Golden Living Center-Dexter House

Golden Living Center-Dexter House

MI Elder Abuse Free Legal ConsultationDid someone you love suffer elder abuse or neglect at Golden Living Center-Dexter House? Our lawyers can help.

Abuse of the elderly is not acceptable and we fight hard in these types of cases. If you suspect Golden Living Center-Dexter House or a caregiver has caused harm to your loved one in someone elses’ care, contact our law firm today for a free legal consultation.

Talking to us does not obligate you to anything, but we may be able to tell you if you have a claim and the value of your case. If we accept your case, you pay no fee unless we recover for you.

About Golden Living Center-Dexter House

Golden Living Center-Dexter HouseGolden Living Center-Dexter House is a for profit, 130-bed Medicare/Medicaid certified skilled nursing facility that provides services to the residents of Malden, Medford, Melrose, Everett, and the other towns in and surrounding Middlesex County, Massachusetts.

Golden Living Center-Dexter House focuses on 24 hour care, respite care, hospice care and rehabilitation services.

Golden Living Center-Dexter House
120 Main St,
Malden, MA 02148

Phone: (781) 324-5600
Website: Golden Living Centers Locator

CMS Star Quality Rating

The Centers for Medicare and Medicaid (CMS) rates all nursing homes that accept medicare or medicaid benefits. CMS created a 5 Star Quality Rating System—1 star is the lowest rating and 5 stars is the highest—that look at three areas.  As of 2017, Golden Living Center-Dexter House in Malden, Massachusetts received a rating of 1 out of 5 stars.

Performance Area Rating
Overall Rating 1 out of 5 (Much Below Average)
State Health Inspections 1 out of 5 (Much Below Average)
Staffing 3 out of 5 (Average)
Quality Measures 2 out of 5 (Below Average)

Fines Against Golden Living Center-Dexter House

The Federal Government fined Golden Living Center-Dexter House $207,589 on December 12th, 2016 and $39,039 on March 17th, 2017 for health and safety violations.

Fines and Penalties

Our Nursing Home Abuse Attorneys inspected government records and discovered Golden Living Center-Dexter House committed the following offenses:

Failed to keep each resident free from physical restraints, unless needed for medical treatment.

Based on observation, record review and interview, the facility failed to ensure a clip seat belt applied to one resident (Resident #13) was the least restrictive intervention to treat a medical symptom in a total sample of 18 residents.

Findings include:

On the first day of survey, 10/4/16, at 9:30 A.M., Nurse #3 on Unit C stated there were no residents utilizing restraints on the unit.

Resident #13 was observed on the first day of survey, 10/4/16, at 10:00 A.M. in his/her room sitting in a scooter chair with a clip seat belt attached around his/her waist. The resident was not able to state why he/she was wearing the clip belt.

Review of the resident’s record indicated the resident was admitted to the facility in 9/2013 with dementia.

A quarterly Minimum Data Set (MDS) completed on 3/11/16 indicated the resident was cognitively impaired, needed supervision for transfers and ambulation and had experienced falls since the last assessment.

Review of an incident report dated 3/27/16 indicated on 3/27/16 at 2:00 P.M., the resident was at the front desk in the lobby, turned and lost his/her balance and fell to the floor on his/her back. There were no injuries noted at that time. The intervention initiated after the fall was a scooter chair with a clip belt and a bed alarm.

Review of the medical record indicated a physicians order for scooter chair with clip seatbelt to increase mobility dated 4/7/16.

Review of the resident’s care plan for falls included the following intervention: – Scooter chair with clip seat belt to increase mobility (initiated 4/7/16).

Subsequent quarterly MDS’s dated 6/10/16 and 9/24/16 indicated the resident now needed extensive assist for transfers and ambulation.

Further review of the medical record indicated there was no assessment for the use of the clip belt.

During an interview with the Director of Nursing (DON) on 10/12/16 at 8:15 A.M., she stated she would look for an assessment for the clip belt, but the resident was able to release the clip belt by himself/herself. The DON returned to the surveyor at 8:50 A.M. and stated the resident could not release the clip belt. An assessment was never completed for the clip belt. Physical Therapy would be completing an assessment today to determine the least restrictive device for the resident.

Failed safely provide drugs and other similar products available, which are needed every day and in emergencies, by a licensed pharmacist

Based on observation and staff interview, the facility failed to ensure pharmacy services that reviewed house stock medications that were of current date, to provide reliability of strength and accuracy of dosage, in 2 of 2 medication rooms and one out of 4 medication carts.

Findings include:

1. During an inspection of the first floor Unit D’s medication room on 10/04/16 at approximately 11:35 A.M., with the Medication Nurse (Nurse #1), the following was observed:

  • One unopened bottle of Acidophilus Lactobacilli with 60 capsules with an expiration date of 1/16.
  • One unopened bottle of Vitamin B-6 50 mg (milligrams) with 100 tablets with an expiration date of 5/16.
  • One unopened bottle of Malt Delyn liquid (multivitamin) 16 fluid ounces with an expiration date of 3/16.
  • One unopened bottle of Oyster Shell Calcium 500/200 IU (International Units) Vitamin D with an expiration date of 4/16.
  • One unopened 3 ounce bottle of Vancomycin 125 mg/5 ml (milliliters)with an expiration date of 9/09/16. Resident was discharged and not in the facility.

During an interview on 10/04/16 at 11:50 A.M., Nurse #1 stated that the bottles of expired medication should have been discarded.

2. During inspection of the second floor Units A and C’s medication rooms on 10/04/16 at 12:15 P.M., with Nurse #1 and the ADON (Assistant Director of Nursing), the following was observed:

  • One unopened box of 30 Ferrous Gluconate 5 grain tablets with an expiration date of 2/16.

3. During observation of a medication pass on medication cart D2, Surveyor #1 observed one 100 capsule bottle of stock Zinc-220 mg. with an expiration date of 3/16.

During an interview on 10/04/16 at 12:15 P.M., the ADON stated that the expired medication should have been discarded and that Pharmacy Services routinely comes to the facility to review medications.

Failed to maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interview, the facility failed to ensure that opened medications were properly dated and out of date medications were removed from use and discarded on 2 of 2 units.

Findings include:

1. On 10/05/16 at 7:50 A.M., during the medication pass from the D 2 Cart, Surveyor #1 observed the Medication Nurse (Nurse #2) pour, from a stock bottle in the cart, one capsule of Zinc–220 mg for Non-sample Resident #1. (NS #1). Surveyor #1 asked what the expiration date was on the bottle. It expired 3/16.

Nurse #2 locked the cart and proceeded to the medication room to obtain another bottle of Zinc-220. There was no Zinc-220 in the medication room. The ADON then brought a bottle of Zinc-220 to the D2 cart with an expiration date that also read 3/16. The Zinc -220 was finally replaced with an expiration date of 9/17.

Surveyor #1 asked Nurse #2 to count the number of capsules remaining in the 100 capsules Zinc-220 bottle. There were 90 capsules remaining in the bottle. Ten capsules were missing. NS #1 had an order for [REDACTED].

The expired medications were discarded.

2. During an inspection of the first floor Unit D’s medication room on 10/04/16 at approximately 11:35 A.M., with the Medication Nurse (Nurse #1), the following was observed:

  • One unopened bottle of Acidophilus Lactobacilli with 60 capsules with an expiration
  • One unopened bottle of Vitamin B-6 50 mg (milligrams) with 100 tablets with an expiration date of 5/16.
  • One unopened bottle of Malt Delyn liquid (multivitamin) 16 fluid ounces with an expiration date of 3/16.
  • One unopened bottle of Oyster Shell Calcium 500/200 IU (International Units) Vitamin D with an expiration date of 4/16.
  • One unopened 3 ounce bottle of Vancomycin 125 mg/5 ml (milliliters) with an expiration date of 9/9/16. Resident was discharged and not in the facility.

During an interview on 10/04/16 at 11:50 A M., NS #1 stated that the bottles of expired medication should have been discarded.

3. During inspection of the second floor Units A and C’s medication room on 10/04/16 at 12:15 P.M., with Nurse #1 and the ADON (Assistant Director of Nursing), the following was observed:

  • One unopened box of 30 Ferrous Gluconate 5 grain tablets with an expiration date of 2/16.

During an interview on 10/04/16 at 12:15 P.M., the ADON stated that the expired medication should have been discarded.

Failed to have a program that investigates, controls and keeps infection from spreading.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, staff interview and review of facility policy, the facility failed to follow proper infection control practices for the prevention and spread of infection. This affected 1 non-sampled resident (NS#2) and 1 sampled resident (#4) in a total sample of 18 residents.

Findings include:

1. On 10/4/16, entrance day to the facility at approximately 8:30 A.M., Surveyor #1 observed a resident go next to the nurses station to a cart with a pitcher of yellow liquid ( lemonade ) and pour a paper cup full and drink it and left the cup on the cart. No staff were present.

On 10/05/16, Surveyor #1 identified that the medication cart D1 was the cart the resident obtained lemonade from and not a refreshment cart. On 10/5/16 at 2:30 P.M. Interview with the Director of Nursing (DON) stated that residents are not to obtain drinks from the medication cart.

2. During observation of the medication pass on the C Unit on 10/04/16 at 2:25 P.M., Non- sample Resident (NS #2) spilled a 4 ounce paper cup of lemonade on the floor. The Per Diem Medication Nurse (Nurse #3) proceeded to wipe the floor with paper towels. Since the floor was still sticky Nurse #3 used a bath towel to clean the floor and proceeded to place the used towel on to the clean medication cart.

Surveyor #1 asked if Nurse #3 was going to clean the medication cart. Nurse #3 stated there were no cleaning wipes on the unit and would call housekeeping for a spray. Housekeeping delivered a packed of bleach wipes to Nurse #3 who cleaned the cart.

3. During observation of the medication pass on Unit C, on 10/04/16 at 2:25 P.M., Nurse #3 administered 50 mg of [MEDICATION NAME] 1/4 tablet (12.5 mg) to non-sample Resident (NS #2) with 4 ounces of lemonade. After administering the medication Nurse #3 proceeded to pour medication without washing her hands with alcohol gel or soap and water until Surveyor #1 asked if she was going to wash her hands. Facility Handwashing/Hand Hygiene Policy identifies to use an alcohol-based hand rub containing at least 62% alcohol, or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations:

  • Before and after direct contact with residents;
  • Before preparing or handling medications. On 10/05/16 @ 2:30 P.M., medication pass infection control concerns were discussed with the DON and Administrator.

4. For Resident #4, Nurse #4 failed to perform proper infection control practices during intravenous (IV) medication administration via a Peripherally Inserted Central Catheter (PICC).

On 10/5/16 at 7:30 A.M., Surveyor #2 approached the medication cart to observe Nurse #4 administer medication. When Surveyor #2 arrived at the cart, Nurse #2 had gloves on. Nurse #2 proceeded to prepare the IV medication by inserting the IV tubing into the IV solution bag.

Nurse #4 picked up the IV medication bag and tubing, a syringe filled with saline used for flushing the PICC and alcohol wipes. She then proceeded into the resident’s room with the same gloves on. Nurse #4 pulled the curtain and moved the resident’s bedside table where she placed all the supplies. Without changing gloves and washing hands, Nurse #4 proceeded to place the IV medication bag and tubing into the IV pump (used to administer the medication).

Nurse #4, with the same gloves, cleansed the PICC port with an alcohol wipe and flushed the port with the syringe filled with saline. She then connected the IV tubing to the port and started the IV pump to administer the medication.

Nurse #4 exited the resident’s room with the gloves on and discarded them at the medication cart. At no time did the nurse remove the gloves or wash her hands during the whole procedure. During an interview with the director of Nursing on 10/12/16 at 4:00 P.M., she stated Nurse #4 did not follow proper infection control practices

Failed to train all employees on what to do in an emergency, and carry out announced staff drills.

Based on staff observation and staff interview, the facility failed to ensure that the emergency equipment on two of two resident care units were functional in the event of an emergency and failed to ensure staff were trained in the set up of emergency equipment.

