Other·April 5, 2022

§483.25(d)(1)(2) 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. The facility failed to provide adequate supervision to prevent one of two residents (Resident 1) from leaving the facility without staff's knowledge and permission when staff did not follow the plan of care to provide a wander alert (such as WanderGuard, a device applied to the resident's body designed to support caregivers, with simple keypad commands, the option for door bypass using keypads that helps prevent elopement), and to monitor Resident 1's location every 60 minutes. These failures compromised Resident 1's health and safety that resulted in admission to the acute hospital admission due to contusion of the head, congestive heart failure (CHF, a heart condition that causes symptoms of shortness of breath, weakness, fatigue, and swelling of the legs, ankles, and feet), and COPD exacerbation (exacerbation of chronic obstructive pulmonary disease [COPD] acute event characterized by sustained worsening or "flare up" of any of the patient's respiratory symptoms (cough, sputum quantity and/or character, dyspnea) that is beyond normal day-to-day variation). Findings: Review of Resident 1's facesheet indicated facilitys admission on 7/18/2020 with diagnoses of vascular dementia (general term describing problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to the brain) with behavioral disturbance, heart failure (a heart condition that causes symptoms of shortness of breath, weakness, fatigue, and swelling of the legs, ankles, and feet), alcohol dependence, nicotine dependence, history of falling, lack of coordination, and unsteadiness on feet. Review of Resident 1's Wandering Risk Assessment dated 7/18/2020 and 10/25/2020 both indicated score of 8 or moderate risk for elopement, with known history of wandering and a known wanderer. The interdisciplinary team (IDT, facility staff members from different departments who coordinate care provided to residents) Care Plan Conference Summary dated 10/15/2020 indicated he was confused and rarely communicates, risk for falling and elopement with no discharge plans. Review of Resident 1's minimum data set (MDS, an assessment tool) dated 7/25/2020 and 10/25/2020 both indicated the resident had not used any wander/elopement alarm. His MDS dated 11/26/2020 indicated short term memory problem, with moderately impaired daily decision making (decisions poor, cues/supervision required), and activities of daily living (ADL) that required supervision on transfer, walking in room and corridor, and locomotion in and off unit, one person assist with toilet use. Review of Resident 1's care plan on "Risk for Elopement/Wanderer" dated 7/18/2020, included wander alert and monitoring of location every 60 minutes. Document wandering behavior and attempted diversional interventions in behavior log. Review of Resident 1's Progress Notes, "Psychosocial Notes", dated 7/22/2020 indicated the resident was found outside by the kitchen area, and was escorted back inside the building. He also tried getting out through the side door, and the progress notes also indicated he had another incident of possible elopement reported by staff at 2:00 p.m. that afternoon. Review of Resident 1's "Care Plan Conference Summary" dated 10/25/2020 indicated the IDT considered him "Risk of falling; elopement" and "doctor indicate he has no capacity to make decisions". Review of Resident 1's Progress Notes dated 11/24/2020 indicated, "Besides due to his diagnosis of Dementia, per owner he tends to wanders and leave their house which is independent living. Even though this resident wants to leave this facility, he is not appropriate to be in a board and care not in a residential care home." Review of Resident 1's SBAR (Situation, Background, Assessment, and Recommendation/Request, a form of nurses progress notes) dated 11/25/2020, indicated at 2:45 p.m., CNA (certified nursing assistant) reported that resident could not be located for the eye appointment. The director of nursing (DON) and administrator (ADM) were notified, and search for the resident all over the facility was initiated. Review of Resident 1's "Progress Notes" dated 11/26/2020 at 11:17 a.m., indicated, "Resident was found missing....search for [Resident 1] was initiated but could not be found, and local police department was notified to search nearby. "Today, cops call and still he had not shown up...". The Progress notes dated 12/1/2020 indicated "resident was found last 11/26/2020 at 2:00, when a store owner noticed him and stayed overnight by his store and called the police". He was taken "at ...hospital for covid testing..". The resident was missing from 11/25/2020 at 2:45 