Health inspection·November 12, 2024

REGULATORY VIOLATION: 483.25(d) Accidents The facility must ensure that: 1.The Patient environment remains as free of accidents hazards as is possible; and 2.Each patient receives adequate supervision and assistance devices to prevent accidents. 72523(a) 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. Based on observation, interview, and record review, the facility failed to provide supervision to one of 36 patients (Patient 1) in the locked memory care unit (a locked unit which is a secure area within the skilled nursing facility where people with dementia live. The locked unit prevents the patients from wandering off or leaving the facility willingly) on October 16, 2024, when staff was unaware Patient 1 (a confused resident with cognitive deficit and a history of falls) had left the facility. It was not until Surveyor 1 (a member of a survey team not employed by the facility) informed facility staff that the resident had eloped (the act of leaving the premises or safe area without authorization or supervision to do so) and was in a field adjacent to the facility building. This failure had the potential to result in serious harm or death to Patient 1 who was at risk for injuries which may occur as a result of being exposed to environmental elements, accident hazards or being without resources such as food, water, and shelter. FINDINGS: Patient 1, was initially admitted to the facility on May 7, 2024, with diagnoses which included dementia (a chronic condition that causes a decline in mental functioning, such as thinking, remembering, and reasoning, that interferes with daily life), encephalopathy (any brain disease, disorder, or damage that affects the brain's structure or function), altered mental status, fall on or from other stairs and steps [subsequent encounter], unsteadiness on feet, and hemiplegia (paralysis on one side of the body). A review of Patient 1's Minimum data set (MDS - an assessment of a patients functional and health status), dated August 19, 2024, section GG0115 indicated Patient 1 had lower extremity impairment on both sides (impairment in both legs) in section, "Functional Limitation in Range of Motion -code for limitation that interfered with daily functions or placed resident at risk of injury in the last 7 days..." Further review of Patient 1's MDS dated August 19, 2024, indicated the type of assistance the patient required for walking 10 feet included, "supervision or touching assistance - helper provides verbal cues and/or touching/steadying and/or contact guard assistance [caregiver places one or two hands on the patient's body to help with balance but provides no other assistance to perform the functional mobility task] as resident completes activity..." A review of Patient 1's Interdisciplinary Team Note (IDT - A group of professionals from different disciplines that work together to meet the needs of patients using their different perspectives and expertise.), dated October 16, 2024, the IDT note indicated Patient 1 had "...confusion and disorientation secondary to diagnosis of dementia. His BIMS score [Brief Interview for Mental Status score - a score of 0-15 used to determine cognitive functioning] is 6 [severe impairment] and does not have the capacity to make decisions..." A review of Patient 1's "Physical Therapy PT Evaluation & Plan of Treatment," with a certification period of July 30, 2024, through August 28, 2024, the physical therapy evaluation indicated, "...Reason for referral/current illness: Patient referred to PT [physical therapy] due to new onset of decrease in functional mobility, falls/fall risk and increased need for assistance from others...PMHX [past medical history] Pt [patient]...change in function post fall with facial bruising...hx [history] of fall at home with difficulty walking and encephalopathy... and decreased cognition..." Further review of the "Physical Therapy PT Evaluation & Plan of Treatment," indicated the patient had "impaired" functioning in his left and right hip, knee, and ankle and his "Safety Awareness" was "impaired." A review of Patient 1's care plan (an individualized plan for the medical care of a patient), titled, "[name of Patient 1] has hesitancy to ambulate [walk] and unsteady shuffling gait [a person manner of walking] which limits physical mobility," dated September 9, 2024, the care plan indicated, "...Goal...will remain free of complications related to immobility, including...fall related injury through the next review date...will maintain current level of mobility 2 person assist for 15 ft [feet] through review date...Interventions - Provide supportive care, assistance with mobility as needed..." During an observation on October 16, 2024, at 11:08 AM, Patient 1 was observed by Surveyor 1 to be walking unassisted in a field behind the facility's parking lot. There was no staff nearby or within eyesight of the patient. During an interview on October 16, 2024, at 11:11 AM, the Administrator (ADMIN) was informed by Surveyor 1 that Patient 1 was in a field next to the parking lot and was unaccompanied by staff. During an interview on October 16, 2024, at 12:15 PM, with the ADMIN, the ADMIN stated supervision in the locked memory care unit included a supervising Licensed Vocational Nurse (LVN), and Certified Nursing Assistants (CNAs) with a one to 10 ratio (1 CNA per 10 patients). The ADMIN further stated on October 16, 2024, it was a surveyor (Surveyor 1) who initially informed him that Patient 1 had left the facility and was in a field. The ADMIN stated facility staff were unaware Patient 1 had left the facility prior to notification from the surveyor. The ADMIN stated he believed Patient 1 had exited out the facility door (which led to the outside) at the far end of a hallway, within the locked memory care unit, and then jumped over a locked gate. Upon being brought back into the facility by staff, the ADMIN stated Patient 1 told him he had jumped over the locked gate. The ADMIN further stated the facility exterior door remained unlocked, but the gate was locked with a keypad code that staff would enter and exit the facility through to gain access to the laundry room and garbage dumpster. When asked if the facility exterior door had an audible alarm to indicate the door had been opened, the ADMIN stated the