Findings include:

On 10/05/16 at 1:50 P.M., Surveyor #1 asked to review the Emergency Equipment/Code Cart Log on floor. The log could not be located. At 1:55 P.M Surveyor #1 reviewed with the Unit D Medication Nurse (Nurse #1) the emergency/code cart for floor one The Oxygen tank read empty and Nurse #1 opened the tank with a green wrench on the cart and the oxygen tank still read empty. Nurse #1 proceeded to obtain and replace the empty oxygen tank with a full one and added it to the code cart.

Surveyor #1 then proceeded to the second floor Units A and C to review the code cart with the Staff Development Coordinator (SDC). When the SDC checked the oxygen tank it also read empty. However, there was no green wrench to open the oxygen tank on the emergency/ code cart. A wrench was found in a small container at the nurses station. The SDC opened the oxygen tank and it was empty. A full tank of oxygen was added to the emergency/code cart. The SDC proceeded to check the suction machine. After several attempts were made to connect the suction tubing to the side of the suction machine where the motor of the machine was located, the SDC left the emergency/code cart and went to the nursing station. Surveyor # 1 overheard Nurse #1 explain to the SDC how to connect the tubing to the suction machine. Nurse #1 came to the area where the emergency/code cart was located and attached the tubing to the machine. The SDC then demonstrated that it was functioning. The Emergency/Code Cart Check List for the second floor could not be located.

Observation of eye wash stations identified that none were available on the units. Two eye wash stations were identified in the facility: one in the kitchen and the other in the locked laundry. When Surveyor #1 asked what one would do if there was a need to flush out someone’s eyes, the SDC said that she would open saline bottles and use them. On 10/05/16 at 2:30 P.M. the Director of Nursing and Administrator were made aware of the concerns regarding the code carts and emergency equipment.

Failed to make sure that residents are safe from serious medication errors.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on records reviewed and interviews, for 1 of 4 sampled residents (Resident #1), the Facility failed to ensure that Resident #1 was free from medication errors and received medications as prescribed by his/her Physician. At approximately 5:15 A.M. on 12/9/16, Resident #1 complained of numbness in his/her throat, arms, and legs, was vomiting, and said the wrong medications were administered to him/her the previous evening. Resident #1 was transferred to the Emergency Department where his/her urine toxicology results revealed the presence of [MEDICATION NAME] (a narcotic used for treating pain and/or drug addiction), which was not a medication prescribed for Resident #1 by his/her Physician and Resident #1 was treated with intravenous fluids for [DIAGNOSES REDACTED].

Findings include:

Resident #1’s Admission Minimum Data Set (MDS) indicated Resident #1 was admitted to the Facility for short term rehabilitation on 11/29/16 and was discharged home with services on 12/12/16. He/she was alert, oriented, and cognitively intact with a BIMS (Brief Interview for Mental Status) score of 13.

A Nurse’s Progress Note, dated 12/9/16 and timed at 6:09 A.M., indicated that Resident #1 vomited twice, was diaphoretic (sweating), complained of numbness in his/her throat, arms, and legs, and Resident #1 said that the reaction was because he/she had been given too much medication the previous night.

The Surveyor interviewed Nurse #1 on 3/17/17 at 4:05 P.M. Nurse #1 said during her 11 P.M. to 7 A.M. shift on 12/9/16, Resident #1 woke up early in the morning and vomited, said he/she was light headed, and he/she was given too much medicine the night before. Nurse #1 said she called to notify Resident #1’s Physician who gave an order to transfer Resident #1 to the Emergency Department.

The Surveyor interviewed the Assistant Director of Nursing (ADON) on 3/21/17 at 11:22 A.M. The ADON said she spoke with Resident #1 prior to his/her transfer to the Hospital. The ADON said Resident #1 told her that around dinner time the night before, when Nurse #2 gave him/her some pills, Resident #1 counted the pills and told Nurse #2 they weren’t his/her pills, but Nurse #2 told Resident #1 to take them because they were his/her pills, or words to that effect. The ADON said, shortly after Resident #1 left the Facility, the Unit Manager informed her that Resident #1’s Roommate (Resident #2) had an order for [REDACTED].

The Surveyor interviewed Nurse #2 on 3/21/17 at 4:12 P.M. Nurse #2 said that on 12/8/16 while he was administering medications, although he did not recall Resident #1’s concerns about receiving medications that were not his/her, he did recall that he was distracted and frequently interrupted while he was trying to administer medications to residents. An Incident Report submitted by the Facility to the Department of Public Health on 12/16/16 indicated that, after an internal investigation, the Facility concluded that a medication administration error had occurred and that Resident #1 was administered Resident #2’s [MEDICATION NAME] on 12/8/16 in error.

Resident #2’s monthly physician’s orders [REDACTED].#2 was to receive four 10mg tablets of [MEDICATION NAME] once per day for which the Facility scheduled to be given daily at 5:00 P.M. Resident #1’s monthly physician’s orders [REDACTED].>Resident #1’s After Visit Summary from the Hospital, dated 12/9/16, indicated that Resident #1’s urine toxicology results were positive for [MEDICATION NAME] and Resident #1 was treated with intravenous fluids for [DIAGNOSES REDACTED].

Failed to let the resident refuse treatment or refuse to take part in an experiment and formulate advance directives.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on records reviewed and interviews for three of seven sampled residents (Resident #3, Resident #4, and Resident #6), the Facility failed to develop advanced directives indicating what the residents chose for life supporting resuscitation in the event of a cardiac or respiratory arrest.

Findings include:

The Massachusetts Medical Orders for Life-Sustaining Treatment (MOLST) form, dated 8/10/13, indicated that the form specified whether a resident wanted cardiopulmonary Resuscitation (for a patient/resident in a cardiac or respiratory arrest), or ventilation (for a patient in respiratory distress), or transfer to the hospital.

The Facility’s Physician Orders for Life-Sustaining Treatment Policy, effective 11/18/16, indicated the POLST form specifies the types of medical treatment that a patient wishes to receive towards the end of life. These medical orders are signed by both the patient’s physician, physician’s assistant, or certified registered nurse practitioner and the patient, or the patient’s surrogate decision maker.

The Resident Rights Policy, revised on 11/28/16, indicated residents had the right to formulate an advance directive.

1. Resident #3 was admitted to the Facility in 01/2017. The Physician’s Orders, dated 1/18/17, indicated Resident #3’s [DIAGNOSES REDACTED]. Review of the Physician orders indicated there was no order regarding Resident #3’s code status.

Resident #3’s Massachusetts Medical Orders for Life-Sustaining Treatment (MOLST) form was blank and there was an X indicating where the patient and the clinician signatures were required.

Review of Resident #3’s medical record indicated there was no documentation regarding a discussion related to Advanced Directives and his/her wishes on his/her care plans.

2. Resident #4 was admitted to the Facility in 01/2017.

The Physician’s Orders, dated 1/18/17, indicated Resident #4’s [DIAGNOSES REDACTED]. Review of the Physician’s orders indicated there was no order regarding Resident #4’s code status.

Resident #4’s Massachusetts Medical Orders for Life-Sustaining Treatment (MOLST) form was blank and there was an X indicating where the patient and the clinician signatures were required.

Review of Resident #4’s medical record indicated that there was no documentation regarding a discussion related to Advanced Directives and his/her wishes on his/her Care Plans.

3. Resident #6 was admitted to the Facility in 11/2016.

The Admission Minimum Data Set (MDS) Assessment, dated 11/18/16, indicated Resident #6 had a [DIAGNOSES REDACTED].

The Physician’s Orders, dated 1/1/17, indicated there was no order for Resident #6’s code status.

Resident #6’s Massachusetts Medical Orders for Life-Sustaining Treatment (MOLST) form was blank and there was an X indicating where the patient and the clinician signatures were required. Review of Resident #6’s medical record indicated that there was an Advanced Directive on his/her Care Plans as a full code.

Surveyor #2 and Surveyor #4 interviewed Unit Manager #1 at 10:40 A.M. on 1/23/17. Unit Manager #1 said there was no MOLST form and no Physician’s order clarifying code status, the Facility staff would presume the resident was a full code (a designation that means to intercede if a resident’s heart stops beating, or if the resident stops breathing).

Surveyor #1 and Surveyor #4 interviewed the Nurse Practitioner at 4:42 P.M. on 1/23/17. The Nurse Practitioner said if there was no MOLST form, then the resident would be considered a full code. The Nurse Practitioner said Resident #3 should be a full code because he/she was here (at the Facility) before and because he/she was young, or words to that effect. The Nurse Practitioner said she thought she documented Resident #3’s code status in his/her record. The Nurse Practitioner looked for documents in Resident #3 and Resident #4’s record regarding the code status but she was unable to find documentation to support what their code status was.

Surveyor #1 and Surveyor #4 interviewed the Director of Social Services at 3:35 P.M. on 1/23/17 and at 10:00 A.M. on 1/25/17. The Director of Social Services said that if the MOLST form was not signed, then we (Facility staff) assumed the resident was a full code. The Director of Social Services was not able to provide documentation that indicated that the Facility had provided information to Resident #3, Resident #4, and Resident #6 or their next of kin/health care agents regarding code status or MOLSTs. The Director of Social Services said they (the Facility) did not have a good system in place to check if a MOLST was signed and reviewed by the Nurse Practitioner, until the Department of Public Health (during this survey) brought it to their attention.

Failed to immediately tell the resident, the resident's doctor and a family member of the resident of situations (injury/decline/room, etc.) that affect the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on records reviewed and interview for two of seven sampled residents (Resident #3 and Resident #6), the Facility failed to ensure that the residents were provided advance notice of a room change.

Findings include:

The Facility’s Transfer of Resident within the Facility Policy, reviewed on 5/3/16, indicated the Facility would enter the room change in the Facility’s electronic medical records, and the Policy’s Guidelines included documenting the date and time the resident and responsible party were notified, location of transfer, department notified, resident’s response, how well the transfer was tolerated, and signature and title.

1. For Resident #3, the Facility failed to provide a room change form to Resident #3 and failed document in his/her chart of his/her room change on 1/19/17. Resident #3 was admitted to the Facility in 01/2017.

The physician’s orders [REDACTED].#3’s [DIAGNOSES REDACTED]. Surveyor #1 and Surveyor #4 interviewed Social Worker #1 at 3:47 P.M. on 1/23/17. Social Worker #1 said although Resident #3 (who was cognitively impaired) gave verbal permission for a room change, she did not fill out any paperwork regarding Resident #3’s room change and did not document the room change in the Facility’s electronic medical records.

2. For Resident #6, the Facility failed to provide a room change form to Resident #6 and failed to document in his/her chart of his/her room change on 1/19/17. Resident #6 was admitted to the Facility in 11/2016.

The Admission Minimum Data Set (MDS) Assessment, dated 11/18/16, indicated Resident #6 had a [DIAGNOSES REDACTED].

Surveyor #1 and Surveyor #4 interviewed the Director of Social Services at 3:55 P.M. on 1/23/17 and at 4:00 P.M. on 1/26/17. The Director of Social Services said although Resident #6’s Health Care Agent gave verbal consent for his/her room change, either on late 1/19/17, or early 1/20/17, no Room Change Form was completed and there was no Social Services Progress note in Resident #6’s record, in indicating a room change had occurred. Review of Resident #3 and Resident #6’s medical records indicated there were no room change forms in their records, and there were no Nurses’ Notes or Social Service Progress notes indicating a room change had occurred or that Resident #6’s Health Care Agent was informed prior to the room change.

Failed to keep each resident free from physical restraints, unless needed for medical treatment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on records reviewed, interviews, and observation for 1 of 7 sampled residents, (Resident #7), the Facility failed to ensure that the seat belt secured around Resident #7’s waist while he/she was seated in his/her wheelchair was not a restraint. On 1/23/17 Resident #7 was observed to be unable to self-release his/her seat belt when he/she was asked to do so and was therefore restrained in his/her wheelchair. There were no Physician’s orders, assessments, or documentation of least restrictive alternative interventions attempted prior to implementation of the seat belt.

