Other·November 10, 2021

F689 §483.25(d) 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. INTENT: §483.25(d) The intent of this requirement is to ensure the facility provides an environment that is free from accident hazards over which the facility has control and provides supervision and assistive devices to each resident to prevent avoidable accidents. This includes: • Identifying hazard(s) and risk(s); • Evaluating and analyzing hazard(s) and risk(s); • Implementing interventions to reduce hazard(s) and risk(s); and • Monitoring for effectiveness and modifying interventions when necessary. Based on observation, interviews and record review, the facility failed to ensure the resident, who had a wandering behavior, did not elope from the facility unnoticed and sustained a fall with abrasions to both knee while outside of the facility for one of four sampled residents (Resident 1). The facility failed to: 1. Ensure the facility’s exit doors Wander Guard alarm system was in working condition to alert staff when Resident 1 attempted to elope. 2. Ensure Resident 1’s care plan was followed to recognize unsafe conditions. 3. Develop a policy and procedure for maintaining a Wander Guard alarm system in working condition. As a result of this deficient practice Resident 1, eloped from the facility on 9/25/21 unnoticed, fell from a wheelchair, and sustained abrasions to both knees. This deficient practice placed Resident 1 and other residents with wondering behavior at high risk for serious injury and death. On 9/27/21, the Department received a Facility Reported incident, (FRI) that Resident 1 was found outside of the facility on 9/25/21, at 5:25 p.m. lying on the ground next to a wheelchair, near the facility’s parking lot area. A good Samaritan found Resident 1 and reported it to the facility staff. On 9/29/2021 at 2:31 p.m. an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was called in the presence of the facility's administrator (ADM), regarding the facility's failure to ensure its Wander Guard System was functional and in working condition to alert staff of residents’ attempted to leave the facility building and prevent the elopement of residents with wandering behavior. On 10/3/2021, the ADM and the Director of Nursing (DON) submitted a Plan of Action (POA, immediate interventions to correct the deficient practices). On 10/3/2021, at 3:35 p.m., after the surveyor reviewed, and verified onsite POA implementations through the observation, interview, and record review the IJ was lifted in the presence of the ADM, DON, Director of Staff Development (DSD), and Maintenance Supervisor. Findings: On September 28, 2021, an unannounced visit was conducted to the facility to investigated FRI regarding Resident 1 elopement. A review of Resident 1’s Admission Record indicated the resident was a 91-year-old female who was initially admitted to the facility on 8/26/17 and re-admitted on 5/1/18, with diagnoses including dementia (loss of memory and thinking abilities), anxiety disorder (mental health condition whereby the individual respond to things with fears) and altered mental status (confused mental functioning). A review of the Physician’s order dated 4/18/21, indicated to apply a wander guard to Resident 1’s lower right extremity and wheelchair for safety, and to check placement and function every shift. A review of Resident 1’s Minimum Data Set (MDS), a standardized assessment and care-screening tool, dated 8/12/21, indicated the resident had severely impaired cognitive skills, (ability to reason and think) for daily decision making. MDS indicated Resident 1 depended on staff for activities for daily living and required two-person physical assistance and total assistance in the areas of bed mobility (how the resident moves in bed), toilet use, and personal hygiene. A review of the Elopement Risk Assessments dated 7/6/18, 4/18/19 and 9/27/21, indicated Resident 1 was assessed as a high risk for elopement. A review of Resident 1’s care plan, dated 7/6/18, for the Potential Risk of Elopement Exit seeking behavior (with purpose to leave), indicated one of the interventions was to monitor the resident’s whereabouts regularly and to recognize any unsafe conditions or escalating patterns. On 9/25/21 at 5:51P.M., during an interview, CNA 1 stated unsafe conditions are situations that place the residents at risk of danger and injuries. CNA 1 stated the condition under which Resident 1 left the facility and was found outside lying on the ground was a very unsafe condition placing the resident at risk for danger and injuries. CNA stated that staff are trying to make sure this type of incident do not happen anymore because. A review of care plan dated 9/26/20, for the Potential Risk of Elopement Exit seeking behavior indicated Resident 1 was constantly seeking for the exit door, constantly wheeling self into the yellow area, constantly standing up unattended and was at risk for elopement, falls and injury. The care plan listed staff’s approaches included to frequently