Other·November 10, 2022

REGULATION VIOLATION: Title 42 of the Federal Code of Regulations 483.25(d) Accidents. The facility must ensure that - 483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents. 72311. Nursing Service - General. (a) Nursing service shall include, but not be limited to, the following: (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan 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. On October 4, 2022, at 11:25 AM, an unannounced visit was conducted at the facility to investigate a facility reported incident regarding Patient 1, a hospice (care for those with six months or less to live) patient who had Alzheimer's dementia (a progressive loss of memory) who eloped (went missing) from the facility on October 3, 2022 at approximately 8:10 PM. Patient 1 was last seen by staff on the facility's smoking patio talking to Patient 2, on October 3, 2022, between approximately 7:30 PM and 7:45 PM. Patient 2 informed a Certified Nursing Assistant 1 (who was returning from break), at approximately 8:10 PM, on October 3, 2022, that Patient 1 had informed her that she (Patient 1) was going to leave the facility to go to her home in [Name of the mountain city]. Patient 1 exited through the facility's smoking patio gate which was unalarmed, unlocked, and unmonitored. Patient 1 was found two days later, on October 5, 2022, when the car driven by an unidentified male was located broken down on a mountain highway. The facility failed to: 1. Provide supervision and monitoring for Patient 1 who was identified to be a wanderer and elopement risk. 2. Implement Patient 1's care plan intervention for "risk of wandering/elopement" by not ensuring every 30-minute checks were done and Patient 1 was not distanced from exits. 3. Implement the facility's policies and procedures for patients at risk for wandering, to take precautions to ensure their safety Patient 1, a 79-year old female, was admitted to the facility on July 14, 2022, with diagnoses of Alzheimer's disease (a brain disorder that destroys memory and thinking skills) and heart failure. The Patient was also receiving hospice care (comfort care provided to an individual with a serious illness who is approaching the end of life). Patient 1 had fluctuations in her level of alertness with periods of confusion and disorientation, was able to walk independently, and had a history of attempting to elope from the facility on one previous occasion. During a review of Patient 1's Minimum Data Set (MDS- an assessment of a Patients functional and health status), dated July 21, 2022, the MDS section "C" - Cognitive Patterns (section used to determine a patients cognitive functioning status) indicated the patient had a Brief Interview for Mental Status score (BIMS score - a score of 0-15 used to determine cognitive functioning) score of 5 (severe impairment). Further review of the MDS in Section "E0900. Wandering - Presence & Frequency" (section used to determine a patient's wandering tendencies), indicated the patient had the behavior of wandering which occurred between 1 to 3 days during the review period. Section "E1000. Wandering - impact" (section used to determine the risk of wandering), indicated "yes" to the question, "Does the wandering place the resident [patient] at significant risk of getting to a potentially dangerous place (e.g. stairs, outside of the facility)?" During review of Patient 1's "Wandering/Elopement Risk Assessment," dated July 18, 2022, indicated, "High Risk for Wandering..." The assessment also indicated the patient was disoriented, was on anti-anxiety and hypnotic medications (medications which can cause drowsiness and can alter balance and memory) and had independent mobility without requiring assistance During review of Patient 1's "IDT Follow Up" (IDT-Interdisciplinary team composed of staff from various clinical disciplines), dated July 19, 2022, the document indicated, "Follow up with the report on 7/18/2022 (July 18, 2022), that [Patient 1] attempted to go outside the building in the facility parking lot...Resident [Patient 1] is disoriented x3 [times three], has Alzheimer's [disease]...Spoke to resident at this time and gave reality orientation related to attempt to elope...Resident is high risk for wandering/elopement..." During a review of Patient 1's care plan (an individualized plan for the medical care of a patient), dated July 9, 2022, the care plan indicated, "Moderate risk for wandering/elopement related to cognitive impairment secondary to Alzheimer's [sic] dementia as evidenced by patient unable to find what she is seeking and pacing repetitively...Interventions...Staff to ensure the resident at risk for wandering distance from exits...staff to monitor resident often at least Q30 (Every 30) minutes and monitor whereabout..." During an interview on October 4, 2022, at 12:01 PM, with the Director of Nursing (DON), the DON stated Patient 1 had eloped from the facility on October 3, 2022 and had not yet been found. The DON further stated throughout her investigation, it was her understanding that Patient 1 was seen socializing with Patient 2 on October 3, 2022, at 7:45 PM, while on the facility's smoking patio. The DON then stated on October 3, 2022, at 8:00 PM, Patient 2 informed a Certified Nursing Assistant 1 (CNA 1) that Patient 1 left the facility through the smoking patio gate. During an interview on October 4, 2022, at 12:46 PM, with Patient 2, Patient 2 stated she was with Patient 1 last night (October 3, 2022) on the smoking patio sometime in the evening (could not recall exact time) when Patient 1 told her she was going to leave the facility and go to her home in [name of mountain community] and proceeded to exit through the gate on the far side of the smoking patio. Patient 2 further stated Patient 1 disappeared from sight after the patient exited the gate and made a left. Patient 2 stated there were no other patients or staff present when Patient 1 left the facility. Patient 2 further stated about 10 minutes later, CNA 1 came to the smoking patio and she (Patient 2) informed the CNA that Patient 1 had left. During an interview on October 4, 2022, at 1:30 PM, with CNA 2, CNA 2 stated he was familiar with Patient 1 and knew she was at risk for leaving the facility and recalled an instance where the patient had previously verbalized a desire to leave (CNA 2 could not remember when). CNA 2 stated he worked on the evening of October 3, 2022, from 3:00 PM to 11:00 PM and he was the nurse assistant assigned to care for Patient 1 during that shift. CNA 2 stated he last saw Patient 1 at 7:30 PM on the smoking patio with Patient 2 and then went on break 15 minute later. CNA 2 further stated he did not recall seeing any staff on the patio with Patient 1 and Patient 2. During an interview on October 4, 2022, at 1:58 PM, with the DON, the DON stated Patient 1 was at risk for elopement and was not supposed to be near or around exits without staff being present. The DON further stated Patient 1 was not supposed to be outside on the smoking patio without staff. During a follow up interview on October 4, 2022, at 2:00 PM, with CNA 2, CNA 2 stated he didn't think much about it when he saw Patient 1 on the patio because he had previously seen her (Patient 1) there on prior occasions with no issues. CNA 2 further stated on October 3, 2022, at 7:30 PM when he last saw Patient 1, he asked her if she wanted to come back in the facility and she said, "No," and that she said she was "catching some sun." CNA 2 then stated he proceeded to assist other patients and went on break 10 or 15 minutes later after informing CNA 3 that he was leaving on break. CNA 2 stated he was not aware that Patient 1 had a care plan intervention to, "...ensure the patient at risk for wandering distance from exits.". CNA 2 stated he should have either brought the patient inside prior to going on break or asked for assistance from the Licensed Vocational Nurse if the patient was getting anxious or didn't want to come in. He stated he did not do that in this case and left the patient outside and didn't recall seeing any other staff present on the patio. During an interview on October 4, 2022, at 3:16 PM, with CNA 3, CNA 3 stated she worked on the evening of October 3, 2022, but was not assigned to Patient 1. CNA 3 stated CNA 2 informed her that he was going on his break and asked her to watch his patients and she agreed. CNA 3 stated she last saw Patient 1 between 7:30 PM and 7:45 PM when she went to check on CNA 2's assigned patients and stated Patient 1 was with Patient 2 on the patio and there were no other staff present. CNA 3 stated after visually checking on Patient 1 on the patio, she went back to assist her own assigned patients in the facility. During an interview on October 4, 2022, at 3:31 PM, with a Registered Nurse 1 (RN 1), RN 1 stated she worked on October 3, 2022, from 7:00 AM until 9:00 PM, and recalled seeing Patient 1 who on that day, demonstrated periods of alternating levels of alertness and confusion while ambulating