p.m. to 11/26/2020 at 2:00 p.m. (almost 24 hours). A review of Resident 1's November 2020 physician's order included Lisinopril (medication to lower blood pressure) 40 mg. (milligrams, unit of measurement) one tablet by mouth daily for HTN (hypertension), hold for systolic blood pressure (SBP, indicates how much pressure your blood was exerting against your arterywalls) <105; Amlodipine besylate 2.5 mg one tablet daily for HTN, hold for SBP <105, Furosemide(diuretic) tablet 20 mg. one tablet every Monday, Wednesday and Friday for hypertensive heart disease with heart failure; Spiriva Respimat Aerosol solution (bronchodilator) 2.5 mcg one inhalation one time a day for Emphysema. Review of Resident 1's November 2020 medication administration record (MAR) indicated he did not get the morning dose due at 0900 for the following medications: Amlodipine, Lisinopril, Spiriva inhaler on 11/26/2020. Review of Resident 1's acute hospital "EMERGENCY PROVIDER REPORT", HPI (history of present illness) Notes dated 11/26/2020 at 3:18 p.m., indicated, "60 y/o male with a history of Schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves), COPD presented in the ED (emergency department). Per EMS, pt (patient) was reported missing from .....since yesterday, today patient discovered laying inside a bush by PD (police department) and EMS(emergency medical services, or ambulance services) was contacted. In the ED, patient states that he fell last night and struck the back of his head on the ground. No LOC (loss of consciousness). Pt currently complains of constant moderate HA (headache) and SOB (shortness of breath)." A sepsis (is a potentially life-threatening condition that occurs when the body's response to an infection damages its own tissues. When the infection-fighting processes turn on the body, they cause organs to function poorly and abnormally. Sepsis may progress to septic shock.) alert was initiated .... Patient was fluid resuscitated. On examination the patient was tachypneic (abnormally rapid breathing) and dyspneic (difficult or labored breathing) with wheezing (is a whistling sound you make when your airway is partially blocked) and crackles (are the clicking, rattling, or crackling noises that may be made by one or both lungs of a human with a respiratory disease during inhalation.)". The Primary Impression included COPD (chronic obstructive pulmonary disease), secondary impressions included CHF (congestive heart failure), Contusion of head, schizophrenia. His initial vital signs taken at 3:30 p.m., included BP 172/99, Pulse 110/minute, Respiration 26/minute. Resident 1's Emergency Provided Report" indicated he complained of constant moderate headache (HA) and shortness of breath (SOB) when he was being attended in the emergency room (ER). Review of Resident 1's acute hospital's "EMERGENCY PATIENT RECORD", dated 11/26/20, indicated Resident 1's emergency room reception arrival on 11/26/2020 at 1504 (3:04 p.m.). The Rapid Initial Assessment done on 11/26/2020 at 1520 (3:20 p.m.) included "SEVERE SEPSIS SCREENING" that indicated he was positive for severe sepsis. Resident 1's Emergency Department Course dated 11/26/2020 indicated a sepsis alert was initiated and he was fluid resuscitated with 2,400 ML (milliliter, units of measurement) Sodium Chloride (an electrolyte that regulates the amount of water in your body that is used to treat or prevent sodium loss caused by dehydration, excessive sweating, or other causes). The ED Course also indicated he was administered the following medications: Piperacillin Sod/Tazobactam sodium chloride (antibiotic) 3.375 GM (gram, unit of measurement) by intravenous route (IV, administration of medication via the vein), albuterol/Ipratropium (bronchodilators, used to treat and prevent symptoms (wheezing and shortness of breath) caused by ongoing lung disease) 3 ML by nebulization, and IV methylprednisolone sodium succinate (steroid, anti-inflammatory) 125 MG. (milligram, unit of measurement). The notes also included, "Differential Diagnosis includes acute coronary syndrome with congestive heart failure cardiomyopathy pericarditis (is inflammation of the heart muscle, and pericarditis is inflammation of the outer lining of the heart) and acute exacerbation of COPD." During an interview on 11/23/21 at 9:30 a.m., the social worker (SW) stated she knew Resident 1 "very well", who came from another facility, was confused, disoriented, verbalized wanting to go home, and "went on wandering and was missing". The SW also stated Resident 1 was considered long term and was no longer appropriate to go back to his previous residential care facility (RCF) because of confusion and wandering. During an interview with registered