Health inspection·October 18, 2021

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. The Department received a facility reported incident on 8/19/2021 indicating a resident (Resident 1) walked away from the facility unnoticed. The facility received a call, at approximately 8:30 p.m., from a general acute care hospital (GACH) social worker indicating the resident was brought to the emergency room (ER) and was in critical condition. On 8/20/2021, an unannounced investigation was conducted at the facility. The facility failed to: 1. Ensure Resident 1, who had behaviors of wandering (traveling from place to place aimlessly) and a previous elopement (leaving unsupervised, undetected without authorization) on 7/26/2021, was adequately monitored and the physician was notified of wandering and elopement. 2. Ensure Resident 1 was appropriately assessed for elopement and wandering behaviors after eloping from the facility on 7/26/2021. 3. Ensure the front doors were locked and the alarm system was activated, as required by the facility policy and procedure titled “alarm system,” on two occasions when Resident 1 eloped. 4. Develop and/or implement an individualized resident-centered care plan after Resident 1 experienced a change of behaviors including increased aggression, increased smoking, and increased eloping on 7/26/2021. As a result, Resident 1, who previously eloped on 7/26/2021, left the facility unsupervised on 8/18/2021 at 8:08 p.m., and wandered into a busy street, resulting in Resident 1 being hit by a car and expiring at 8:38 p.m. (approximately 30 minutes after eloping from the facility) from the injuries sustained from the car impact. During a review of Resident 1’s Admission Record (Face Sheet), the face sheet indicated Resident 1, a 64 year-old female, was admitted to the facility on 10/8/2015 and last re-admitted on 5/22/2020. Resident 1’s diagnoses included chronic obstructive pulmonary disease ([COPD] a long-term lung disease that makes it hard to breath), bipolar disorder (serious mental illness that causes shifts in a person's mood, energy, and ability to function), and nicotine dependence (addiction to tobacco). During a review of Resident 1’s History and Physical (H/P), dated 5/18/2021, the H/P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1’s Minimum Data Set (MDS) a standardized assessment and care planning tool), dated 5/31/2021, the MDS indicated Resident 1 was alert, but required supervision (oversight, encouragement and cueing) on and off the unit, assistance with personal hygiene, and activities of daily living (ADLs). During a review of Resident 1’s Admit/Re-admit Evaluation, dated 5/22/2020, the evaluation indicated Resident 1 was not identified as a high risk for wandering or elopement. The evaluation did not indicate a re-evaluation was done in the month of July 2021, when Resident 1 eloped from the facility. During a review of Resident 1’s Psychiatric Notes, dated 10/9/2020 and 6/17/2021, under the area of Judgement and Insight, indicated Resident 1 had moderately impaired judgement and insight. The report further indicated under the area of Impulse control the resident had inadequate impulse control. During an interview with the Administrator (ADM) on 8/20/2021 at 3:15 p.m., she was asked if Resident 1 had eloped from the facility before. The ADM stated Resident 1 left the facility on 7/26/2021 and was found at the liquor store after a previous staff member saw the resident at the store and called the facility. The ADM was asked for an investigation regarding that elopement on 7/26/2021. The ADM provided a document dated 8/23/2021 (after the second incident) and titled, “Internal Investigative Statements,” the statements indicated Resident 1 eloped on 7/26/2021 at approximately 8:30 p.m. and went to the liquor store. The investigation was done on 8/23/2021 indicated the social services director (SSD) provided a statement after receiving a call at approximately 8:30 p.m. on 7/26/2021 of Resident 1 being at the liquor store. The SSD documented on her statement Licensed Vocational Nurse 1 (LVN 1) brought Resident 1 back to the facility. The statement indicated Resident 1 had left the facility to go buy cigarettes. During a review of Resident 1’s Interdisciplinary Team (IDT) note, dated 5/31/2021, the IDT indicated no complications with Resident 1’s smoking behavior. There was no follow-up IDT note to address Resident 1’s increased smoking urges, increased aggressive behavior, and the previous elopement on 7/26/2021. During a review of Resident 1’s care plans and assessments, from June 2021 through August 2021, there were no care plans to address the resident’s previous elopement on 7/26/2021 and/or her wandering behavior. During an interview with the Activities Director (AD) on 8/20/2021 at 2:33 p.m., the AD stated after 6:30 p.m., it was the responsibility of the charge nurse to monitor the entry and exit points. The AD stated the front doors were locked at 8 p.m. and the alarms activated until the next day at 7 a.m. During an interview with