Other·November 23, 2022

F656 §483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following — (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40. §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. §72311. Nursing Service - General. (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. (B) Development of an individual, written patient care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time-limited. (C) Reviewing, evaluating, and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. On 9/6/2022, the Department received a facility reported incident (FRI) regarding a resident-to-resident physical altercation between Resident 1 and Resident 2. While onsite an elopement situation for Resident 2 was identified. On 9/9/2022, an unannounced investigation was conducted at the facility. The facility failed to: 1. Supervise and prevent Resident 2’s elopement (when a resident who is not capable of protecting or caring for themselves leaves the facility without authorization). Resident 2 was cognitively (ability to think and reason) impaired, displayed behaviors of wandering (walking around aimlessly without a fixed plan), and had a history of prior elopements. 2. Develop and implement a resident-centered care plan upon admission on 8/30/2022 to ensure Resident 2 had a detailed monitoring plan to address the resident’s wandering and elopement history. 3. Evaluate and revise care plan interventions after Resident 2 refused to wear the wander guard multiple times (device resident wears and alarm are activated when the device is near the sensors installed by the exit door). As a result, Resident 2 eloped from the facility on 9/2/2022, 9/6/2022, and 9/9/2022 which placed the resident at high risk for injury and harm. During a review of Resident 2’s Admission Record, dated 9/11/2022, the Admission Record indicated Resident 2, was a 56 year-old male, who was admitted to the facility on 8/30/2022, with diagnoses not limited to metabolic encephalopathy (problem in the brain), cellulitis (skin infection causing it to be swollen and painful) of left lower limb, abnormalities of gait and mobility, alcohol dependence, schizoaffective disorder (mental health condition when resident has apparent perception of something not present), ?disorganized thinking, unspecified psychosis (when people lose some contact with reality), bipolar disorder (mental health problem causes extreme mood swings), major depressive disorder (mood disorder that?causes a persistent feeling of sadness and loss of interest), and anxiety (feeling of fear dread, and uneasiness). During a review of Resident 2's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 9/6/2022, MDS indicated the cognitive skills for daily decisions making was severely impaired. MDS indicated Resident 2 wandered in the last 1 to 3 days. During a review of Resident 2’s Admission Data Tool (ADT), dated 8/30/2022 at 6:40 p.m., the ADT indicated Resident 2 was admitted on 8/30/2022 at 7:06 p.m., was uncooperative, irritable, restless, and confused. The ADT indicated Resident 2 had a history of wandering, was pacing, tried to get out of the door, find family or friend, and “perceived they may be doing something other than what they were doing and has risk for elopement.” During a review of Resident 2’s nurses progress notes dated 8/31/2022 at 8:30 p.m., note indicated Resident 2 was admitted alert with episodes of confusion and was noted going into other residents’ rooms. During a review of Resident 2's Interdisciplinary Team ([IDT] group of different disciplines working together towards a common goal for a resident) conference meeting dated 9/1/2022 at 2:58 p.m., the IDT note indicated the social worker (SW) spoke with Family Member 1 (FM 1) and said Resident 2 had psychiatric issues for at least 20 years and should be placed in a psychiatric hospital instead. The IDT note indicated FM 1 had mentioned Resident 2 had a history of elopement twice from previous facilities. During a review of Resident 2’s medical record, starting on admission dated 8/30/2022 care plans, medical record had no documented evidence of a care plan to address Resident 2’s risk for elopement and wandering behavior to ensure a monitoring plan was in place to address the resident’s safety. During a review of Resident 2’s Nurses notes (NN) dated 9/2/2022 at 6:39 p.m., the NN indicated on 9/2/2022 at 4:50 p.m., Resident 2 was last seen on his wheelchair going around the unit. The NN indicated Resident 2 was nowhere to be found at unspecified time. On 9/2/2022 at 6:45 p.m., the activities staff found Resident 2 down the street at a store 282 feet away from facility and the charge nurse brought the resident back to the facility. The NN indicated Resident 2 was missing for approximately 2 hours from 9/2/2022 at 4:50 p.m. to 6:45 p.m. On 9/2/2022 at 11:06 p.m. a wander guard was applied on Resident 2. During a review of Resident 2’s NN dated 9/6/2022 at 5:15 a.m., the NN indicated Resident 2 left the facility and was located across street at a gas station (443 feet from facility and resident had to cross the street twice to get to the location) with no wander guard in place. The NN indicated Resident 2 was missing for approximately 30 minutes. During a review of Resident 2’s physician orders dated 9/6/2022 at 12:55 p.m., the physicians order indicated a psychiatrist consultation for Resident 2. No documented evidence of follow up was noted on order.[PM1][MJ2] During a review of Resident 2’s NN, dated 9/7/2022 and 9/8/2022, the NN indicated Resident 2 removed wander guard and refused to wear wander guard on following dates: On 9/7/2022 1:36 a.m. at 10:16 a.m.[PM3][MJ4] On 9/8/2022 1:09 a.m. at 10:27 p.m. During a review of Resident 2’s elopement care plan initiated 9/3/2022 (after the first elopement) no documented evidence of updated interventions for elopement risk was noted despite the resident refusal to use the wander guard bracelet.