Other·May 25, 2022

T22 DIV 5 CH3 ART 5 § 72523 Patient Care Policies and Procedures (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. The facility failed to identify the root cause of elopements and failed to develop interventions to prevent further occurrence of elopement incidents. This failure resulted in Resident 3 eloping multiple times and managing to cross a busy street, undetected by facility staff, which could have led to serious harm, including major permanent loss of function and accidental death. Resident 3 was a 57-year-old male, admitted to the facility on 7/3/15, with diagnoses including Dementia (memory disorder) with behavioral disturbance, Schizophrenia (a serious mental illness that interferes with a person's ability to think clearly, manage emotions, make decisions and relate to others), Anoxic Brain Damage (harm to the brain due to a lack of oxygen) and Hemiplegia and Hemiparesis (paralysis of one side of the body), following other Cerebrovascular diseases (group of conditions, diseases, and disorders that affect the blood vessels and blood supply to the brain), affecting right dominant side (stronger side of the body; writing and eating are usually done with the hand on the dominant side). During a clinical record review for Resident 3, the MDS, dated 7/11/18, indicated Resident 3 had a total BIMS score of 11/15 (Brief Interview for Mental Status - a 15-point cognitive [relating to thinking or reasoning] screening measure that evaluates memory and orientation and includes free and cued recall items. A score of 13 - 15 is cognitively intact, 08 - 12 is moderately impaired, and 00 - 07 is severe impairment), indicating Resident 3 had moderate cognitive impairment (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). 1. First Elopement During a clinical record review for Resident 3, the Nurses Progress Notes, dated 9/6/18 at 1:59 p.m., indicated Resident 3 left the facility and walked across the street at around 8:30 a.m., and returned to the facility at 8:40 a.m. During a clinical record review for Resident 3, the Elopement (an act or instance of leaving a safe area or safe premises) Care Plan, initiated on 9/6/18, indicated interventions for, "1:1 monitoring (resident was provided with a sitter) for three days to ensure (Resident 3's) safety; Constant reminder to (Resident 3) not to go out of the building until he gets it; Wanderguard (a signaling device to alert staff of resident's attempt of leaving facility unsupervised) on at all times; frequent rounds by staff and frequently aware of (Resident 3's) whereabouts." 2. Second Elopement During a clinical record review for Resident 3, the Nurses Progress Notes, dated 9/24/18 at 3:55 p.m., indicated Resident 3 walked across the street yelling. Two nurses escorted Resident 3 as he walked through the traffic and entered a neighboring facility. The doctor was notified, after Resident 3 was brought back to the facility, and ordered to monitor Resident 3's whereabouts every hour for 72 hours. During a clinical record review for Resident 3, the Elopement Care Plan, initiated on 9/24/18, indicated interventions for staff to monitor and record Resident 3's activity every 30 minutes; call the police if not able to convince Resident 3 to return to the facility; medicate Resident 3 per doctor's order; and for staff to stay with Resident 3 at all times. These interventions were discontinued on 10/25/18. During a clinical record review for Resident 3, the Elopement Risk Assessment, dated 9/24/18 at 3:55 p.m., indicated Resident 3 wandered (to move around or go to different places, usually without having a particular purpose or direction) aimlessly and scored 26, which put Resident 3, "At High Risk for Elopement." 3. Third Elopement During a clinical record review for Resident 3, the Incident Report, dated 9/29/18 at 8:30 p.m., indicated Resident 3 was walking across the street through traffic with a Certified Nurse Assistant (CNA) and another nurse. Staff tried to redirect Resident 3, but Resident 3 was persistent to go across the street. 911 was called, per Doctor's order, to have Resident 3 evaluated at the nearest hospital. The predisposing situation factor indicated Resident 3 was a wanderer. During a clinical record review for Resident 3, the Elopement Care Plan did not indicate new interventions after the 9/29/18, elopement incident, to prevent Resident 3 from leaving the facility unsupervised. There was no Interdisciplinary Team (IDT - group of health care professionals with various areas of expertise who work together toward the goals of the resident) Note, indicating the team did an analysis of what caused Resident 3 to leave the facility. 