Findings include:

The Facility Policy, titled Physical Restraints Review Procedures and dated 11/2/16, indicated the Facility must ensure the Medical Record of any Resident with a restraint contains:

  • Documentation of the appropriateness of the restraint
  • Completion of a Restraint Assessment
  • Documentation that the least restrictive device was chosen
  • An Informed Consent Form signed and dated by the Resident or Responsible Party and Physician orders that include:
  • The type of restraint · Reason for the Restraint · How long the restraint is to be used

The Minimum Data Set (MDS) Assessment, dated 12/23/16. indicated Resident #7’s medical [DIAGNOSES REDACTED].#7 had a fall with major injury. A care plan, dated 1/6/17, indicated Resident #7 was identified at risk for falls, however, there was no indication for implementation of any type of seat belt to Resident #7’s wheelchair.

On 1/23/17 at 10:38 A.M., Surveyor #2 and Surveyor #3 observed Resident #7 seated in his/her wheelchair with a Velcro seatbelt fastened around his/her waist. Surveyor #3 asked Nurse # 4 if Resident #7 was able to release the seat belt or if the seat belt was a restraint. Nurse #4 said Resident #7 had the ability to self-release the seat belt when asked to do so and proceeded to ask Resident #7 to open the seat belt. Resident #7 continued to look at Nurse #4 without acknowledging the seat belt and made no attempt to release it.

Nurse #4 said that although Resident #7 was unable to self-release the seat belt at that time, sometimes Resident #7 is more lucid and is able to self-release at times, or words to that effect. On 1/23/17 at 12:55 P.M., Surveyor #1 and Surveyor #3 observed Resident #7 with CNA #3 in Resident #7’s room. Resident #7 was seated in his/her wheelchair with the Velcro seat belt secured around his/her waist and CNA #3 said Resident #7 was sometimes able to self-release the seat belt when asked to do so. CNA #3 asked Resident #7 to open the seat belt and Resident #7 did not make any attempt to self-release the seat belt. CNA #3 asked Resident #7 to open the seat belt a second time and Resident #7 made unintelligible vocalizations, did not acknowledge the seat belt, and made no attempt to self-release the seat belt when asked.

Surveyor #3 and Surveyor #4 interviewed the Interim Therapy Coordinator on 1/23/17 at 3:54 P.M. The Interim Therapy Coordinator said that Resident #7’s seat belt had been in use since December 2016 and Resident #7 had severe cognitive impairment, poor follow through and he/she could only follow 1 step instructions approximately 25% of the time. The Interim Therapy Coordinator said although the seat belt was considered a restraint if Resident #7 was unable to self-release the seat belt when asked, she had never attempted to ask Resident #7 to self-release the seat belt. The Interim Therapy Coordinator said it was the responsibility of the Nurses to perform a restraint assessment, obtain Physician orders and develop a Care Plan for the restraint.

There was no documentation indicating that staff performed a restraint assessment prior to implementation of the seatbelt in December 2016.

Surveyor #3 and #4 interviewed the Director of Nursing (DON) on 1/23/17 at 5:17 P.M. The DON said that she was unaware Resident #7 had a seat belt/restraint on his/her wheelchair. The DON said there was a breakdown in communication in relation to Resident #7’s restraint.

A Physician’s Telephone Order, obtained and dated 1/23/17 and timed at 11:35 A.M., was obtained for Resident #7 to have an alarmed Velcro belt while in his/her wheelchair every day and evening. The Physician’s order did not contain the reason for the placement of Resident #7’s restraint, how long the restraint is to be used, and release times for the restraint. This was not consistent with the Facility Policy titled Physical Restraints Review Procedures.

Surveyor #1 and Surveyor #3 interviewed Nurse #4 on 1/23/17 at 2:40 P.M. Nurse #4 said that Physician’s Orders were not obtained for the seat belt prior to being placed on Resident #7. Nurse #4 said there was no documentation in Resident #7’s treatment records to reflect that staff was monitoring Resident #7 during the use of the restraint because she had only obtained a Physician’s Order for Resident #7’s seat belt after Surveyor #3 had questioned her about Resident #3’s seat belt earlier in the day.

A Restraint and Device Assessment form provided to Surveyor #3 on 1/23/17 at 2:40 P.M. was documented as completed on 1/23/17. Nurse #4 said she had completed the form at approximately 11:00 A.M., which was shortly after Surveyor #3 had questioned her about Resident #7’s ability to self-release the seat belt. The Restraint and Device Assessment form provided to Surveyor #3 did not include the type of restraint in use, why the restraint was in use, or that the least restrictive restraint device was chosen. This was not consistent with the Facility Policy titled Physical Restraints Review Procedures.

Review of Resident #7’s Care Plans identified Resident #7 did not have a Care Plan established which indicated a restraint was in use for Resident #7, the type of restraint used, frequency of which the restraint was released, the risks of restraint use, or evidence of a reduction and/or elimination of Resident #7’s. This was not consistent with the Facility Policy titled Physical Restraints Review Procedures.

Review of Resident #7’s Medical Record identified there was no Informed Consent form completed and signed by Resident #7’s Health Care Agent for Resident #7’s restraint. This was not consistent with the Facility Policy titled Physical Restraints Review Procedures.

Failed to develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on records reviewed, interviews, and observations for 4 of 7 sampled Residents (Resident #1, #2, #5, and #7), the Facility failed to develop comprehensive Care Plans that addressed their individual care needs.

– Resident #1, who was cognitively impaired, did not have a plan of care to prevent elopement, eloped from the Facility on the evening of 1/17/17 and was found dead on the morning of 1/18/17.

-Resident #2 who was cognitively impaired, did not have an effective elopement care plan in place, eloped from the Facility on 1/1/17 and was found outside near a busy street.

-Resident #5 who was known to independently exit the Facility, however no plan of care or assessment for safety was in place to address potential safety concerns for a resident capable of exiting the Facility alone.

-Resident #7 for whom the Facility failed to obtain Physician orders and develop a Care Plan for a Velcro seatbelt restraint secured to Resident #7 while he/she was seated in his/her wheelchair.

Findings include:

1. Resident #1 was admitted to the Facility in October, 2016, and his/her [DIAGNOSES REDACTED].

A Minimum Data Set (MDS) assessment, dated 12/8/16, indicated; Resident #1 was severely cognitively impaired, and required minimal assistance from staff for ambulation. A Plan of Care, dated, 12/14/16, indicated Resident #1 was at risk for falls, and a pressure sensitive alarm (a device that sounds when a resident has moved) was ordered for Resident #1’s bed.

Resident #1’s health status improved with Physical Therapy over the course of the next few months. A Physical Therapy Progress Note, dated 12/1/16, indicated; Resident #1’s mobility and ambulation status had improved, and he/she was able to walk 400ft with minimal staff assistance. A Discharge Planning Meeting minutes note, dated, 1/11/17, indicated; Resident #1 had made tremendous progress physically, but not in cognitive status, and would be transferred to long term care.

A Clinical Health Status assessment, which included a risk for elopement assessment, dated 12/27/16, indicated; Resident #1 had a memory problem. The risk for elopement section of the assessment was not completed. There was not an updated risk for elopement assessment completed to reflect Resident #1’s improved mobility status, (this was inconsistent with Facility Policy titled Elopement Guideline)

A Weekly Care Management Meeting Note, dated 1/10/17, indicated Resident #1 could transfer him/her self independently, was cognitively impaired, and had poor safety awareness. A Nurse Progress Note, dated 1/17/17, timed 2:27 P.M. indicated Resident #1 was transferred to the B Wing from another unit within the Facility.

A Nurse Progress Note, dated 1/18/17, timed 12:06 A.M. indicated staff were not able to locate Resident #1, and a report had been filed with the local Police Department. The note did not indicate when Resident #1 was first noticed missing.

A Police Report from a neighboring city, dated 1/18/17, indicated Resident #1 was found, unresponsive, at approximately 6:23 A.M., outside, behind a business building. Resident #1 was pronounced dead at the scene by emergency first responders, at 06:30 A.M. 2. Resident #2 was admitted to the Facility in December, 2016, and his/her [DIAGNOSES REDACTED].

A Physician’s order, dated 12/31/16, indicated, Resident #2 was to have a wander alert bracelet (a device which triggers an alarm to alert staff when a person is near an exit) to prevent elopement. A Nurse Progress Note, dated 1/1/17, timed 11:15 A.M., indicated, Resident #2 was found outside the Facility, when another Resident alerted staff that he/she had walked out the front door of the Facility.

Surveyor #1 interviewed Nurse #3 at 8:46 A.M., on 1/25/17. Nurse #3 said another resident alerted staff that Resident #2 was outside, sometime late in the morning on 1/1/17. Nurse #3 said Resident #2 had a wander alert bracelet in place, which was functioning, and the alarm at the door was sounding. Nurse #3 said Resident #2 was at the sidewalk in front of the Facility, which is on a main road, when she and CNA #2 caught up with him/her and were able to redirect him/her back into the Facility.

Surveyor #1 interviewed CNA #2 at 9:57 A.M., on 1/25/17. CNA #2 said sometime late in the morning on 1/1/17, another resident alerted her that Resident #2 was outside. CNA #2 said she and Nurse #3 ran outside through the front main door of the Facility, and caught up to Resident #2, outside the Facility, near a main road. CNA #2 could not recall if she heard the wander alert alarm sounding at the time.

A corrective action plan, dated 1/8/17, and submitted to the Department of Public Health indicated; Resident #2 would have 1:1 direct supervision on the day and evening shifts, the door to the B Wing unit would be kept closed as a barrier to prevent elopement, and the Facility was proceeding to transfer Resident #2 to a different Facility with a secured unit.

A Care Plan, dated 1/9/17, indicated a goal to discharge Resident #2 to a secured unit at another Facility, due to risk for elopement. No interventions to prevent elopement were identified in this care plan.

A Nurse Progress Note, dated 1/9/17, timed 12:05 P.M., indicated Resident #2 was wandering intrusively through other residents’ rooms, was difficult to redirect, and continued on every 15 minute checks by staff (this was inconsistent with the corrective action plan that indicated Resident #2 would be provided 1:1 direct supervision by staff).

A Nurse Progress Note, dated 1/10/17, timed 11:30 A.M., indicated Resident #2 continued to wander throughout the unit, was redirected by staff with only short term effect, and continued on every 15 minute checks by staff.

CNA #2 said she was not aware of other interventions put in place to prevent elopement after Resident #2 eloped, and the doors at the end of the B Wing were not kept closed after Resident #2’s elopement. CNA #2 said Resident #2 had a wander alert bracelet in place, and every 15 minute checks for safety by staff.

3. Resident #5 was admitted to the Facility 12/2016, and his/her [DIAGNOSES REDACTED]. A Clinical Health Status assessment, which included a risk for elopement assessment, dated 12/1/16, indicated Resident #5 was not physically able to leave the building on his/her own.

Resident #5’s care plan did not reflect his/her ability to leave the Facility independently, or any safety concerns regarding Resident #5 leaving the Facility independently. Surveyor #1 and Surveyor #2 observed, at 3:21 P.M., on 1/19/17, Resident #5, self-propelling in his/her wheelchair, exit the Facility through the front main door, and to the sidewalk in front of the building. The Administrator followed Resident #5 out to the sidewalk, and he and Resident #5 came back in to the Facility approximately 2 minutes later.

Surveyor #1 and Surveyor #2 interviewed the business office manager at 3:23 P.M., on 1/19/17. The business office manager, who was also responsible for monitoring the front desk, said Resident #5 had been looking for his/her family member, who she said had gone to use the bathroom, but she had not seen the family member leave, as it had been very busy in the front lobby, so she was unable to monitor who had left through the front main door of the Facility.