[PM5][MJ6][MJ7] During a review of Resident 2’s NN, NN indicated that on 9/9/2022 at 8:00 p.m., Receptionist (REC 1) saw Resident 2 at a corner store on his wheelchair. “Due to darkness, rain and unsafe environment, law enforcement was notified, and the police officers brought resident back to facility.” On 9/13/2022 at 4:50 a.m., Resident 2 attempted to get out of rear door. During a phone interview with the REC 1 on 9/13/2022 at 7:35 p.m., REC 1 stated on 9/9/2022 at approximately 8:53 p.m., she observed Resident 2 sitting on his wheelchair in front of the liquor store [280 feet from the facility] so she notified the charge nurse. REC 1 stated Resident 2 more likely exited from the back door and exited from the side gate because the side door gate in the parking lot can be opened by just pushing it open. REC 1 stated she monitors the back exit door, but she works 5 days a week from 11:30 a.m. to 8:00 p.m., and when she was off or after 8 p.m., there was no one at the back exit to monitor. During a phone interview with the Licensed Vocational Nurse 3 (LVN 3) on 9/13/2022 at 7:47 p.m., LVN 3 stated Resident 2 has a history of wandering into other resident’s rooms since admission on 8/30/2022 but refused to put on the wander guard. LVN 3 stated, after being alerted by activities staff via phone call, on 9/6/2022 she drove LVN 4 to the gas station, 443 feet from facility and picked up Resident 2. LVN 3 stated, Resident 2 did not have his wheelchair, nor did he have a wander guard on when they found Resident 2. LVN 3 stated he probably exited through the back door and through the side gate and anyone can open the gate to go outside. LVN 3 stated no one was at the door monitoring residents who were at risk for elopement. During an observation on 9/15/2022 at 8:57 a.m., upon entry to the facility's parking lot, the car gate was observed open and was jammed with a cardboard to prevent from closing. During an interview with receptionist 2 (REC 2) on 9/15/2022 at 9:00 a.m., REC 2 stated after 8:00 p.m. no one was monitoring the back exit door, and anyone can go out if they push the door. During a record review of the facility’s schedule for receptionists, the schedule indicated receptionist coverage ended at 8:00 p.m. daily. During an interview with payroll clerk (PC) on 9/15/2022 at 9:52 a.m., the PC stated the back exit to the parking lot had no one monitoring from 8:00 p.m. to 7:30 a.m. The PC stated no one was monitoring the main entrance of the facility and Residents can exit through the main entrance in the front just by pushing the unlocked door. During facility tour observation on 9/15/2022 at 10:06 a.m., it was observed that the front main door can be pushed open from the inside and no staff was watching the front exit door. During an observation and interview with the maintenance director (MS) to check door alarms on 9/15/2022 at 10:06 a.m., the parking lot exit door alarm was observed not working. It did not trigger the alarm when someone opened the door. The MS stated when someone open the door, it was supposed to make an audible alarm. During a concurrent interview and record review of alarm monitoring system on 9/15/2022 at 10:10 a.m., with the MS, the MS stated the facility should check exit alarms daily but unable to provide documents showing the alarm was being checked. During a record review of Resident 2's medical records and interview with minimum data set coordinator (MDSC) on 10/13/2022 at 11:10 a.m., the MDSC stated Resident 2 was admitted with a known psychiatric history and already exhibited behaviors of wandering into residents’ rooms. Per the MDSC an intervention and monitoring should have been in place to prevent elopement. Per the MDSC, Resident 2 eloped three times from the facility and that was not safe. Per the MDSC, when the resident kept removing the wander guard after it was initiated on 9/2/2022 interventions should have been changed and monitoring increased, and maybe even a one to one (term used for a healthcare staff whose role it is to provide one to one nursing or observation care to a resident for a period). Per the MDSC, Resident 2 should not have been able to elope three times from the facility. During a review of the facility’s policy and procedure (P&P) titled, “Safety and Supervision of residents,” dated 7/2017, the P&P indicated, Facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. P&P indicated: 1. The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents. 2. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. 3. Implementing interventions to reduce accident risks and hazards shall include the following: a. Communicating specific interventions to all relevant staff. b. Assigning responsibility for carrying out interventions. c. Providing training, as necessary. d. Ensuring that interventions are implemented; and e. Documenting interventions. 4. Monitoring the effectiveness of interventions shall include the following: a. Ensuring that interventions are implemented correctly and consistently. b. Evaluating the effectiveness of interventions. c. Modifying or replacing interventions as needed; and d. Evaluating the effectiveness of new or revised interventions. During a review of the facility’s P&P titled, “Care plans --baseline,” dated 3/2022, the P&P indicated, a baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission. The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care and must include the minimum healthcare information necessary to properly care for the resident. The baseline care plan is updated as needed to meet the resident's needs until the comprehensive care plan is developed. The facility failed to: 1. Supervise and prevent the elopement for Resident 2, who was cognitively impaired, displayed behaviors of wandering, and had a history of prior elopements. 2. Develop and implement a resident-centered care plan upon admission on 8/30/2022 to ensure Resident 2 had a detailed monitoring plan to address the resident’s wandering and elopement history. 3. Evaluate and revise care plan interventions after Resident 2 refused to wear the wander guard multiple times (device resident wears and alarm are activated when the device is near the sensors installed by the exit door). As a result, Resident 2 eloped from the facility on 9/2/2022, 9/6/2022, and 9/9/2022 which placed the resident at high risk for injury and harm. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security for Resident 2.