visually observe and redirect Resident 1’s behavior. A review of the nurses Progress Note dated 9/25/21, at 6 p.m. indicated Resident 1 was seen in the hallway by the kitchen door at approximately 5:05p.m. and at 5:15p.m. a certified nursing assistant (CNA1) had served dinner to Resident 1 near the outside of the resident’s room. Ten minutes later the CNA 1 approached the charge nurse (CN) asking if the nurse had seen Resident 1. At this point facility’s staff began to search for Resident 1, until a good Samaritan rang the doorbell and notified staff that Resident 1 was outside on the street lying on the ground. The CNA 1 and other staff went out and found the resident lying on the ground next to a wheelchair. A Pull-Tab alarm (a pull-string that attached magnetically to the alarm with garment clip to the resident. When the resident attempts to rise out of their chair the pull-string magnet is pulled away from the alarm causing the alarm to sound and alerting the caregiver) was attached to the wheelchair. Resident 1 was assessed and noted to have a right and left knee abrasion. During an observation on 9/28/21, at 1:20 p.m., Resident 1 was sitting up in a wheelchair eating lunch. The resident was observed to have abrasion to the right and left knee. Concurrently, during an interview, Resident 1 stated, “I was out on the other side of the door and got cut on the knee until someone brought me back to the facility.” During an interview on 9/28/21, at 1:21 p.m., DON stated the exit doors did not have a functioning Wander Guard alarm. DON stated that consequently the exit door alarm did not go off when the resident exited from the facility and therefore the staff did not know when the resident left facility. She further stated, Resident 1 did have a Wander Guard device attached to the left side of the wheelchair during the time of elopement. On 9/28/21, at 1:49 p.m., CNA 2 was observed wheeling Resident 1 to the exit door where the facility suspected Resident 1 had exited. During the observation the Wander Guard alarm did not activate and did not function. The maintenance supervisor (MS) was present during the observation on 9/28/21 at 1:49 p.m. and witnessed Resident 1 being wheeled outside and inside without Wander Guard alarm activation. The administrator and DON also were present and witnessed that the exit door Wander Guard alarm did not activate and was non-functional. Concurrently, during the observation on 9/28/21, Resident 2 was also wheeled through the same exit door and Wander Guard alarm did not active to produce warning sound and was did not function. This was witnessed by the MS, administrator, DON, and CNA 2. On 9/28/21, at 2:04 p.m. during an observation, Resident 1, who had a Wander Guard alarm device attached to her right hand and to the left side of the wheelchair was transported through the front door of the facility. The Wander Guard alarm did not sound to alert staff. The door alarm system was non-functional. At the same time, Resident 2, who also had a Wander Guard alarm device in place, for elopement risk was also transported through the same door with no alarm response. This was witnessed by the administrator, DON, MS, and CNA 2. On 9/28/21, at 3:26p.m., during an interview, CNA1 stated the incident happened on 9/25/21, at approximately, 5:05p.m. Resident 1 was in the hallway, close to the nursing station. CNA 1 stated he was going to pass a tray to Resident 1 in the room, however, Resident 1 was not in the room at 5:25 p.m. CNA 1 then started to search for Resident 1 in all the other rooms. On 9/28/21 at 5:30 p.m., the CN told CNA 1 that someone was knocking at the front door entrance. When CN and CNA 1 answered the front door, a good Samaritan informed them Resident 1 was outside on the street lying on the ground by the pedestrian walk. CNA 1 stated they went outside and found Resident 1 laying down on the ground with a wheelchair on the right side of the resident. CN assessed Resident 1 and noticed the resident had abrasion to the right and left knee. CN and CNA 1 assisted Resident 1 back in wheelchair and brought the resident back to the facility. CNA 1 stated they did not hear any alarm sound when Resident 1 eloped from the facility through the back exit door, even though the door had installed Wander Guard alarm system. CNA 1stated the exit door Wander Guard alarm was not working. CNA 1 continued stating that Resident 1 constantly wandered and was monitored every hour. CNA 1 had been assigned ten residents on the day of Resident 1’s elopement and could not monitor Resident 1 frequently. CNA 1 stated Resident 1 had a Pull-Tab alarm on the wheelchair on the day of elopement. CNA1 stated residents identified with wandering behaviors should be monitored every 15 minutes to hourly, and all Pull-Tab alarms and exit door Wander Guard alarms must be always checked to ensure its working condition. On 9/29/21, a 12:30 p.m., during an interview, the DON stated the Wander Guard system can replace staff monitoring of residents with wandering