Certified Nursing Assistant 1 (CNA 1) on 8/20/2021 at 3:20 p.m., CNA 1 stated she was assigned to Resident 1 on 8/18/2021. CNA 1 stated on the day of the incident and everyday previously, Resident 1 was very busy, anxious, confused at times, easily agitated, and constantly walked around the facility. CNA 1 stated Resident 1 often spent time on the back patio and often requested to go outside for a cigarette. CNA 1 stated Resident 1 was a risk for wandering away from the facility, because the resident was constantly pacing in the patio asking for cigarettes. CNA 1 stated she was instructed to monitor Resident 1 every two (2) hours. CNA 1 stated she started her shift at 3 p.m., at 7:30 p.m. - 8:04 p.m., she took her lunch break. When she was clocking back-in she saw Resident 1 in the hallway. CNA 1 stated she was unaware Resident 1 was missing until someone told her later that night. During an interview with CNA 2 on 8/20/2021 at 4:16 p.m., CNA 2 stated she was familiar with Resident 1 because she was always walking around requesting cigarettes. CNA 2 stated Resident 1 was at risk for leaving the facility because of her walking around the facility and attempting to obtain cigarettes. During an interview with SSD on 8/20/2021 at 4:49 p.m., SSD stated she visited Resident 1 on 8/18/2021 prior to the incident. The SSD stated Resident 1's behavior included walking around the facility and requested to go outside and smoke. The SSD stated Resident 1 requested all day from all staff to take her outside to smoke. The SSD stated Resident 1 requested to go outside so often it was annoying. The SSD indicated an undocumented meeting took place between SSD, DON, and Administrator (ADM) to increase Resident 1’s smoking breaks every two hours. The SSD stated the team thought increasing smoke breaks would eliminate Resident 1’s behavior to want to go outside. The SSD stated Resident 1 was at high risk for elopement because she had a previous elopement (7/26/2021). During an interview with the Director of Nursing (DON) on 8/20/2021 at 5:24 p.m., the DON stated Resident 1 was ambulatory and walked around the facility most of the time. The DON stated Resident 1 was addicted to smoking and her addiction placed her at high risk for elopement due to her constantly wanting to go outside to smoke. The DON stated a care plan for elopement and wandering for Resident 1 was necessary and was not aware why it was not created. The DON stated the alarm system was placed on 8/5/2021 to prevent elopements and ensure staff could hear the alarms when a resident opened the door at nighttime. The DON stated Registered Nurse 1 (RN 1) forgot to set the alarms and lock the door on 8/18/2021 (as required by the policy and procedure). During an observation of the video surveillance on 8/26/2021 at 4:47 p.m., in the presence of the ADM, the video surveillance, dated 8/18/2021, indicated Resident 1 was observed exiting the front double doors of the facility at 8:08 p.m. The facility’s double doors were observed not locked. The alarm did not sound when Resident 1 opened the double doors. There was no staff observed in the facility’s front lobby. Resident 1 was dressed in pants, shoes, shirt, and coat. Resident 1 exited the facility front iron gate. Resident 1 walked westbound toward the liquor store. Resident 1 was observed in the crosswalk walking toward the liquor store. At approximately 8:12 p.m., Resident 1 was struck by a car. During an interview with Registered Nurse 1 (RN 1) on 8/25/2021 at 3:20 p.m., RN 1 stated Resident 1 was at high risk for elopement because of her previous elopement. RN 1 stated Resident 1 exited the facility looking for cigarettes on 7/26/2021 and was found at the liquor store (located across the street from the facility). RN 1 stated there were times Resident 1 was seen by an exit door and was redirected back to her room. RN 1 stated he was not able to find a care plan for elopement. RN 1 stated Resident 1 walked around the facility and often went towards the exit doors. RN 1 stated staff monitored Resident 1 with frequent visual checks but did not document in the resident’s clinical record. RN 1 stated there were no other interventions implemented. RN 1 stated it was his responsibility to lock the front doors and set the alarms at 8 p.m. RN 1 stated on 8/18/2021 he forgot to set the alarm and lock the front doors. RN 1 stated if the doors were locked, and alarms activated Resident 1 would not have eloped and died from a hit and run accident. During a concurrent interview with the DON and review of Resident 1’s assessment on 8/26/2021 at 3:43 p.m., the DON stated Resident 1 was not identified as at risk for elopement on the admit/re-admit assessment dated 5/22/20. The DON stated Resident 1 was at risk for elopement based on her constant walking around the facility and constant urge to go outside to smoke. The DON stated she was aware the resident eloped to the liquor store on 7/26/2021, but no Situation Background Assessment Re-evaluation Communication form ([SBAR] internal communication tool), was