door had not been alarmed since he started working at the facility within the last three years. During an interview on October 16, 2024, at 12:26 PM, with Certified Nursing Assistant 1 (CNA 1) stated on October 16, 2024, he was at lunch when he received a phone call at 11:13 AM from CNA 2 informing him Patient 1 had left the facility building and was in a field. CNA 1 further stated there was supposed to be at least one CNA stationed in each of the two halls in the memory care unit to provide supervision to the patients. CNA 1 stated he informed CNA 2 and a charge nurse that he was going to lunch, and it was CNA 2 who was supposed to be supervising patients while he was at lunch at the time Patient 1 eloped. CNA 1 stated the door leading to the exterior of the building (in the hall in which Patient 1 allegedly eloped from), used to have an alarm in the past but did not any longer. During an interview on October 16, 2024, at 12:43 PM, with CNA 2, CNA 2 stated the memory care unit (two total hallways) was supposed to have at least one CNA supervising each hallway. CNA 2 further stated there was usually four CNAs assigned to the memory care unit (2 for each hallway), but at the time Patient 1 had eloped, the two CNAs assigned to the hallway where Patient 1's room was located and where the door Patient 1 used to go outside was also located, were at lunch at the same time. CNA 2 stated she was assigned to the other hallway but was tasked with supervising both hallways. When asked where CNA 3 was (the third of four CNAs assigned to the memory care unit), CNA 1 stated CNA 3 was in the activity room (located in the memory care unit) and that CNA 3 was supposed to be helping her supervise the patients but did not know why CNA 3 was in the activity room instead. CNA 2 stated she also saw Licensed Vocational Nurse 1 (LVN 1) at the nurses' station in the memory care unit. During an interview on October 16, 2024, at 1:07 PM, with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated there were four CNAs assigned to the memory care unit to supervise patients. LVN 1 further stated the CNAs' in the halls were supposed to take lunch opposite each other so there was one CNA at a time taking a lunch from each hallway. This would leave one CNA in each hallway to supervise patients. LVN 1 stated she was "just covering the lower dementia [locked memory care unit] unit as extra eyes" while LVN 2 was at lunch. LVN 1 further stated she was aware CNA 1 was on lunch but didn't know if any of the other CNAs were on lunch or break. LVN 1 stated she saw CNA 2 supervising the hallways but didn't see any other CNAs in the hallways. LVN 1 stated she was aware CNA 3 was providing supervision to patients in the activity room. LVN 1 stated LVN 2 came back from her lunch at approximately 11:05 AM and she (LVN 1) then went to lunch while LVN 2 went to go check a patient's blood sugar (test to determine the level of sugar in the blood) in a patient's room. During an interview on October 16, 2024, at 1:30 PM, with LVN 2, LVN 2 stated she came back from lunch and at the time Patient 1 eloped, she was doing a blood sugar check on a patient in the patients' room. LVN 2 further stated she knew CNA 1 was supervising the halls but did not know where CNA 4 was. During an interview on October 16, 2024, at 1:39 PM, with CNA 3, CNA 3 stated she was supervising the hallways earlier in the day but was asked by an activities staff member to come and help provide supervision in the activities room because there were more than 10 patients in the activity room and they needed more than 1 staff member to provide supervision. CNA 3 further stated she was aware CNA 1 and CNA 4 were on lunch which meant there was only her and CNA 2 left to supervise the hallways but stated she (CNA 3) could only be in one place at a time so she decided to go to the activity room to help the activities staff member. CNA 3 stated after approximately 20-30 minutes of being in the activity room, she was walking back to the hallway from the activity room when she was made aware Patient 1 had eloped. During a concurrent observation and interview on October 16, 2024, at 5:24 PM, with Patient 1, Patient 1 was observed to be in his room which was located immediately adjacent to a facility exit door located at the end of the hallway where there was a locked gate upon exiting the building. Patient 1 was alert and oriented x (times) 1 (one) (oriented to person but not oriented to place, time, or situation). Patient 1 stated he didn't know where he was, what day or month it was and stated he thought he was on TV during our discussion. Patient 1 was unable to answer if he recalled if or how he left the facility. During an interview on October 18, 2024, at 9:59 AM, with the Director of Staff Development, the DSD stated the staffing schedule (in use at the time Patient 1 eloped) did not indicate who was supposed to cover each hallway during staff breaks and lunches and it was facility practice to ensure verbally with each other that there was someone in each hallway to supervise patients. A review of the facility's policy and procedure titled, "Elopement/Unsafe Wandering," dated December 2023, the policy indicated, "This facility is committed to promoting resident autonomy by providing an environment that remains as free of accident hazards as possible. Each resident is assisted in attaining or maintaining their highest practicable level of function through providing the resident adequate supervision and diversional programs to prevent unsafe wandering while maintaining the least restrictive environment for those at risk for elopement...Elopement is when a resident leaves the facility premises or a safe area without authorization (i.e. [for example] an order for discharge or leave of absence) and/or any necessary supervision to do so..." CONCLUSION: In violation of the above cited standards, the facility failed to: 1.Provide supervision and monitoring for Patient 1 while in the facility's locked memory care unit. 2.Implement the facility's policies and procedures regarding elopement and wandering by not ensuring precautions were taken to ensure the patients safety. These violations, jointly, separately or in any combination, had a direct or immediate relationship to the health, safety, or security of patients or residents.