Health inspection·January 26, 2021

F 689 K §483.25(d) Accidents. The facility must ensure that §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents. T 22 §72637(a) The facility, including the grounds, shall be maintained in a clean and sanitary condition and in good repair at all times to ensure safety and well-being of patients, staff and visitors. The facility failed to follow the aforementioned regulations by not providing adequate supervision and environmental barriers to prevent unauthorized entry or exit from the facility, which resulted in an Immediate Jeopardy (IJ, a situation in which a facility's actions places one or more residents/patients in jeopardy of being significantly harmed up to the point of possible death if not immediately corrected) on 4/30/2020, at 4:00 p.m., with the Administrator and Director of Nursing (DON). The facility failure to provide locking mechanisms to prevent fully opening one window in Room A, a sliding glass door in Room C, and a sliding glass door in Room D, had the potential to result in unauthorized access by strangers to the facility, or unauthorized exit (elopement) from the facility by residents. These failures resulted in Resident 1's elopement from the facility for 16 hours. Resident 1's elopement placed him at risk of injury and serious harm from falling while walking on unfamiliar terrain, wandering into traffic, and lack of prescribed medications, shelter, food, and water. Through observation, interview, and record review, the facility demonstrated they had initiated the plan of action for providing adequate supervision and environmental barriers to prevent elopement. During an observation and interview on 5/4/2020 at 11:50 a.m., with Maintenance Supervisor (MS), MS confirmed the repair work was completed. Room A's window was intact, with a functional window lock in use; Room C and Room D had functional sliding door locks in use. During a review of Resident 1's monitoring log titled, "Resident's Q Shift Monitoring," dated 4/29/2020, through 5/6/2020, the log indicated certified nursing assistants had documented Resident 1's location and activity every 15 minutes from 4/29/2020, at 4:30 p.m., until 5/4/2020, at 12 p.m. The Immediate Jeopardy was lifted on 5/4/2020 at 3:13 p.m. During a review of Resident 1's Facesheet, printed 4/29/19, the Facesheet indicated Resident 1 was admitted to the facility in 2019, with diagnoses of schizophrenia (a mental illness that causes disturbed or unusual thinking, and strong or inappropriate emotions), and brain damage from a stroke (interrupted blood flow to the brain) which caused an inability to speak, and difficulty eating. The Facesheet indicated Resident 1 was assigned to Room A. During a review of Resident 1's History and Physical (H & P), dated 1/8/2020, the H & P showed Resident 1 had a conservator to make all his medical, financial, and personal decisions. During a review of Resident 1's comprehensive Minimum Data Set (MDS, an assessment tool used to guide patient care), dated 3/9/2020, the MDS indicated Resident 1 was unable to complete the Brief Interview for Mental Status examination (BIMS, an assessment tool for a resident's orientation to time, and capacity to remember.) The MDS indicated Resident 1 was unable to complete the BIMS examination, so staff assessed his capacity as modified independent. The MDS indicated Resident 1 required a four wheeled walker (an assistance device for ambulation, with handlebars and four wheeled legs) to be able to balance while walking. During a review of the Medication Administration Record (MAR) for April 2020, the MAR indicated Resident 1 received two medications for treatment of schizophrenia: olanzapine 10 milligrams (mg), twice a day, for treatment of unreal beliefs and visions, and valproic acid 250 mg, twice a day, for stabilizing sudden anger outbursts. The MAR also indicated Resident 1 had an order for doxazocin, a medication to control high blood pressure, 1 mg, a once a day. The MAR indicated Resident 1 missed one dose of olanzapine, one dose of valproic acid, and one dose of doxazocin on 4/29/2020. During an interview on 5/5/2020, at 7:15 a.m., with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated she completed her rounds on assigned residents between 11:45 p.m. on 4/28/2020, and 12 a.m. on 4/29/2020. CNA 1 stated she observed Resident 1 laying on his bed in Room A, during her rounds. During an interview on 5/6/2019, at 12:50 p.m., with Certified Nursing Assistant 3 (CNA 3), CNA 3 stated she exited the facility through the front lobby on 4/29/2020 around 1 a.m., to check her car. CNA 3 stated she noticed the window screen from Room A had been dislodged, so she returned to the facility to notify Licensed Vocational Nurse 2 (LVN 2) about the screen. CNA 3 stated she checked Room A, and Room A's bathroom, but was unable to locate Resident 1. CNA 3 stated she and CNA 1 drove around the local area, but were not able to find Resident 1. During an interview on 5/5/2020, at 7:15 a.m., with Certified Nursing Assistant (CNA 1), CNA 1 stated she returned to Resident 1's room around 1 a.m., on 4/29/2020, after CNA 3 told her about the dislodged screen of Room A. CNA 1 noticed Resident 1 was no longer in Room A, the room's window was broken, and the room's window screen was on the outside steps below the window. During an interview on 5/7/2020, at 12:02 p.m., with Certified Nursing Assistant 4 (CNA 4), CNA 4 stated on 4/29/2020, around 1 a.m., Licensed Vocational Nurse 2 (LVN 2) informed her that Resident 1 was gone. CNA 4 stated she and the other three certified nursing assistants looked for Resident 1 inside the building, and on the adjacent street. CNA 4 stated she noticed Room A's sliding window was pushed open. During an interview on 5/5/2020, at 11:33 p.m., with LVN 2, LVN 2 stated on 4/29/2020, he had been administering medications from 12 a.m. to 1 a.m. LVN 2 stated between 12 a.m. and 1 a.m., the certified nursing assistants (CNAs) were occupied gathering linen, and assisting a resident who required three personnel for repositioning and care. LVN 2 stated CNA 3 told him, around 1 a.m., that Room A's screen was pushed out onto the stairs, the sliding portion of the window was open, the bottom of the sliding portion of the window was cracked, and Resident 1 was missing. LVN 2 stated he and the other staff