created for the incident. The DON stated and confirmed an elopement/wandering assessment and care plan was not created for Resident 1. The DON stated the facility’s staff were concerned with Resident 1’s nicotine dependence behavior and not her eloping from the facility. The DON stated Resident 1’s wandering and elopement behaviors were overlooked. During an interview with the ADM on 8/26/2021 at 4:26 p.m., the ADM stated there was no documentation of the meeting when Resident 1 first eloped from the facility on 7/26/2021. The ADM stated and acknowledged the staff did not develop an elopement/wandering care plan for Resident 1. The ADM stated frequent visual checks meant always knowing where the resident was located. The ADM stated on 8/18/2021 approximately 8:04 p.m. to 8:30 p.m., the staff were not aware of Resident 1’s whereabouts. The ADM stated the facility staff were notified by the GACH on 8/18/2021 of Resident 1 being in critical condition in the Emergency Department (ED). The ADM stated the staff were not aware Resident 1 was not in the facility. The ADM stated the street outside of the facility was very busy. The ADM stated due to the street being so busy it was important to ensure the facility’s doors were locked and the alarms activated. During a review of the GACH’s ED report, dated 8/18/2021 and timed at 9 p.m., the ED report indicated Resident 1 arrived in the ED on 8/18/2021 at 8:35 p.m., after being hit by a car. The ED report indicated Resident 1’s entire body was mangled (severely disfigured, crushed), with multiple deformities, crepitus (crackling sound) bilateral (both sides) chest and neck and no pulse. The ED note indicated Resident 1 was declared dead at 8:38 p.m. During a review of the Traffic Collision Report, dated 8/18/2021, the report indicated on 8/18/2021 at 8:09 p.m., a call was received of a hit and run and a person laying on the road facing down. The report indicated blunt force trauma (injury to the body caused by forceful impact) to the body and head, both shoes and socks came off the resident, and human skin and blood was seen away from Resident 1’s body. During a review of the facility's undated policy and procedure (P/P) titled, "Care Plans: Goals and Objectives," indicated Care Plans shall incorporate goals and objectives that lead to the resident's highest obtainable level of independence. 1. Care Plan goals and objectives are defined as the desired outcome for a specific resident problem. 2. When goals and objectives are not achieved, the resident's clinical record will be documented as to why the results were not achieved and what new goals and objectives have been established. Care\ Plans will be modified accordingly. 3. Care Plans goals and objectives are derived from information contained in the resident's comprehensive assessment and: a) Are resident oriented; b) Are behaviorally stated; c) Are measurable; and d) Contain timetables to meet the resident's needs in accordance with the comprehensive assessment. 4. Goals and objectives are entered on the resident's needs in accordance with the comprehensive Assessment. 5. Goals and objectives are reviewed and/or revised: a) When there has been a significant change in the resident's condition; b) When the desired outcome has not been achieved; c) When the resident has been readmitted to the facility from a hospital rehabilitation stay; and d) At least quarterly. During a review of the facility's undated P/P titled, "Elopement Prevention and Response," indicated it is the policy of the facility to provide a safe and secure environment and ensure the safety of any resident attempting to elope from the facility to identify residents at risk for elopement through the completion of the Elopement Risk Assessment. Upon admission, residents who are cognitively impaired or mobile (via either wheelchair or ambulatory) and/or who have a history of elopement or wandering, will have a Wandering/Elopement Evaluation (see attachment) by Nursing or Social Services. If resident is determined to be an Elopement Risk, a Care Plan goal with approaches to ensure safety will be implemented as determined by the Interdisciplinary Team. The incident will be documented on an Incident/ Accident Report as well as in the resident's Clinical Record and other State required reports, in addition, the family and attending physician will be notified of the incident. The resident Care Plan will be updated with appropriate interventions implemented to prevent future elopement and ensure resident safety. a) Interventions should be based on assessment of 1. Pharmacological review, 2. Environment triggers to resident elopement, 3. Increased diversion in activities, 4. Psychosocial triggers (new environment, change of routine, family dynamics and 5. Cognitive status (purposeful exit seeking, impulsiveness/poor judgment, unaware of surrounding). b) Suggested interventions may include: 1. Change in Activities, 2. Appropriate level of stimulation, 3. Physician evaluation, 4. Pharmacological review, 5. Resident's treatment sc