4. Fourth Elopement During a clinical record review for Resident 3, the Incident Report, dated 3/14/19 at 9:03 a.m., indicated Resident 3 was found sitting outside the facility on the bushes. Resident 3 was brought back to the facility via wheelchair and was assessed upon return. No injuries were observed at time of incident. The predisposing situation factor indicated Resident 3 was a wanderer. The Nurses Note did not indicate Resident 3's Wanderguard activated the sensor alarm. During a clinical record review for Resident 3, the Elopement Care Plan did not indicate new interventions after the 3/14/19, elopement incident, to prevent Resident 3 from leaving the facility unsupervised. There was no IDT Note, indicating the team did an analysis of what caused Resident 3 to leave the facility. During a clinical record review for Resident 3, the Activities of Daily Living (ADL - the tasks of everyday life. Basic ADLs include eating, dressing, getting into or out of a bed or chair, taking a bath or shower, and using the toilet) record, from 4/6/19 to 4/12/19, indicated facility staff did not provide any form of supervision for Resident 3, when Resident 3 was up and moving within the facility. The ADL Record indicated 18 out of 20 shifts (period of work time), for ADL questions: 1) "How did the resident move off the unit (e.g., areas set aside for dining, activities or treatments)?" The CNAs responded, "Not Applicable;" and, 2) "Staff Support provided for moving to/ from off unit locations." CNAs responded, "Response not Required." 5. Fifth Elopement During a review of Resident 3's clinical record, the Nurses Notes, dated 5/8/19 at 6:41 a.m., indicated Resident 3 left the facility and was found lying down on the bushes in the middle of a busy street. Five staff members assisted Resident 3 to sit on a wheelchair, and he was brought back to the facility. The Nurses Note did not indicate Resident 3's Wanderguard was activated. During a clinical record review for Resident 3, the Elopement Care Plan did not indicate new interventions after the 5/8/19, elopement incident, to prevent Resident 3 from leaving the facility unsupervised. There was no IDT note indicating the team did an analysis of what caused Resident 3 to leave the facility. During an interview and observation with Licensed Vocational Nurse (LVN) A on 9/29/21 at 1:40 p.m., when asked what to do if a resident had exit-seeking behavior, LVN A stated she would check the resident's elopement care plan for interventions, redirect the resident and apply a Wanderguard. LVN A stated the facility had a tester kept in the medication cart to test the Wanderguard for proper functioning. LVN A was not able to demonstrate how to test the Wanderguard because LVN A could not find the tester. During a concurrent interview and record review with the Director of Staff Development (DSD) on 9/29/21 at 1:46 p.m., when asked how Resident 3 managed to leave the facility on 5/8/19, and was subsequently found lying on the bushes in the middle of a busy street, the DSD stated, "I don't know if that really happened, but I remembered (Resident 3) was found at the nursing facility across our building watching T.V. (Resident 3) was hard to manage. As soon as he opens the door he would go straight to the street." The DSD stated 1:1 monitoring was utilized only for three days for every incident of Resident 3 leaving the facility. Staff were expected to frequently check Resident 3's whereabout after 1:1 monitoring was discontinued. The DSD stated they had a monitoring log showing Resident 3's whereabout during their staff rounds. The DSD showed a copy of Resident 3's monitoring log for 2017. The DSD stated she was not able to find a record for 2018 and 2019. When asked how Wanderguards were tested and what their process was to ensure Wanderguards issued to residents were functioning properly, the DSD stated they did not have a tester for Wanderguards. Residents' Wanderguards were used to activate their alarm (departure alert system) by placing the device close to the sensor alarm located at the entrance door. When the sensor alarm beeped, they knew it was working properly. The DSD stated all Wanderguards issued to residents had an expiration date and were recorded in a tracking log which included the issue date. The DSD was not able to provide a copy of their tracking log showing when a Wanderguard was issued to Resident 3. During an interview with Certified Nurse Assistant (CNA) B on 9/29/21 at 1:59 p.m., CNA B stated Resident 3 was independent with walking. When asked how supervision was provided to residents who were independent with walking and had an exit-seeking behavior, CNA B stated they checked their residents at least every two hours. During an interview