behaviors. However, the facility policy is to monitor residents with elopement risk behavior every two hours. Also, she stated the Wander Guard alarm will alert staff of any elopement attempts by residents. On 9/30/21, at 4:11 p.m., during an interview, the licensed vocational nurse (LVN) stated the facility had four residents with wandering behavior. LVN1 stated that on 9/28/21 at around 5:05p.m. Resident 1 was seen wheeling self around the hallway. The dinner trays arrived between 5:10 p.m., and 5: 25 p.m. The assigned CNA 1 started to look for Resident 1’s whereabouts and asked if I had seen the resident. While we were looking for Resident1 1throughout in the facility, a bystander rang the front door doorbell. A bystander informed that there was a resident outside the facility. We went outside and saw Resident 1 lying on the ground with wheelchair on the right side. We lifted Resident 1 from the ground and placed on the wheelchair with assistance of the CNA 1 and social service personnel. CN assessed Resident 1 and noted the resident had an abrasion injury on right knee. Resident 1 was offered pain medication, however, the resident refused. LVN 1 further stated Resident 1 always wanted to leave the facility and the alarm would normally go off but, on that day, the alarm did not sound so we did not know about Resident 1’s elopement. LVN 1 stated the alarm failed and needed repair so that the elopement does not occur again. On 10/2/21, at 1:37 p.m., an onsite monitoring of the four-exit doors with installed Wander Guard alarm system was conducted to check for its working condition. The exit door alarms did not activate and were not working. A review of the facility’s policy and procedure titled ‘Elopement and Missing Resident’ dated 12/2017, indicated to monitor and evaluate residents at risk for wandering and elopement. The interdisciplinary Team (IDT) is responsible for identifying residents at risk for elopement, implementing preventative measures to reduce risk, and provide a process for action if an incident of elopement occurs. The policy further noted staffs are to do the following: a. To assess, monitor and manage resident safety specific to wandering and elopement b. Upon admission, assess each resident’s wandering and elopement risk and initiate a care plan as appropriate. c. Initiate interventions to address resident’s elopement risk, which may include implementing an electronic alert system such as a Wander Guard bracelet. d. Check placement of alert devices daily at minimum. e. Check alert devices for proper functioning weekly, at minimum. f. When a resident observed to moving toward an unsafe situation or exiting the facility, the nearest staff member, should intervene to redirect the resident and summon help. A review of the Manufacturers Instruction Guide, titled ‘Wander Management Transmitters User Guide’ indicated it is the responsibility of the facility to establish and facilitate a regular maintenance schedule to include regular inspection, testing and cleaning. The manufacturer recommended monthly maintenance and testing, and to keep records of maintenance and test completions. A review of the user guide indicated that failure to provide regular maintenance and testing of the product may result in equipment and/or system failure. The manufacture cautions indicated to not rely exclusively on the resident generated alarms for resident care and safety. The alarm function of equipment in the possession of residents must be verified periodically and regular resident surveillance is recommended. On 9/29/21 at 11:35 a.m., during an interview, the MS stated it was his responsibility to make sure that all alarm doors with Wander Guard system were always functional. The MS stated he performs weekly check every Friday on all the exit doors to test functionality of the exit doors, however. could not explain the oversight. On 9/29/2021 at 2:31 p.m. an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was called in the presence of the facility's administrator (ADM), regarding the facility's failure to ensure its Wander Guard System was functional and in working condition to alert staff of residents’ attempted to leave the facility building and prevent the elopement of residents with wandering behavior. On 10/3/2021, the ADM and the Director of Nursing (DON) submitted a Plan of Action (POA, immediate interventions to correct the deficient practices). On 10/3/2021, at 3:35 p.m., after the surveyor reviewed, and verified onsite POA implementations through the observation, interview, and record review the IJ was lifted in the presence of the ADM, DON, Director of Staff Development (DSD), and Maintenance Supervisor. As a result of the facility’s failure to ensure the Wander Guard system was in working condition to alert staff when a resident attempted to elope, Resident 1 eloped from the facility unnoticed, fell out of a wheelchair, and sustained abrasions to both knees. The above violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Resident 1.