Surveyor #1 and Surveyor #2 interviewed the Administrator at 3:26 P.M., on 1/19/17. The Administrator said Resident #5 would often leave the Facility on his/her own. 4. The Facility Policy, titled Physical Restraints Review Procedures and dated 11/2/16, indicated that Care Plans for residents with restraints in use include; the type of restraint used, frequency of which the restraint is released, risks of restraint use, and evidence of the reduction/elimination of the restraint.

The MDS, dated [DATE], indicated Resident #7’s medical [DIAGNOSES REDACTED].#7 had a fall with major injury.

On 1/23/17 at 10:38 A.M., Surveyor #2 and Surveyor #3 observed Resident #7 seated in his/her wheelchair with a Velcro seatbelt fastened around his/her waist. Surveyor #3 asked Nurse # 4 if Resident #7 was able to release the seat belt or if the seat belt was a restraint. Nurse #4 said Resident #7 had the ability to self-release the seat belt when asked to do so and proceeded to ask Resident #7 to open the seat belt. Resident #7 continued to look at Nurse #4 without acknowledging the seat belt and made no attempt to release it. Nurse #4 said that although Resident #7 was unable to self-release the seat belt at that time, sometimes Resident #7 is more lucid and is able to self-release at times.

On 1/23/17 at 12:55 P.M., Surveyor #1 and Surveyor #3 observed Resident #7 with CNA #3 in Resident #7’s room. Resident #7 was seated in his/her wheelchair with the Velcro seat belt secured around his/her waist and CNA #3 said Resident #7 was sometimes able to self-release the seat belt when asked to do so. CNA #3 asked Resident #7 to open the seat belt and Resident #7 did not make any attempt to self-release the seat belt. CNA #3 asked Resident #7 to open the seat belt a second time and Resident #7 made unintelligible vocalizations, did not acknowledge the seat belt, and made no attempt to self-release the seat belt when asked.

Surveyor #3 and Surveyor #4 interviewed the Interim Therapy Coordinator on 1/23/17 at 3:54 P.M. The Interim Therapy Coordinator said that Resident #7’s seat belt had been in use since December and Resident #7 had severe cognitive impairment, poor follow through and he/she could only follow 1 step instructions approximately 25% of the time. Occupational Therapist #1 said although the seat belt is considered a restraint if Resident #7 was unable to self-release the seat belt when asked, she had never attempted to ask Resident #7 to self-release the seat belt and it was the responsibility of the Nurses perform an assessment, obtain Physician orders and develop a Care Plan for the restraint.

Surveyor #1 and Surveyor #3 interviewed Nurse #4 on 1/23/17 at 2:40 P.M. Nurse #4 said she was unsure of how long Resident #7’s seat belt had been in use and unsure if Resident #7 had a Restraint Care Plan. Nurse #4 said that Physician’s Orders were not obtained for the seat belt prior to use on Resident #7 and she had obtained a Physician’s Order only after Surveyor #3 had questioned her about Resident #3’s seat belt earlier in the day. A Physician’s Telephone Order, dated 1/23/17 and timed at 11:35 A.M., was obtained for an alarmed Velcro seat belt for Resident #7 for use in his/her wheelchair every day and evening. The Physician’s order did not contain the reason for the placement of Resident #7’s restraint, how long the restraint is to be used, and release times for the restraint. This was not consistent with the Facility Policy titled Physical Restraints Review Procedures.

Review of Resident #7’s Medical Record identified there was no Care Plan which indicated a restraint was in use for Resident #7, or the type of restraint used, frequency of which the restraint is released, risks of restraint use, and evidence of a reduction and/or elimination of Resident #7’s restraint and there were no Physician’s orders obtained prior to Resident #7’s seat belt being placed. This was not consistent with the Facility Policy titled Physical Restraints Review Procedures.

Failed to make sure that the nursing home area is free from accident hazards and risks and provides supervision to prevent avoidable accidents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on records reviewed, interviews, and observations for 4 of 7 sampled Residents (Resident #1, #2, #5, and #7), the Facility failed to develop comprehensive Care Plans that addressed their individual care needs.

  • Resident #1, who was cognitively impaired, did not have a plan of care to prevent elopement, eloped from the Facility on the evening of 1/17/17 and was found dead on the morning of 1/18/17.
  • Resident #2 who was cognitively impaired, did not have an effective elopement care plan in place, eloped from the Facility on 1/1/17 and was found outside near a busy street.
  • Resident #5 who was known to independently exit the Facility, however no plan of care or assessment for safety was in place to address potential safety concerns for a resident capable of exiting the Facility alone.
  • Resident #7 for whom the Facility failed to obtain Physician orders and develop a Care Plan for a Velcro seatbelt restraint secured to Resident #7 while he/she was seated in his/her wheelchair.

Findings include:

1. Resident #1 was admitted to the Facility in October, 2016, and his/her [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment, dated 12/8/16, indicated; Resident #1 was severely cognitively impaired, and required minimal assistance from staff for ambulation. A Plan of Care, dated, 12/14/16, indicated Resident #1 was at risk for falls, and a pressure sensitive alarm (a device that sounds when a resident has moved) was ordered for Resident #1’s bed.

Resident #1’s health status improved with Physical Therapy over the course of the next few months. A Physical Therapy Progress Note, dated 12/1/16, indicated; Resident #1’s mobility and ambulation status had improved, and he/she was able to walk 400ft with minimal staff assistance. A Discharge Planning Meeting minutes note, dated, 1/11/17, indicated; Resident #1 had made tremendous progress physically, but not in cognitive status, and would be transferred to long term care.

A Clinical Health Status assessment, which included a risk for elopement assessment, dated 12/27/16, indicated; Resident #1 had a memory problem. The risk for elopement section of the assessment was not completed.

There was not an updated risk for elopement assessment completed to reflect Resident #1’s improved mobility status, (this was inconsistent with Facility Policy titled Elopement Guideline)

A Weekly Care Management Meeting Note, dated 1/10/17, indicated Resident #1 could transfer him/her self independently, was cognitively impaired, and had poor safety awareness. A Nurse Progress Note, dated 1/17/17, timed 2:27 P.M. indicated Resident #1 was transferred to the B Wing from another unit within the Facility.

A Nurse Progress Note, dated 1/18/17, timed 12:06 A.M. indicated staff were not able to locate Resident #1, and a report had been filed with the local Police Department. The note did not indicate when Resident #1 was first noticed missing.

A Police Report from a neighboring city, dated 1/18/17, indicated Resident #1 was found, unresponsive, at approximately 6:23 A.M., outside, behind a business building. Resident #1 was pronounced dead at the scene by emergency first responders, at 06:30 A.M.

2. Resident #2 was admitted to the Facility in December, 2016, and his/her [DIAGNOSES REDACTED]. A Physician’s order, dated 12/31/16, indicated, Resident #2 was to have a wander alert bracelet (a device which triggers an alarm to alert staff when a person is near an exit) to prevent elopement. A Nurse Progress Note, dated 1/1/17, timed 11:15 A.M., indicated, Resident #2 was found outside the Facility, when another Resident alerted staff that he/she had walked out the front door of the Facility.

Surveyor #1 interviewed Nurse #3 at 8:46 A.M., on 1/25/17. Nurse #3 said another resident alerted staff that Resident #2 was outside, sometime late in the morning on 1/1/17. Nurse #3 said Resident #2 had a wander alert bracelet in place, which was functioning, and the alarm at the door was sounding. Nurse #3 said Resident #2 was at the sidewalk in front of the Facility, which is on a main road, when she and CNA #2 caught up with him/her and were able to redirect him/her back into the Facility.

Surveyor #1 interviewed CNA #2 at 9:57 A.M., on 1/25/17. CNA #2 said sometime late in the morning on 1/1/17, another resident alerted her that Resident #2 was outside. CNA #2 said she and Nurse #3 ran outside through the front main door of the Facility, and caught up to Resident #2, outside the Facility, near a main road. CNA #2 could not recall if she heard the wander alert alarm sounding at the time.

A corrective action plan, dated 1/8/17, and submitted to the Department of Public Health indicated; Resident #2 would have 1:1 direct supervision on the day and evening shifts, the door to the B Wing unit would be kept closed as a barrier to prevent elopement, and the Facility was proceeding to transfer Resident #2 to a different Facility with a secured unit.

A Care Plan, dated 1/9/17, indicated a goal to discharge Resident #2 to a secured unit at another Facility, due to risk for elopement. No interventions to prevent elopement were identified in this care plan.

A Nurse Progress Note, dated 1/9/17, timed 12:05 P.M., indicated Resident #2 was wandering intrusively through other residents’ rooms, was difficult to redirect, and continued on every 15 minute checks by staff (this was inconsistent with the corrective action plan that indicated Resident #2 would be provided 1:1 direct supervision by staff).

A Nurse Progress Note, dated 1/10/17, timed 11:30 A.M., indicated Resident #2 continued to wander throughout the unit, was redirected by staff with only short term effect, and continued on every 15 minute checks by staff. CNA #2 said she was not aware of other interventions put in place to prevent elopement after Resident #2 eloped, and the doors at the end of the B Wing were not kept closed after Resident #2’s elopement. CNA #2 said Resident #2 had a wander alert bracelet in place, and every 15 minute checks for safety by staff.

3. Resident #5 was admitted to the Facility 12/2016, and his/her [DIAGNOSES REDACTED]. A Clinical Health Status assessment, which included a risk for elopement assessment, dated 12/1/16, indicated Resident #5 was not physically able to leave the building on his/her own.

Resident #5’s care plan did not reflect his/her ability to leave the Facility independently, or any safety concerns regarding Resident #5 leaving the Facility independently.

Surveyor #1 and Surveyor #2 observed, at 3:21 P.M., on 1/19/17, Resident #5, self-propelling in his/her wheelchair, exit the Facility through the front main door, and to the sidewalk in front of the building. The Administrator followed Resident #5 out to the sidewalk, and he and Resident #5 came back in to the Facility approximately 2 minutes later.

Surveyor #1 and Surveyor #2 interviewed the business office manager at 3:23 P.M., on 1/19/17. The business office manager, who was also responsible for monitoring the front desk, said Resident #5 had been looking for his/her family member, who she said had gone to use the bathroom, but she had not seen the family member leave, as it had been very busy in the front lobby, so she was unable to monitor who had left through the front main door of the Facility.

Surveyor #1 and Surveyor #2 interviewed the Administrator at 3:26 P.M., on 1/19/17. The Administrator said Resident #5 would often leave the Facility on his/her own.

4. The Facility Policy, titled Physical Restraints Review Procedures and dated 11/2/16, indicated that Care Plans for residents with restraints in use include; the type of restraint used, frequency of which the restraint is released, risks of restraint use, and evidence of the reduction/elimination of the restraint. The MDS, dated [DATE], indicated Resident #7’s medical [DIAGNOSES REDACTED].#7 had a fall with major injury.

On 1/23/17 at 10:38 A.M., Surveyor #2 and Surveyor #3 observed Resident #7 seated in his/her wheelchair with a Velcro seatbelt fastened around his/her waist. Surveyor #3 asked Nurse # 4 if Resident #7 was able to release the seat belt or if the seat belt was a restraint. Nurse #4 said Resident #7 had the ability to self-release the seat belt when asked to do so and proceeded to ask Resident #7 to open the seat belt. Resident #7 continued to look at Nurse #4 without acknowledging the seat belt and made no attempt to release it. Nurse #4 said that although Resident #7 was unable to self-release the seat belt at that time, sometimes Resident #7 is more lucid and is able to self-release at times.

On 1/23/17 at 12:55 P.M., Surveyor #1 and Surveyor #3 observed Resident #7 with CNA #3 in Resident #7’s room. Resident #7 was seated in his/her wheelchair with the Velcro seat belt secured around his/her waist and CNA #3 said Resident #7 was sometimes able to self-release the seat belt when asked to do so. CNA #3 asked Resident #7 to open the seat belt and Resident #7 did not make any attempt to self-release the seat belt. CNA #3 asked Resident #7 to open the seat belt a second time and Resident #7 made unintelligible vocalizations, did not acknowledge the seat belt, and made no attempt to self-release the seat belt when asked.