with LVN C on 9/29/21 at 2:18 p.m., LVN C stated she did not know how to test the Wanderguard for proper functioning. During concurrent interview and record review with the Medical Records Designee (MRD) on 10/1/21 at 10:46 a.m., the MRD verified there was no record of post-elopement Interdisciplinary Team (IDT) meetings for 9/29/18; 3/14/19 and 5/8/19, in Resident 3's clinical record. During a concurrent interview and record review with the Director of Nursing on 10/01/21 at 2:39 p.m., the DON verified the following, after reviewing Resident 3's record: - Resident 3's Elopement Care Plan did not indicate new interventions for the following elopement episodes: 9/29/18, 3/14/19, and 5/8/19. - There was no tracking log of the Wanderguard issued to Resident 3, to verify model compatibility with the facility's departure alert system (alarm will not sound if signaling device is not compatible with the departure alert system). - There was no record of Resident 3's Wanderguard being checked daily for functioning. - There was no record of Resident 3's monitoring log (15 minutes safety checks), as indicated in the facility Policy and Procedure titled, "Emergency Procedure - Missing Residents," for every episode of Resident 3 leaving the facility. - Facility Policy and Procedure for Wanderguard did not include maintenance instructions to ensure signaling device was functioning properly. Review of the document provided by the facility titled, "Stanley Healthcare," Wanderguard user instructions, indicated how to test the signaling device and listed the following warnings: - "Test each signaling device before using. Thereafter, test the device daily and record the results in the resident's records." - "Not all WanderGuard signaling devices are designed to work with all WanderGuard departure alert systems. Strictly follow the 'WanderGuard signaling device compatibility' chart. Failure to comply with the chart may cause an unauthorized departure." - "The 1-year signaling device is designed to work for 1-year. Each device has a stamp on the side of the case. This 'DO NOT USE PAST' date is the last date the device should be on a resident..." Review of facility policy and procedure titled, "Policy and Procedure on Wanderguard," revised on 7/2012, indicated, "Facility attempts to meet needs and provide services to residents admitted in this facility. In this connection a Wanderguard equipment is installed to have surveillance to residents who have tendency to wander out from the facility aimlessly." The facility policy and procedure did not indicate how Wanderguards were maintained and tested for proper functioning. Review of facility policy & procedure titled, "Elopement Risk Precautions and Procedures," revised on 01/2013, indicated, "It is the policy of the facility to identify residents who are wanderers or who are a threat to leave the facility unattended without the knowledge of the facility staff." Procedures indicated: - "A plan of care will be developed and implemented with specific approaches and a goal for the resident who is exit seeking or has a history of elopement." - "Staff is responsible for knowing and recognizing the resident who has exit seeking behavior to intervene as needed." - "The medical record will also reflect an analysis of the events leading up to the elopement and interventions to prevent another occurrence. Prevention methodologies will also be reflected in the care plan." Review of facility policy and procedure titled "Emergency Procedure - Missing Resident," not dated, indicated, "Document the incident and events objectively in the resident record, including...circumstances and precipitating factors...additional prevention strategies implemented." The policy indicated nursing staff were to update the care plan and evaluate implementing additional measures. Review of the facility Policy and Procedure titled, "Care Plan" indicated, "A care plan is the summation of resident concerns, goals, approaches and interventions to meet the goals and help minimize if not totally eradicate resident's problems." Procedure indicated, "The evidence of care plan that has been reviewed should include but not be limited to the new interventions that have been added in addition to the current ones." Therefore, the facility failed to identify the root cause of elopements and failed to develop interventions to prevent further occurrence of elopement incidents. This failure resulted in Resident 3 eloping multiple times and managing to cross a busy street which could have led to serious harm, including major permanent loss of function and accidental death. These violations had a direct or immediate relationship to the health, safety, or security of Resident 1.