around the facility. RN 1 stated Patient 1 was at risk for elopement and CNA 2 was assigned to the patient that shift. RN 1 further stated the patio area was an area patients could go to get fresh air, but confused patients were supposed to be supervised by staff while on the patio. RN 1 further stated Patient 1 was confused most of the time and therefore was supposed to be supervised any time she was on the patio. RN 1 stated her expectation was if Patient 1 was on the patio at any time, the patient would be accompanied by staff. RN 1 further stated regarding who was responsible for supervision of the patio area, that whoever is assigned to the patient was expected to supervise them on the patio. RN 1 stated if a staff member is accompanying a patient on the patio that needs supervision and the staff is going to leave the area, they should inform the RN supervisor so the RN can assign someone else to monitor the patient. During an interview on October 4, 2022, at 3:46 PM, with CNA 1, CNA 1 stated she worked on October 3, 2022, from 3:00 PM to 11:00 PM and she was familiar with Patient 1. CNA 1 stated the supervision and monitoring that Patient 1 required was constant, because of her risk for elopement and that she thought Patient 1 should be supervised at all times until the patient went to bed. CNA 1 further stated there was a prior instance (CNA 1 could not recall when) where the patient pushed open an exit door and attempted to leave the facility and that there should be no instances where Patient 1 was left on the smoking patio without staff being present. CNA 1 stated she last saw Patient 1 on the patio on October 3, 2022, between 7:30 PM and 7:40 PM and then she (CNA 1) went to her lunch break. CNA 1 stated when she arrived back from her lunch around 8:10 PM, she went to smoke on the smoking patio when Patient 2 informed her that she had witnessed Patient 1 leave out the patio gate approximately 20 minutes earlier. CNA 1 stated when she went to look for the patient, she could not find her. During an observation on October 4, 2022, at 4:01 PM, of the facility's smoking patio, there was a glass door from within the facility which leads to an outside patio area where there were 3 tables. On the far side of the patio (west side), there was a white gate with a latch that was not locked, does not alarm when opened, and can be easily opened. The gate leads to an area near the rear of the facility where there is a parking lot. There is a camera in this area. During a telephone interview on October 5, 2022, at 11:40 AM, with [name of hospice company] Chief Operating Officer (COO), the COO stated he had hospice staff checking on the patient's home every hour due to concerns of her wellbeing. The COO further stated the police had dispatched a helicopter and K-9 (canine - police dog) units to aid in the search and the patient was ultimately found on the side of a mountain community highway, while broken down in a vehicle accompanied by an unidentified male. During an interview on October 5, 2022, at 12:33 PM, with the DON, the DON stated she started working at the facility since mid-July 2022, and the smoking patio camera was not working at that time and has not worked since then, at minimum. During a review of the facility's policy and procedure, titled, "Emergency Procedure - Missing Resident," revised August 2018, the policy indicated, "Resident elopement resulting in a missing resident is considered a facility emergency. Policy Interpretation and Implementation 1. Residents at risk for wandering and/or elopement will be monitored, and staff will take necessary precautions to ensure their safety..." During a review of the facility's policy and procedure, titled, "Wandering and Elopements," revised March 2019, the policy indicated, "Policy Statement...The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. Policy Interpretation and Implementation 1. If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety..." Conclusion: In violation of the above cited standards, the facility failed to: 1. To provide supervision and monitoring for Patient 1 who was identified to be a wanderer and elopement risk. 2. Implement Patient 1's care plan intervention for "risk of wandering/elopement" by not ensuring every 30- minute checks were done, and Patient 1 was not distanced from exits. 3. Implement the facility's policies and procedures for patients at risk for wandering, to take precautions to ensure their 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.