Surveyor #3 and Surveyor #4 interviewed the Interim Therapy Coordinator on 1/23/17 at 3:54 P.M. The Interim Therapy Coordinator said that Resident #7’s seat belt had been in use since December and Resident #7 had severe cognitive impairment, poor follow through and he/she could only follow 1 step instructions approximately 25% of the time. Occupational Therapist #1 said although the seat belt is considered a restraint if Resident #7 was unable to self-release the seat belt when asked, she had never attempted to ask Resident #7 to self-release the seat belt and it was the responsibility of the Nurses perform an assessment, obtain Physician orders and develop a Care Plan for the restraint.

Surveyor #1 and Surveyor #3 interviewed Nurse #4 on 1/23/17 at 2:40 P.M. Nurse #4 said she was unsure of how long Resident #7’s seat belt had been in use and unsure if Resident #7 had a Restraint Care Plan. Nurse #4 said that Physician’s Orders were not obtained for the seat belt prior to use on Resident #7 and she had obtained a Physician’s Order only after Surveyor #3 had questioned her about Resident #3’s seat belt earlier in the day. A Physician’s Telephone Order, dated 1/23/17 and timed at 11:35 A.M., was obtained for an alarmed Velcro seat belt for Resident #7 for use in his/her wheelchair every day and evening. The Physician’s order did not contain the reason for the placement of Resident #7’s restraint, how long the restraint is to be used, and release times for the restraint. This was not consistent with the Facility Policy titled Physical Restraints Review Procedures.

Review of Resident #7’s Medical Record identified there was no Care Plan which indicated a restraint was in use for Resident #7, or the type of restraint used, frequency of which the restraint is released, risks of restraint use, and evidence of a reduction and/or elimination of Resident #7’s restraint and there were no Physician’s orders obtained prior to Resident #7’s seat belt being placed. This was not consistent with the Facility Policy titled Physical Restraints Review Procedures.

Failed to make sure that the nursing home area is free from accident hazards and risks and provides supervision to prevent avoidable accidents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interviews, records reviewed, and observations, for 2 out of 7 sampled residents (Resident #1 and Resident #2), the Facility failed to provide adequate supervision to prevent elopement. On 1/17/17, Resident #1 eloped, and was found dead the following morning by local police. In addition, Resident #2 eloped from the Facility, and was noticed outside, on the sidewalk. In addition the Facility failed to:

  • Accurately assess 2 Resident out of 7 sampled residents (Resident #1 and Resident #5) for elopement risk. Resident #1 was admitted in October 2016, in December ambulation had improved and the Facility failed to ensure Resident #1 was re-assessed for elopement risk. Resident #5 was documented as physically unable to exit the building, however was observed by Surveyor #1 and Surveyor #2 exiting the Facility on his/her own, staff said he/she would exit the Facility frequently, however no assessment or plan of care was in place to address Resident #5’s safety when outside of the Facility.
  • Relay information to staff caring for residents at risk for elopement;
  •  To ensure no residents had left the Facility or perform a head count of residents on the unit when the door alarm (which sounded when a person had exited)sounded at the front main entrance of the Facility;
  • To maintain up to date accurate information regarding residents who had been identified at risk for elopement for the staff who supervised the front door from 8:00 A.M. to 6:00 P.M.

The Facility relied on the use of a door alarm after 6:00 P.M. that alerted staff whenever the front main door was opened. However, staff who routinely worked on the unit said the alarm was not audible in all areas of the unit, such as residents’ rooms. Staff said that when the alarms sounded and they shut the alarm off, they did not check to see if a resident exited the facility through the front door and did not perform a head count to ensure all residents at risk for elopement were present.

Findings include:

1: Facility Policy titled Elopement Guideline dated 01/12/2017, indicated the Facility will identify environmental hazards such as entrances, stairwells or exits that pose a foreseeable danger to residents who wander or have exit seeking behavior, and will implement interventions to minimize these risks and hazards as appropriate, and all residents at risk for elopement would be assessed quarterly and as needed.

Facility Policy titled Transfer of Resident Within the Facility, dated 5/3/16, indicated Nursing would conduct a thorough hand off communication regarding care of the resident. Resident #1 was admitted to the Facility in October, 2016, and his/her [DIAGNOSES REDACTED]. A Clinical Health Status assessment, which included a risk for elopement assessment, dated 10/13/16, indicated Resident #1 was not physically able to leave the building on his/her own, was cognitively impaired and disoriented at all times, and had impaired decision making skills.

A Minimum Data Set (MDS) assessment, dated 10/20/16, indicated; Resident #1 was severely cognitively impaired, and required extensive assistance from staff for ambulation. Resident #1’s health status improved with Physical Therapy over the course of the next few months. A Physical Therapy Progress Note, dated 12/1/16, indicated Resident #1’s mobility and ambulation status had improved, and he/she was able to walk 400ft with minimal staff assistance at the time of discharge from skilled services. A Discharge Planning Meeting minutes note, dated, 1/11/17, indicated Resident #1 had made tremendous progress physically, but not in cognitive status, and would be transferred to long term care. A Clinical Health Status assessment, which included a risk for elopement assessment, dated 12/27/16, indicated; Resident #1 had a memory problem. The risk for elopement section of the assessment was not completed.

There was not an updated risk for elopement assessment completed to reflect Resident #1’s improved mobility status, which would have changed the outcome of his/her elopement risk assessment. (This was inconsistent with Facility Policy titled Elopement Guideline). An MDS assessment, dated 12/8/16, indicated Resident #1 was severely cognitively impaired, and required minimal assistance from staff for ambulation. A Plan of Care, dated, 12/14/16, indicated Resident #1 was at risk for falls, and a pressure sensitive alarm (a device that sounds when a resident has moved) was ordered for Resident #1’s bed to prevent falls.

A Weekly Care Management Meeting Note, dated 1/10/17, indicated Resident #1 could transfer him/her self independently, was cognitively impaired, and had poor safety awareness. A Progress Note, dated 1/17/17, timed 2:27 P.M., indicated Resident #1 was transferred to the B Wing from another unit within the Facility. A Nurse Progress Note, dated 1/18/17, timed 12:06 A.M., indicated staff were not able to locate Resident #1, and a report had been filed with the local Police Department. The note did not indicate when Resident #1 was first noticed missing.

Surveyor #1 and Surveyor #2 interviewed the Business Office Manager at 11:59 A.M. on 1/19/17. The Business Office Manager said she was stationed at the front desk near the front main door of the Facility Monday through Friday from 8:00 A.M., to 6:00 P.M., while performing her own office tasks such as answering the phone and other work, and there would be a staff person scheduled to sit at the front desk on Saturdays and Sundays. The Business Office Manager said after 6:00 P.M., no one was stationed at the front main door, and the front door alarm would be turned on to alert staff when someone opened the door. Surveyor #1 and Surveyor #2 interviewed Nurse #1 at 10:51 A.M. on 01/20/17. Nurse #1 said the alarm at the front door will sound when opened after 6:00P.M., however the alarm was hard to hear from the unit, and is unable to be heard from the resident rooms. Nurse #1 said during the 3:00 P.M. to 11:00 P.M. shift on 1/17/17, the front lobby was very busy, she had to turn off the front door alarm several times, and said she did not always check to see who had exited the building through the front door.

Surveyor #1 interviewed Nurse #2 at 3:11 P.M., on 1/23/17. Nurse #2 said she worked during the 7:00 A.M. to 3:00 P.M. shift on the B Wing of the Facility on 1/17/17. Nurse #2 said Resident #1’s room was changed from another unit within the Facility around 1:45 P.M., to the B Wing. Nurse #2 said she did not receive a Nurse to Nurse report when Resident #1 was moved to the B Wing (this was inconsistent with Facility policy titled Transfer of Resident Within the Facility).

Nurse #2 said Resident #1 did not have a pressure sensitive alarm in place, was able to ambulate on his/her own, and had short term memory loss. Nurse #2 said Resident #1 had not been identified as at risk for elopement to her. Nurse #1 said she received shift change report from Nurse #2 at 3:00 P.M. on 1/17/17, and she was told Resident #1 had been moved to B Wing from another unit within the Facility earlier that day. Nurse #1 said she was told Resident #1 was forgetful, was known to wander, had short term memory loss, would forget where his/her room was, was able to ambulate on his/her own, could use the bathroom independently, and did not have a pressure sensitive alarm in place, (this was inconsistent with Resident #1’s care plan).

Nurse #1 said she did not give report to the Certified Nurses’ Aides (CNAs) on the unit that shift. Nurse #1 said she last saw Resident #1, in bed, just after 7:00 P.M., when she gave him/her medications. Nurse #1 said around 7:45 P.M., CNA #1 told her Resident #1 was not in his/her room, a Facility-wide search was initiated, staff were not able to locate Resident #1, and the local Police were notified. Surveyor #1 and Surveyor #2 interviewed CNA #1 at 3:41 P.M., on 1/19/17. CNA #1 said the alarm for the front main door of the Facility was hard to hear from the unit, and she could not hear the alarm when working in a resident room. CNA #1 said she did not receive a report from Nurse #1 during the 3:00 P.M. to 11:00 P.M. shift on 1/17/17, and said she was not familiar with Resident #1 or his/her care needs, and she did not know if he/she was at risk for elopement. CNA #1 said Resident #1 did not have a bed alarm in place, and he/she was using the bathroom and ambulating in his/her room independently (this was inconsistent with Resident #1’s care plan). CNA #1 said she last saw Resident #1 in bed, around 7:00 P.M. and around 7:45 P.M., she noticed Resident #1 was not in his/her room, she notified Nurse #1, and a search of the Facility was initiated.

A Police Report, dated 1/17/17 indicated, the Facility called to report Resident #1 missing at 8:08 P.M., and reported he/she had last been seen by staff between 7:00 P.M., and 7:30 P.M. on 1/17/17. A Police Report from a neighboring city, dated 1/18/17, indicated Resident #1 was found, unresponsive at approximately 6:23 A.M., outside, behind a business building. Resident #1 was pronounced dead at the scene by emergency first responders, at 6:30 A.M. on 1/18/17. 2: Resident #2 was admitted to the Facility in December, 2016, and his/her [DIAGNOSES REDACTED].

A physician’s orders [REDACTED].#2 was to have a wander alert bracelet (a device which triggers an alarm to alert staff when a person is near an exit) to prevent elopement. A Nurse Progress Note, dated 1/1/17, timed 11:15 A.M. indicated, Resident #2 was found outside the Facility, when another Resident alerted staff that he/she had walked out the front door of the Facility. Surveyor #1 interviewed Nurse #3 at 8:46 A.M., on 1/25/17. Nurse #3 said another resident alerted staff that Resident #2 was outside, sometime late in the morning on 1/1/17. Nurse #3 said Resident #2 had a wander alert bracelet in place, which was functioning, and the alarm at the door was sounding. Nurse #3 said Resident #2 was at the sidewalk in front of the Facility, which is on a main road when she and CNA #2 caught up with him/her and were able to redirect him/her back into the Facility. Nurse #3 said she could not recall if there was a staff member at the front desk that day.

Surveyor #1 interviewed CNA #2 at 9:57 A.M., on 1/25/17. CNA #2 said sometime late in the morning on 1/1/17, another resident alerted her that Resident #2 was outside. CNA #2 said she and Nurse #3 ran outside through the front main door of the Facility, and caught up to Resident #2, outside the Facility, near a main road. CNA #2 could not recall if she heard the wander alert alarm sounding at the time.

On 1/19/17, The Wander Prevention Watch List, dated 1/3/17, located in the front of the Elopement Book indicated there were 12 residents at risk for elopement. This list was not accurate because Resident #2, who had been discharged from the Facility on 1/11/17, was listed as at risk for elopement.

