/10/09. CNA-1 stated the resident s primary CNA (CNA-2) had told her that three times that day, the resident would not stay in her room. CNA-1 stated, [Resident #1] seemed a little confused about where her room was, because she tried to go into a different room. CNA-1 indicated, however, that the resident was easily redirected and stated, I wouldn t have known anything was different if [CNA-2] wouldn t have said anything. CNA-1 stated, From the time I put her in her room it was 1:30 p.m. to when all the commotion started was right at 15 minutes. CNA-1 stated that after the incident, the Administrator told her the resident s Wander-guard had been taken off two days earlier. CNA-1 stated, Otherwise, I didn t know it was off.

7 On 12/16/09 at 3:15 p.m., CNA-2 was interviewed by telephone regarding Resident #1 s behavior and the Wander-guard on 12/10/09. CNA-2 stated, After lunch [Resident #1] was standing at the nurses station and I took her to her room and she went in. Then, about 1:30 p.m., I saw another worker take her to her apartment. CNA-2 stated, Sometimes she isn t too cooperative, but she was that day. When asked if she was aware the Wander-guard had been removed, CNA-2 stated, I did not know. On 12/16/09 at 3:15 p.m., the Administrator was asked for the investigative interviews related to Resident #1 s 12/10/09 elopement/fall. The Administrator provided hand written notes. Review of these notes revealed eleven names/interviews on seven pages. However, none of the pages, and none of the entries, were dated, timed or signed. One page contained three names, two CNAs and one business office staff. Another page contained five names, one Activities staff, one CNA and three LNs. The remaining five pages contained individual interviews. However, one CNA was named twice in the seven pages. The page with three names documented No next to each of the names. The page with five names documented, [D]idn t know Wander-guard was off next to four of the names. On 12/16/09 at 4:50 p.m., the Administrator was asked to clarify the meaning of no next to the names on the page with three staff names, and what the note Didn t know Wander-guard was off meant next to the four staff names on the page with five staff names on it. The Administrator stated, No meant they didn t know the resident s Wander-guard was off. The Administrator confirmed that the four staff, on the page with five names, also did not know the Wander-guard was off. The Administrator was asked when the interviews were conducted. The Administrator said all but one interview was conducted on 12/10/09 shortly after Resident #1 s elopement/fall and the last interview was conducted the next day. The Administrator did not recall the times of the interviews. The investigative interview notes and the staff and Administrator interviews revealed that four of four CNAs, three of three business office staff and three of three LNs were not aware that Resident #1 s Wander-guard had been removed on 12/4/09. On 12/16/09 at 2:00 p.m., the Administrator was asked if there was any system in place to monitor the front door to ensure that cognitively impaired residents without Wander-guards, such as Resident #1, did not exit the building without being noticed or accompanied. The Administrator stated no. The Administrator was also asked if the front door was ever locked after hours and/or when the receptionist was not on duty. The Administrator stated he was not sure but would find out. The Administrator later returned and stated the front entrance door remained unlocked 24 hours per day, seven days per week. He again stated the only way the front door was monitored, when the receptionist was off duty, was for staff to listen for the Wander-guard alarm. Resident #1 was seriously harmed and placed at risk for death when the facility failed to ensure the resident, who was cognitively impaired and wore a Wander-guard for over 2 years, was appropriately assessed and care planned prior to the removal of the Wander-guard on 12/4/09. The facility also failed to alert the resident s care staff, and other staff responsible for assisting to monitor residents attempts to leave the building, that Resident #1 s Wander-guard was removed. Finally, the facility failed to ensure that the front door was adequately monitored to prevent cognitively impaired residents, who were independently mobile, from exiting the building without notice.

8 On 12/17/09 at 11:00 a.m., the Administrator provided an acceptable plan of correction and the immediate jeopardy was abated. The Plan of Correction included: Resident #1 was admitted to the hospital for care. The resident later returned to the facility and a Wander-guard was put in place. Care plans for all existing residents were reviewed between 12/11/09 and 12/15/09. The care plans for residents identified as having, or potentially having, exit-seeking behaviors were modified to include preventative measures. Twenty-four hour a day visual monitoring of the front entrance door access began on 12/16/09 at 5:00 p.m. A 24-hour schedule was provided that listed staff assigned to monitor the front entrance door until the installation of a door alarm is completed. Installation of a front entrance door alarm that will include a coded key pad for exit. The alarm will sound when anyone attempts to exit without entering the alarm code. Installation of the new system is scheduled for 12/18/09. The administrator provided a copy of a quote from the company installing the alarm. Once installed, the maintenance department will check the alarm system daily for one week, three times a week for three weeks, and then monthly. Information about the alarm system will be documented and followed up in the Performance Improvement Program (PIP) on a monthly basis and will become a part of the ongoing PIP program. Decisions concerning a resident s risk of exit-seeking behaviors will be assessed by the IDT (Interdisciplinary Team). If a decision is made to remove a monitoring device, the rationale for removing the device will be documented in the Care Management Meeting notes. The facility staff will be notified through the 24 Hour Report, at daily stand-up meetings and in the daily nursing rounds meetings. The charge nurse will notify CNAs at shift change of any changes in monitoring devices for any resident, and for the need for increased monitoring per the updated care plan. Changes in monitoring devices will be noted in the care plan. The care plan will also include increased resident monitoring for at least 72 hours after removal of the device, or longer, as deemed appropriate. If any exit-seeking behavior is noted, the monitor device will be reinstated. On 12/12/09, care staff were in-serviced to review the 24 hour report at shift change for issues related to changes in Wander-guards as well as behaviors that could lead to exit seeking. On 12/12/09, CNAs were also in-serviced to make a visual head count at shift change and report results to the Charge Nurse. An updated list of residents identified as potential elopement risks has been placed at the nurses station as well as the reception desk. The book includes pictures of the residents listed. To monitor compliance, the DON will check the 24 hour report on a daily basis, for one week, for any changes in monitoring devices. If any changes are noted the DON will review all of the above steps to ensure compliance. If no discrepancies are noted for one week, the DON will continue weekly monitoring for one month. If no instances of noncompliance are noted for the month, the DON will continue monthly monitoring on an ongoing basis. Reports of the monitoring will be reviewed in the monthly QI (Quality Improvement) meeting. The risk of elopement will be assessed with quarterly care plan updates and as needed. There will be a review in the monthly QI meeting of who is care planned for a monitoring device and who has one. Any exit seeking behaviors will be addressed immediately and reviewed in QI.