searched the building, and drove around the area, but were unable to locate Resident 1. LVN 2 stated he called the police and reported Resident 1's elopement. During a review of Resident 1's nurses' notes by LVN 2, dated 4/29/2020, at 4:01 a.m., the notes indicated LVN 2 called 9-1-1 and reported the elopement on 4/29/2020, at 1:30 a.m. During a review of the Police Department document, "Missing Person Report," dated 4/29/2020, indicated Resident 1 was last seen around 12 a.m., discovered absent around 1:30 a.m., and Resident 1 might have left the facility through his bedroom window. During an interview on 4/30/2020, at 11:00 a.m., with the Maintenance Supervisor (MS), MS stated he was driving on a city street on 4/29/2020, around 4 p.m., when he saw Resident 1 ambulating on the sidewalk with his walker. MS stated he pulled over to the curb, called Resident 1 by name, and Resident 1 got into the car, and MS returned him to the facility. During an interview on 4/30/2020, at 10:15 a.m., with the Director of Nursing (DON), the DON stated MS brought Resident 1 back to the facility on 4/29/2020, around 4:20 p.m. During an interview on 5/5/2020 at 4:07 p.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated Resident 1 returned to the facility on 4/29/2020, with the Maintenance Supervisor at approximately 4:20 p.m., LVN 1 stated Resident 1 was moved to Room B, because the window in Room A was still not repaired. LVN 1 stated he had completed a skin assessment, and noted a bruise on Resident 1's left buttock. LVN 1 stated Resident 1 was unable to verbalize words, and could only point or move his head in response to questions. LVN 1 stated Resident 1 did not respond to his question of whether Resident 1 had any pain anywhere, beyond wiping down his bed with a blue cloth. During a review of Resident 1's, "Skin Assessment Sheet," dated 4/29/20, at 5 p.m., the Assessment indicated the new presence of a 3 by 2 (no units indicated) "bluish discoloration" on his left buttock. During an observation on 4/30/2020, at 10 a.m., the facility had five steps leading up to the lobby entrance. The steps were bordered on one side by the building, and on the other side by a metal guardrail. There was a handrail attached to the building alongside the steps, with a window four inches above the handrail at the second step from the top. The window was a two section window: the section toward the back of the building was immobile; the section toward the front of the building was able to slide in a track toward the back of the building to open that side of the window. Each window section measured four feet high by two feet wide. The sliding section had an improperly fitting screen on the outside of the window. The sliding window had duct tape around the edges of the glass, and a dollar sized portion of the bottom corner, closest to the front of the building, had missing glass. The bottom of the window was three feet and four inches above the second step from the top of the stairs. At the top of the stairs was a landing leading to the entry of the facility. Upon entry to the facility, the window was identified as the window to Room A, Resident 1's room at the time of the elopement. During a concurrent observation and interview in Room A, on 4/30/2020, at 10:22 a.m., with MS, MS confirmed Room A's sliding window had a section of broken glass in the corner, covered by duct tape. At the bottom of the stationary portion of the window, was a track for the sliding portion of the window. The sliding window track had two metal devices screwed onto the track; both devices were not secured to the track, but moved freely along the track. MS stated when the devices were fastened securely on the track, the devices prevented the sliding window from fully opening. MS stated checking the devices was not part of his routine maintenance checks. During a concurrent observation and interview, in Room C, on 4/30/2020, at 11:11 a.m., with the Director of Nursing (DON), Room C had a sliding glass door which opened onto a fenced patio. The patio was enclosed by a three foot high railed metal fence, the fence separated the patio from the facility parking lot and the exit to the city street. DON grabbed the handle of the room's sliding glass door handle, which became dislodged. DON confirmed the door handle was missing the bottom screw which secured the handle in place. DON was able to fully open the sliding door; devices to secure the door from fully opening were located at the extreme end of the sliding door track, and had not prevented the door from opening. During an observation in Room D, on 4/30/2020, at 12:01 p.m., Room D also opened onto the same fenced patio as Room C. The sliding door of Room D was fully open, with no staff supervision in the area. During an observation and interview on 4/30/2020, at 11:30 a.m., with MS, the back door to the facility alarmed when opened; the alarm stopped when the door closed. The door exited into a parking lot which had direct, unobstructed street access. MS stated he had entered the facility one night, and staff had not checked on the reason the back door alarm sounded; MS found staff watching television in an unoccupied resident room. During an interview on 5/4/2020, at 1:17 p.m., with the DON, DON stated all staff were responsible for determining the reason for an exit door alarm. During a review of the facility's policy and procedure titled, "Maintenance Service," revised December 2009, indicated the Maintenance Department was responsible for maintaining the building in good repair and free from hazards. The PNP indicated, "Maintenance personnel shall follow established safety regulations to ensure the safety and well-being of all concerned." During a review of the facility's policy and procedure (PNP) titled, "Elopement Prevention," undated, the PNP indicated the facility used, "multi-faceted approaches to assure resident safety." The approaches included environmental measures such as secured doors, secured exterior gates, and weekly checks of the exit door alarms. Therefore, the facility failed to provide adequate supervision and environmental barriers to prevent unauthorized entry or exit from the facility, allowing Resident 1 to elope for 16 hours and potentially allowing other residents to elope or other persons to gain unauthorized access to the facility.