Surveyor #1 and Surveyor #2 interviewed the Director of Nurses(DON) at 3:20P.M. on 1/19/17. DON said she was responsible for keeping the elopement book up to date, it was reviewed weekly, and had been reviewed with no changes needed on the morning of 1/19/17 (this was inconsistent with the fact that Resident #2 had been discharged , and was still on the Wander Prevention Watch List). 3. The Facility failed to ensure resident safety by failing to secure oxygen tanks, located in an unlocked closet, in a back room which were accessible by 2 unlocked doors and were adjacent to areas frequented by the resident population (the main dining room and a hallway on a residential unit).

Throughout the survey on 1/19/17 and 1/23/17, it was observed, the door to the oxygen closet, which contained 2 large unsecured portable oxygen tanks, 4 small portable oxygen tanks on a shelf and unsecured, one large green refillable oxygen tank, and several small green refillable oxygen tanks was unlocked, and the back room where the oxygen room was located was accessible through unlocked doors adjacent to the main dining room as well as a hallway on a resident unit at the following times:

  • At 12:10 P.M. on 1/19/17, by Surveyor #1 and Surveyor #2. At that time, Surveyor #2 informed the Administrator that the room containing oxygen tanks should be locked, for resident safety.
  • At 10:53 A.M. on 1/23/17, by Surveyor #1, Surveyor #3, and Surveyor #4.
  • At 5:48 P.M. on 1/23/17, by Surveyor #1 and Surveyor #2. At that time, the Assistant Director of Nurses was present, and the surveyors informed her that the room containing oxygen tanks should be locked, for resident safety.
Failed to have a program that investigates, controls and keeps infection from spreading.

Based on observations and interviews, the Facility failed to ensure that clean ice was available for residents, when coolers of ice were stored in the dirty utility rooms on the units, and used for resident consumption.

Findings include:

Facility policy, titled Infection Control- Preparation, Dining Services, dated 3/29/16, indicated all food must be properly prepared to prevent potential foodborne illness, and all equipment and prep counters will be washed and sanitized to prevent contamination. During survey on 1/23/17, the following were observed:

At 11:00 A.M. Surveyor #1 and Surveyor #4 observed, in the room labeled Utility Room on the B Wing of the Facility, a small blue cooler filled with ice, and a clear plastic scoop in a clear plastic container on the counter. The Utility Room also contained a flushable unit designed to rinse soiled linen, trash bins which had trash in them, a dirty linen bin with dirty linen in it, and a red biohazard bin. A malodorous scent was detected within the utility room.

At 12:46 P.M., Surveyor #1 and Surveyor #3 observed, in the room labeled Utility Room on the C Wing of the Facility, a small blue cooler filled with ice, and a clear plastic scoop in a clear plastic container on the counter. The Utility Room also contained a flushable unit designed to rinse soiled linen, trash bins which had trash in them, a dirty linen bin with dirty linen in it, a soiled hospital gown was observed in a sink, and a red biohazard bin. A malodorous scent was detected within the utility room.

Surveyor #1 and Surveyor #3 interviewed CNA #3 at 1:06 P.M. on 1/23/17. CNA #3 said when filling a beverage for a resident, staff would get ice from the cooler in the utility room. The Administrator, Director of Nurses, and the Field Service Clinical Director were made aware of the coolers filled with ice for resident consumption stored in the utility rooms, at 6:15 P.M. on 1/23/17. The Administrator and the Field Service Clinical Director said they would remove and dispose of the coolers immediately, as they posed an infection control risk to the resident population.

Failed to set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on records reviewed and interviews, for 2 of 7 sampled Residents, (Resident #1 and Resident #2), the Facility failed to ensure that an effective system was established for accurately monitoring and preventing cognitively impaired Residents from eloping from the facility and failed to ensure that elopements were reviewed as part of the Facility’s Quality Assurance and Performance Improvement Program.

Findings include:

The Facility Policy, titled Elopement Guideline and dated 10/2015, indicated that all elopement events will be reviewed, analyzed, and summarized by the Quality Assurance and Performance Improvement (QAPI) Committee to ensure the appropriate process improvement actions have been taken.

On 1/6/17, after an investigation conducted by the Department of Public Health, the Facility was cited and issued a Statement of Deficiencies related to an elopement that occurred on 11/21/16 for which a resident had exited the Facility without the knowledge of staff and was found approximately 2 miles away from the Facility.

QAPI Minutes, for meetings dated 11/30/16 and 12/21/16, did not indicate that the elopement on 11/21/16 was reviewed, analyzed, and/or summarized by the QAPI Committee. This was not consistent with the Facility Policy titled, Elopement Guideline.

Resident #2 was admitted to the Facility in December, 2016, with [DIAGNOSES REDACTED]. A Nurse Progress Note, dated 1/1/17 and timed 11:15 A.M. indicated Resident #2 was found, outside, after another Resident notified staff that Resident #2 had walked out the front door of the Facility. Nurse #3 said Resident #2 was on the sidewalk in front of the Facility, which is on a main road, and she could not recall if there was a staff member at the front desk when Resident #2 exited the Facility.

A Minimum Data Set (MDS) evaluation, dated 12/8/16, indicated Resident #1 was admitted to the Facility in October, 2016, his/her [DIAGNOSES REDACTED].#1 had severe cognitive impaired, and required minimal assistance from staff for ambulation.

A Nurse Progress Note, dated 1/18/17, timed 12:06 A.M., indicated staff were not able to locate Resident #1, and a report had been filed with the local Police Department. The note did not indicate when Resident #1 was first noticed missing. A Police Report, dated 1/18/17, indicated Resident #1 was found unresponsive at approximately 6:23 A.M. outdoors, behind a building. Resident #1 was pronounced dead at the scene at 06:30 A.M.

Surveyor #1 and Surveyor #3 interviewed the Administrator on 1/23/17 at 6:26 P.M. The Administrator said the he was unsure if QAPI Committee had convened for an ad hoc (unplanned additional meeting) meeting to review the 11/21/16 elopement or Resident #1’s and Resident #2’s elopements. The Administrator was unable to produce meeting minutes that reflected any of the 3 elopements were reviewed, analyzed, and/or summarized by the QAPI Committee. This was not consistent with the Facility Policy titled, Elopement Guideline. Surveyor #1 and Surveyor #4 interviewed the Medical Director on 1/24/17 at 11:13 A.M. The Medical Director said that he was unsure if the QAPI Committee discussed any of the 3 elopements and could not recall that an ad hoc (unplanned additional meeting) QAPI Committee Meeting had taken place.

Failed to honor all of the resident's rights as a resident of the nursing home, free of coercion and reprisal, and as a citizen or resident of the United States.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on records reviewed and interviews for 1 of 4 sampled residents (Resident #4), the Facility failed to ensure that Resident #4, who was cognitively impaired and required 1:1 supervision due to aggressive behaviors and periods of agitation, understood and consented to being hidden in a basement level office, on 1/25/17, during a Mock Elopement Drill. Approximately 2 hours later, Resident #4 was transferred and admitted to the Hospital under a Section 12 order (emergency involuntary psychiatric hospitalization ) for physical aggression and inability to understand his/her situation.

Findings include:

The Facility’s Policy, titled Residents Rights and dated 11/28/16, indicated the Facility must promote and facilitate resident self-determination through support of resident choice, including but not limited to, the right to make choices about aspects of his or her life in the Facility. An Admission Minimum Data Set (MDS) assessment, dated 11/18/16, indicated Resident #4 had a [DIAGNOSES REDACTED]. A Nurse’s Progress note, dated 1/23/17 and timed at 12:01 A.M., indicated Resident #4 was agitated with periods of restlessness and aggressive behaviors, and was placed on direct 1 to 1 staff observation.

A Nurse Practitioner’s Progress Note, dated 1/25/17, indicated that prior to Resident #4’s admission to the Facility, he/she had worsening paranoia with agitation. Surveyor #2 and Surveyor #3 interviewed CNA #1 on 2/1/17 at 11:23 A.M. CNA #1 said that on 1/25/17, after lunch time, she relieved CNA #3 who was assigned to Resident #4 for 1:1 observation. CNA #1 said at that time Resident #4 was asleep in bed. CNA #1 said the Staff Development Coordinator came to Resident #4’s room and told CNA #1 to take Resident #4 downstairs to an office on the basement level of the Facility, because a Mock Elopement Drill was about to take place. CNA #1 said, I woke Resident #4 up, got him/her out of bed, took him/her downstairs into the office, and closed the door, or words to that effect. CNA #1 said she stayed with Resident #4 until a staff member found them approximately 5-7 minutes later.

CNA #1 said she did not explain what was going on to Resident #4 or why she was taking him/her from his/her bed and bringing him/her to the basement floor into the closed office. This was not consistent with the Facility’s Policy titled Resident’s Rights. Surveyor #1 and Surveyor #2 interviewed the Administrator on 1/31/17 at 1:30 P.M. The Administrator said that he was standing at the Nurse’s Station during the Mock Elopement Drill and was startled, or words to that effect, when someone opened the office door directly accross from the Nurse’s Station and he saw Resident #4. The Administrator said he did not recall a decision being made by the Interdisciplanary Team members to hide Resident #4 in the office during the Mock Code Elopement Drill.

The Administrator said consent was not obtained from Resident #4’s Health Care Agent for Resident #4 to be taken from his/her unit and hidden in the Facility during the Mock Elopement Drill. This was not consistent with the Facility Policy titled Resident’s Rights.

An Elopement/Missing Person Mock Drill form dated 1/25/17 and timed at 1:40 P.M. indicated Resident #4 was located within the Facility at 1:44 P.M. An Application For Authorization of Temporary Involuntary hospitalization (Section 12) dated 1/25/17 and timed at 1:46 P.M., indicated that Resident #4 was physically aggressive and unable to understand his/her situation.

The Emergency Department Record, dated 1/25/17 and timed at 3:46 P.M., indicated that Resident #4 was sent from the Facility on a Section 12 order for behavior disturbances, combativeness, and worsening agitation, and that Resident #4 was unsure why he/she was there. Resident #4 was admitted to a Psychiatric Unit for further evaluation.

Failed to immediately tell the resident, the resident's doctor and a family member of the resident of situations (injury/decline/room, etc.) that affect the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interviews and records reviewed, for 1 out of 3 sampled residents (Resident #1), the Facility failed to notify the Physician of an acute change in condition, when Resident #1, who was cognitively impaired, eloped from the Facility, and was found approximately 2 miles from the Facility, outside exposed to temperatures between 30 to 37 degrees Fahrenheit, for approximately 1 hour and 30 minutes, and when found, had sustained abrasions to his/her right knee, had pain in both hips, a body temperature of 96.2 degrees Fahrenheit (F), and fatigue. Nurse Practitioner #1 was on call, was not notified until approximately 90 minutes after Resident #1 was found and returned to the Facility, and was not notified of Resident #1’s body temperature of 96.2 degrees F.

Findings include:

A Facility policy titled: Notification of Changes in Resident Health Status dated 10/20/16, indicated, the Facility will immediately consult the resident’s physician, nurse practitioner, or physician’s assistant when there is an accident or acute significant change in the resident’s status which results in injury and has the potential for requiring physician intervention.

A local weather report from weather.com indicated, temperatures on 11/21/16 were between 30-37 degrees Fahrenheit.

Resident #1’s [DIAGNOSES REDACTED].

A Minimum Data Set (MDS) evaluation, dated 11/14/16, indicated Resident #1 was cognitively impaired, and required minimal assist with ambulation. A Plan of Care, dated 11/20/16, indicated, Resident #1 was identified at risk for wandering, and a wander alert bracelet (a device which causes an alarm to sound when a person is close to an exit) was applied.

Resident #1 was discharged from the Facility before this investigation, therefore, the Surveyor was unable to observe his/her care. A Nurse Progress Note, dated 11/18/16, indicated, Resident #1 was wandering, exit seeking, and went to the exit door and elevator several times.