nurse A (RN A) on 11/23/21 at 10:57 a.m., RN A stated she remembered Resident 1 was not wearing any WanderGuard during those days when she had worked with him. RN A also stated if resident had a WanderGuard, then facility's alarm system would sound off when resident went out of the building. During a follow up interview on 11/23/21 at 11:38 a.m., the SW stated staff had an in-service in the afternoon the day when Resident 1 went missing and could not be found. Police were called and when the police officer checked the facility's video camera, it was seen Resident 1 stepped out of the facility's main door. The SW also stated staff would have heard the door alarm sound if Resident 1 had a WanderGuard, "we did not hear any door alarm otherwise we could have responded." During a record review and concurrent interview on 11/23/21 at 12:25 p.m., RN A reviewed Resident 1's clinical record and did not find any documented evidence that Resident 1 had a physician's order for WanderGuard. RN A confirmed Resident 1 had no WanderGuard applied since his admission until the elopement episode happened. RN A confirmed Resident 1 was not an elopement risk and had no previous elopement episode so a WanderGuard was never applied on him. During a follow-up interview on 11/23/21 at 1:35 p.m., RN A stated for any resident with known episode/s of elopement, a WanderGuard should be applied. She also stated staff should follow/implement Resident 1's care plan. Review of Resident 1's care plan on "Risk for Elopement/Wanderer" dated 7/18/2020, indicated interventions that included wander alert and monitoring the location every 60 minutes. Document wandering behavior and attempted diversional interventions in behavior log. During an interview and concurrent record review on 11/23/21 at 1:45 p.m., the administrator (ADM) and director of nursing (DON) both confirmed Resident 1 was at risk for elopement based on the "Wandering Risk Assessment" completed. Both the ADM and DON reviewed the resident's care plan that included the need for wander alert and monitoring of location every 60 minutes, document wandering behavior and attempted diversional activities in behavior log. The DON stated staff should have followed the care plan and should have applied a WanderGuard since he needed a wander alert device since admission. The DON also stated if there was no MD (doctor of medicine) order for a WanderGuard, "call MD to get an order for it to help prevent elopement from the facility". During interview and concurrent record review on 11/30/21 at 1:10 p.m., RN A reviewed Resident 1's clinical record but could not find any documented evidence that monitoring of the resident's location every 60 minutes was done and documented in a behavior log and wander alert device was applied, as indicated in the care plan dated 7/18/2020. During a telephone interview on 12/1/21 at 2:29 p.m., licensed vocational nurse B (LVN B) stated she was the charge nurse when Resident 1 was found missing on 11/15/2020. LVN B confirmed Resident 1 was confused, ambulatory and walked around the hallways and "he did not have any WanderGuard alarm". During an interview on 12/1/21 at 3:53 p.m., certified nursing assistant C (CNA C) stated she worked that day when Resident 1's elopement incident happened. CNA C recalled having responded to Resident 1's bed alarm multiple times because it sounded off as resident kept getting out of bed. CNA C also stated she did not hear the main door alarm sound off whenever Resident 1 would pass by or went near the main door. CNA C stated if Resident 1 had a wander alert in place, the door alarm would sound off. Review of the facility's undated policy, "Wandering, Unsafe Resident", indicated the facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement. The staff will identify residents who are at risk for harm because of unsafe wandering (including elopement), reassess at- risk individuals for potentially correctable risk factors related to unsafe wandering. The resident's care plan will indicate the resident is at risk for elopement or other safety issues. Interventions to try to maintain safety, such as detailed monitoring plan will be included. Review of the undated facility's policy, "Comprehensive Assessments and Care Delivery Process", indicated comprehensive assessments will be conducted to assist in developing person-centered care plans. Comprehensive assessments, care planning and the care delivery process involve collecting and analyzing information, choosing and initiating interventions, and then monitoring results and adjusting interventions. This failure had direct relationship or immediate relationship to the health, safety, and security of the resident.