A Nurse Progress Note, dated, 11/21/16, indicated, Resident #1 had eloped from the Facility some time right after 7:00P.M., an internal search was conducted, and Resident #1’s spouse was notified as well as the local Police Department, and he/she was found at or around 8:35 P.M., by a staff, approximately 2 miles from the Facility. The note indicated that when found, Resident #1 had sustained abrasions to his/her right knee, was complaining of pain in both hips, had a body temperature of 96.2 Fahrenheit, and Nurse Practitioner #1 was notified, who ordered X-rays of the sites to rule out fractures. A Police Report, dated 11/21/16, indicated, Resident #1 was reported missing at 7:52 P.M., (approximately 52 minutes after Resident #1 was first noticed missing), and was located by Facility staff, 30 minutes after the police were notified.

Nurse #1 was interviewed at 1:37 P.M., on 12/12/16. Nurse #1 said he noticed Resident #1 was not on the unit some time around 7:00 P.M., on 11/21/16, and a search of the interior, exterior, and surrounding neighborhood was conducted by staff. Nurse #1 said he called Resident #1’s spouse, then the local Police Department about 15 minutes after first noticing Resident #1 was missing, (this was inconsistent with the Police report). Nurse #1 said Resident #1 was found, by CNA #1 around 8:35 P.M., (approximately 1 hour and 30 minutes after he/she was missing), walking along a main road, and was returned to the Facility. Nurse #1 said Resident #1 was shivering, and his/her body temperature was assessed at 96.something or words to that effect, and he/she had sustained abrasions to his/her right knee, however, due to cognitive loss, was unable to recall if he/she had fallen. Nurse #1 said he updated the local Police that Resident #1 had been found. Nurse #1 said he notified Nurse Practitioner #1 regarding Resident #1’s elopement and assessment upon return to the Facility, and an order for [REDACTED].#1 said he did not notify the Medical Director of Resident #1’s elopement.

CNA #1 was interviewed at 3:27 P.M., on 12/12/16. CNA #1 said he Nurse #1 told him Resident #1 was missing around 7:00 P.M., on 11/21/16, and he aided in searching the Facility for Resident #1. CNA #1 said staff on the other units were also searching for Resident #1, and when he/she could not be found, Nurse #1 called the local Police Department, approximately 45 minutes to 1 hour after Resident #1 was first noticed missing. CNA #1 said, after the Police became involved, Facility staff stopped searching, and continued to provide care for the other residents. CNA #1 said he later took his 30 minute break, and was driving his car, and noticed Resident #1 walking and stumbling along a main road, approximately 2 miles from the Facility. CNA #1 said Resident #1 was wearing a lined plaid coat, no hat, gloves, or mittens, was shivering, and said he/she was cold. Nurse Practitioner #1 was interviewed at 2:12 P.M., on 12/13/16, and again at 8:30 A.M., on 12/14/16. Nurse Practitioner #1 said she was notified, at 10:08 P.M., on 11/21/16, that Resident #1 had eloped from the Facility and was found around 8:30 P.M., had sustained abrasions on his/her right knee, and was complaining of pain in both hips. Nurse Practitioner #1 said she was not notified that Resident #1 had been missing from the Facility for 1 hour and 30 minutes before he/she was found, or that his/her body temperature was measured at 96.2 degrees Fahrenheit. This was inconsistent with Facility policy and Nurse #1’s statement. Nurse Practitioner #1 said she was unaware of the weather conditions that night, and said I make and receive these calls from inside my condo, or words to that effect. Nurse Practitioner #1 said she told Nurse #1 to refer to the Facility’s policy and/or the Medical Director’s discretion to determine whether to send Resident #1 to the emergency room.

The Medical Director was interviewed at 11:05 A.M., on 12/16/16. The Medical Director said he could not recall being notified of Resident #1’s elopement on 11/21/16.

Failed to provide care for each resident in a way that keeps or builds the resident's quality of life.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records reviewed and interviews for 1 of 4 sampled residents (Resident #4), the Facility failed to maintain an environment that met Resident #4’s behavioral health needs. On 1/25/17, Resident #4, who was cognitively impaired and on 1:1 observation for increased anxiety and aggressiveness, was taken from his/her room on the ground level of the Facility, into an office on the basement level of the Facility, and hidden behind closed doors during a Mock Elopement Drill. Approximately 2 minutes after the drill was over, staff completed an application for Section 12 transfer (emergency involuntary psychiatric hospitalization ) and approximately 2 hours later Resident #4 was transferred to the Hospital for Psychiatric evaluation, and was admitted and treated for [REDACTED].

Findings include:

An Admission Minimum Data Set (MDS) assessment, dated 11/18/16, indicated that Resident #4 had a [DIAGNOSES REDACTED]. A Behavioral Care Plan, dated 11/14/16, indicated Resident #4 had aggressive behaviors, and staff were to avoid situations that were upsetting to Resident #4.

A Nurse Practitioner’s Progress Note, dated 1/25/17, indicated that prior to Resident #4’s admission to the Facility, he/she experienced worsening paranoia with agitation and Resident #4 had been placed on 1 to 1 observation for aggressive behaviors. Surveyor #3 interviewed the Director of Social Services 2/2/17 at 4:03 P.M. The Director of Social Services said Resident #4’s behavior was unstable and he/she was unable to understand his/her environment which made him/her aggressive.

Surveyor #2 and Surveyor #3 interviewed CNA #1 on 2/1/17 at 11:23 A.M. CNA #1 said that on 1/25/17, after lunch time, she relieved CNA #3 who was assigned to Resident #4 for 1 to 1 observation. CNA #1 said at that time Resident #4 was asleep in bed. CNA #1 said the Staff Development Coordinator came to Resident #4’s room and told CNA #1 to take Resident #4 downstairs to an office on the basement level of the Facility, because a Mock Elopement Drill was about to take place. CNA #1 said she woke Resident #4 up, got him/her out of bed, took him/her downstairs into the office, and closed the door, or words to that effect. CNA #1 said she stayed with Resident #4 until a staff member found them approximately 5-7 minutes later. CNA #1 said she did not explain what was going on to Resident #4 or why she was taking him/her from his/her bed and bringing him/her to the basement floor into the closed office. This was not consistent with Resident #4’s Behavior Care Plan.

Surveyor #1 and Surveyor #2 interviewed the Staff Development Coordinator on 1/31/17 at 2:22 P.M. The Staff Development Coordinator said that, during an Interdisciplinary Team (IDT) meeting, unsure of exact date or time, a decision was made by the IDT members to use Resident #4 during the Mock Elopement Drill, and hide him/her in the Staff Developer’s office located in the basement level of the Facility, because they wanted staff to take the drill seriously and because Resident #4 moves fast and looks like a visitor, or words to that effect. The Staff Development Coordinator said she did not recall asking CNA #1 to take Resident #4 downstairs to the office. This was not consistent with statement made by CNA #1. An Elopement/Missing Person Mock Drill Form dated 1/25/17 indicated Resident #4 was located within the Facility at 1:44 P.M.

Surveyor #1 and Surveyor #2 interviewed the Administrator on 1/31/17 at 1:30 P.M. The Administrator said that he was standing at the Nurse’s Station during the Mock Elopement Drill and he was startled, or words to that effect, to see Resident #4 in the office directly accross from the Nurse’s Station when a Staff member opened the door. The Administrator said he did not think the Facility was supposed to use residents for Mock Drills and he asked a staff member to take Resident #4 back upstairs to his/her room. An Application For Authorization of Temporary Involuntary hospitalization (Section 12) was dated 1/25/17 and timed at 1:46 P.M., 2 minutes after the Mock Elopement Drill ended, documentation indicated that Resident #4 was physically aggressive and unable to understand his/her situation.

Surveyor #3 interviewed the Nurse Practitioner on 2/2/17. The Nurse Practitioner said she saw Resident #4 on the morning of 1/25/17 and at that time Resident #4 was not agitated. The Nurse Practitioner said the Facility did not notify her as to why a Section 12 Application was completed for Resident #4 at 1:46 P.M. on 1/25/17. The Nurse Practitioner said she did not give an order to transfer Resident #4 to the hospital on [DATE] and it wasn’t until she visited the Facility on 1/26/17, that she learned Resident #4 had been transferred for a Psychiatric Evaluation, at which time she signed the Telephone Order. The Emergency Department Record, dated 1/25/17 and timed at 3:46 P.M., indicated that Resident #4 was sent from the Facility on a Section 12 order for behavioral disturbances, combativeness, and worsening agitation, and Resident #4 was unsure why he/she was there. The Physician History and Physical, dated 1/26/17, indicated that Resident #4 was having increased episodes of agitation, combativeness, difficulty following directions, and had increased irritability late in the afternoon into the evening.

Failed to make sure services provided by the nursing facility meet professional standards of quality.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on records reviewed and interviews for 1 of 4 sampled residents (Resident #4), who was cognitively impaired and required 1 to 1 supervision due to periods of aggressive behaviors and agitation, that during a Mock Elopement Drill conducted on 1/25/17, the Facility failed to ensure:

  • Staff obtained consent prior to hiding Resident #4 in a basement office.
  • That prior to completing a Section 12 (emergency involuntary psychiatric hospitalization order) application, that staff notified Resident #1’s Physician and or Nurse Practitioner, and failed to ensure a thorough clinical assessment was completed with supporting documentation to support the decision to transfer Resident #4 to the hospital, approximately 2 hours after the Mock Elopement Drill was completed.
  • A valid Physician order [REDACTED]. to the Hospital under a Section 12 order.
  • Resident #4 was admitted to the Hospital for in-patient treatment for [REDACTED].

Findings include:

1. Pursuant to Massachusetts General Law (M.G.L.), chapter 112, individuals are given the designation of Registered Nurse and Practical Nurse which includes the responsibility to provide nursing care. Pursuant to the Code of Massachusetts Regulation (CMR) 244, Rules and Regulations 3.02 and 3.04 define the responsibilities and functions of a Registered Nurse and Practical Nurse respectively. The regulations stipulate that both the Registered Nurse and Practical Nurse bear full responsibility for systematically assessing health status and recording the related health data.

According to 244 CMR 9.03 Standards of Conduct for Nurses (44) Documentation: A nurse licensed by the Board shall make complete, accurate, and legible entries in all records required by federal and state laws and regulations and accepted standards of nursing practice. On all documentation requiring a nurse’s signature, the nurse shall sign his his or her name as it appears on his or her license.

A House Bill 4681, an Act to Improve Emergency Access to Mental Health Services (Section 12 Law), indicated as of November 8, 2010, LICSWs in the Commonwealth of Massachusetts will be authorized to sign a Section 12(a), known as a pink paper. Part of the procedure indicates that documentation supporting the bases for the decision to seek a commitment is an integral part of the process.

2. The Facility Policy, titled Residents Rights, dated 11/28/16, indicated the Facility must promote and facilitate resident self-determination through support of resident choice, including but not limited to, the right to make choices about aspects of his or her life in the Facility.

The Facility’s Policy, titled Content of the Medical Record Policy, dated 11/28/16, indicated the Nursing Progress Note documentation should include resident’s changes in behavior and documentation of resident’s visits to the hospital. The Facility’s Policy, titled Physician Telephone Orders, dated 1/29/14, indicated the Licensed Nurse must document all Physician’s telephone orders including the date the order was obtained, time the order was obtained, the content of the physician’s orders [REDACTED].

3. An Admission Minimum Data Set (MDS) assessment, dated 11/18/16, indicated Resident #4 had a [DIAGNOSES REDACTED].

A Nurse’s Progress note, dated 1/23/17 and timed at 12:01 A.M., indicated Resident #4 was agitated with periods of restlessness and aggressive behaviors, and was placed on direct 1 to 1 staff observation.

Surveyor #2 and Surveyor #3 interviewed CNA #1 on 2/1/17 at 11:23 A.M. CNA #1 said that on 1/25/17, after lunch time, she relieved CNA #3 who was assigned to Resident #4 for 1:1 observation. CNA #1 said at that time Resident #4 was in asleep in bed. CNA #1 said the Staff Development Coordinator came to Resident #4’s room and told CNA #1 to take Resident #4 downstairs to an office on the basement level of the Facility because a Mock Elopement Drill was about to take place.

CNA #1 said she woke Resident #4 up, took him/her out of bed, brought him/her downstairs into the office, and closed the door, or words to that effect. CNA #1 said she stayed with Resident #4 until a staff member found them approximately 5-7 minutes later. CNA #1 said she did not explain what was going on to Resident #4 or why she was taking him/her from his/her bed and bringing him/her to the basement floor into the closed office. This was not consistent with the Facility Policy titled Resident’s Rights. An Elopement/Missing Person Mock Drill Form, dated 1/25/17, indicated Resident #4 was located within the Facility at 1:44 P.M.

An Application For Authorization of Temporary Involuntary hospitalization (Section 12), dated 1/25/17 and timed at 1:46 P.M., 2 minutes after the Mock Elopement Drill ended, indicated that Resident #4 was physically aggressive and unable to understand his/her situation.

There was no documentation in Nurse Progress Notes or Behavior Sheets, on 1/25/17, which indicated a thorough clinical assessment was performed on Resident #4 prior to completion of the Section 12 order, or a reason why Resident #4 was transferred out of the Facility on a Section 12 order for a psychiatric evaluation.

Surveyor # 3 interviewed the Director of Social Services on 2/2/17 at 4:03 P.M. The Director of Social Services said that although she did complete a Section 12 Application for Resident #4 on 1/25/17, she did not speak to Resident #1’s Physician or Nurse Practitioner regarding this Application. The Director of Social Services said Resident #4 had a history of [REDACTED].#4 would require a psychiatric evaluation, or words to that effect, and to the best of her recollection Resident #4 was fine, or words to that effect, on 1/25/17.

A Physician Telephone Order, dated 1/25/17 timed at 2:35 P.M. and documented as signed by Nurse #1, indicated Resident #4 was to be transferred to the emergency room for evaluation.

Surveyor #3 interviewed Nurse #1 on 2/2/17 at 2:21 P.M. Nurse #1 said that although she did write the Physician’s telephone order on 1/25/17 to transfer Resident #4 to the Hospital for a psychiatric evaluation, she never called to obtain the order from Resident #4’s Physician or Nurse Practitioner because the Director of Social Services told her she wanted to transfer Resident #4 to the Hospital quickly and told her to Just write the order herself, or words to that effect.

This was not consistent with the Facility Policy titled, Physician Telephone Orders. Surveyor # 3 interviewed the Director of Social Services on 2/2/17 at 4:03 P.M. The Director of Social Services said she had no recollection of telling Nurse #1 to write a physician’s orders [REDACTED].#4 to the Hospital for Psychiatric Evaluation on 1/25/17. An emergency room Admission report, dated 1/25/17, indicated Resident #4 arrived at Hospital at 3:46 P.M. on a Section 12 for behavioral disturbance and worsening agitation, he/she was unsure why he/she was there, and Resident #4 was admitted to a Psychiatric Unit with a [DIAGNOSES REDACTED].

Surveyor #3 interviewed the Nurse Practitioner on 2/2/17. The Nurse Practitioner said she saw Resident #4 on the morning of 1/25/17 and at the time Resident #4 was not agitated. The Nurse Practitioner said the Facility did not notify her as to why a Section 12 Application was completed for Resident #4 at 1:46 P.M. on 1/25/17. The Nurse Practitioner said she did not give an order to transfer Resident #4 to the hospital on [DATE] and it wasn’t until she visited the Facility on 1/26/17, that she learned Resident #4 had been transferred for a Psychiatric Evaluation and she signed the Telephone Order at that time.

Failed to make sure that the nursing home area is free from accident hazards and risks and provides supervision to prevent avoidable accidents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interviews and records reviewed, for 1 out of 3 sampled residents, (Resident #1), the Facility failed to maintain a secure environment and provide adequate supervision, which led to Resident #1, who was cognitively impaired, to elope from the building, and walk outside along the streets after sunset, with temperatures averaging 32 degrees F, causing Resident #1 to suffer abrasions on his/her knee, pain in both hips,when found 90 minutes later, Resident #1’s body temperature was 96.2 degrees F, and fatigue.

Findings include:

A local weather report from weather.com indicated, temperatures on 11/21/16 were between 30-37 degrees Fahrenheit.

Facility policy titled Elopement Guideline, dated 10/2015, indicated, the (Facility) will identify such environmental hazards such as entrances, stairwells or exits that pose a foreseeable danger to residents who wander or have exit seeking behavior. The (Facility) will implement interventions to minimize these risks and hazards as appropriate, and upon admission, each resident is reviewed to establish elopement risk using the Clinical Health Status form, and the Family may be interviewed for resident’s previous history of elopement and responses recorded in the medical record.

Resident #1’s [DIAGNOSES REDACTED]. After the incident of elopement, his/her spouse revealed he/she had a history of [REDACTED].

A Minimum Data Set (MDS) evaluation, dated 11/14/16, indicated Resident #1 was cognitively impaired, and required minimal assist with ambulation. A Plan of Care, dated 11/20/16, indicated, Resident #1 was identified at risk for wandering, and a wander alert bracelet (a device which causes an alarm to sound when a person is close to an exit) was applied.

Resident #1 was discharged from the Facility before this investigation, therefore, the Surveyor was unable to observe his/her care. A Nurse Progress Note, dated 11/18/16, indicated, Resident #1 was wandering, exit seeking, and went to the exit door and elevator several times.

A Nurse Progress Note, dated, 11/21/16, indicated, Resident #1 had eloped from the Facility some time right after 7:00P.M., an internal search was conducted, and he/she was found at or around 8:35 P.M., by a staff, approximately 2 miles from the Facility, had sustained abrasions to his/her right knee, was complaining of pain in both hips, had a body temperature of 96.2 Fahrenheit, Nurse Practitioner #1 was notified, and orders for X-rays of the sites to rule out fractures was obtained.

A Police Report, dated 11/21/16, indicated, Resident #1 was reported missing at 7:52 P.M., (approximately 52 minutes after Resident #1 was first noticed missing), on 11/21/16, and was located 30 minutes later by Facility staff.

Nurse #1 was interviewed at 1:37 P.M., on 12/12/16. Nurse #1 said Resident #1 was known to wander, was exit seeking, and a wanderguard bracelet was in place. Nurse #1 said he noticed Resident #1 was not on the unit some time around 7:00 P.M., and a search of the interior, exterior, and surrounding neighborhood was conducted by staff. Nurse #1 said he called Resident #1’s spouse, then the local Police Department about 15 minutes after first noticing Resident #1 was missing. This was inconsistent with the Police report. Nurse #1 said Resident #1 was found, by CNA #1 around 8:35 P.M., (approximately 90 minutes after he/she was missing), walking along a main road, and was returned to the Facility. Nurse #1 said Resident #1 was shivering, and his/her body temperature was assessed at 96.something or words to that effect, and he/she had sustained abrasions to his/her right knee, however, due to cognitive loss, was unable to recall if he/she had fallen. Nurse #1 said he updated the local Police that Resident #1 had been found.

Nurse #1 said Resident #1 had his/her wanderguard alarm bracelet in place upon return to the Facility, and the wanderguard system and Resident #1’s wanderguard bracelet were functioning.

CNA #1 was interviewed at 3:27 P.M., on 12/12/16. CNA #1 said he Nurse #1 told him Resident #1 was missing around 7:00 P.M., on 11/21/16, and he aided in searching for Resident #1. CNA #1 said staff on the other units were also searching for Resident #1, and when he/she could not be found, Nurse #1 called the local Police Department, approximately 45 minutes to 1 hour after Resident #1 was first noticed missing. CNA #1 said, after the Police became involved, Facility staff stopped searching, and continued to provide care for the other residents. CNA #1 said he later took his 30 minute break, and was driving his car, and noticed Resident #1 walking and stumbling along a main road, approximately 2 miles from the Facility. CNA #1 said Resident #1 was wearing a lined plaid coat, no hat, gloves, or mittens, was shivering, and said he/she was cold.

The Director of Nurses was interviewed at 9:32 A.M., on 12/12/16. The Director of Nurses said there was an internal investigation conducted to determine the root cause of Resident #1’s elopement, and it was determined Resideent #1 might have followed a visitor or an ambulance crew out the door, however there were no conclusive findings. The Director of Nurses said only staff of the Facility are allowed to know the code to disarm the alarm at the door, and staff are to accompany anyone exiting the Facility after 6:00 P.M.

Failed to keep accurate, complete and organized clinical records on each resident that meet professional standards.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on records reviewed and interviews, the Facility failed to ensure:

  • For 1 of 4 sampled residents (Resident #4), that staff accurately documented the reasons why Resident #4 was transferred to the hospital when, on 1/25/17, Resident #4 was transferred to the hospital via a Section 12 order (an Emergency restraint and hospitalization of persons posing risk of serious harm by reason of mental illness).
  • For 2 of 4 sampled residents (Resident #4 and Resident #7), that the Attending Physician’s Office Phone number listed on the Admission Record Information Sheet (the Face Sheet) was up-to-date and accurate.

Findings include:

1. The Facility’s Policy, titled Content of the Medical Record Policy, dated 11/28/16, indicated Nursing Progress Note documentation should include resident’s changes in behavior and documentation of resident’s visits to the hospital. The Section 12 Application, dated 1/25/17 and timed at 1:46 P.M., Section 2A, indicated Resident #4 had mental illness for which he/she was unable to understand his/her situation and was physically aggressive to other residents and staff. Section 2B indicated Resident #4 was a substantial risk of physical harm to other persons as manifested by evidence of homicidal or other violent behaviors or evidence that others were placed in reasonable fear of violent behavior and serious physical harm to them.

The Physician’s Telephone Order, dated 1/25/17 and timed at 14:37 (2:37 P.M.) indicated to transfer Resident #4 to the hospital for a a Psychiatric evaluation.

Surveyor #3 interviewed Nurse #1 on 2/2/17 at 2:21 P.M. Nurse #1 said that although she did write the Physician’s telephone order on 1/25/17 to transfer Resident #4 to the Hospital for a psychiatric evaluation, she never called to obtain the order from Resident #4’s Physician or Nurse Practitioner because the Facility wanted to transfer Resident #4 to the Hospital quickly and the Social Worker told her to Just write the order herself, or words to that effect.

Surveyor #3 interviewed the Nurse Practitioner on 2/2/17. The Nurse Practitioner said she saw Resident #4 on the morning of 1/25/17 and at the time Resident #4 was not agitated. The Nurse Practitioner said the Facility did not notify her as to why a Section 12 Application was completed for Resident #4 at 1:46 P.M. on 1/25/17. The Nurse Practitioner said she did not give an order to transfer Resident #4 to the hospital on [DATE] and it wasn’t until she visited the Facility on 1/26/17, that she learned Resident #4 had been transferred for a Psychiatric Evaluation and she signed the Telephone Order at that time. Review of Resident #4’s medical record indicated there was no documentation in his/her physician’s orders [REDACTED].#4’s Section 12 and the reason for the Section 12 when, on 1/25/17, Resident #4 was transferred to the hospital via a Section 12 order.

Surveyor #1 and Surveyor #2 interviewed Nurse #2 at 2:08 P.M. on 1/31/17. Nurse #1 said that on 1/25/17 she obtained Resident #4’s Section 12 order and she was the nurse who had Resident #4 transferred to the hospital. Nurse #1 said she knew Resident #4 had wandering behavior but said she could not recall the reason for transferring Resident #4 to the hospital. Nurse #1 said she did not write a Nurse’s Progress Note in Resident #4’s chart regarding his/her Section 12 to the hospital on [DATE].

Surveyor #1 and Surveyor #2 interviewed the Interim Director of Nurses (DON) and the Field Service Clinical Director at 1:44 P.M. on 1/31/17. The Interim DON and the Field Service Clinical Director said it was the expectation that when transferring a resident to the hospital, staff would document the reason for an evaluation.

2. The Facility’s Content of the Medical Record Policy, dated 11/28/16, indicated Every Resident’s Medical Record would include a Record of Admission (Face Sheet) that contained information and demographic data that accurately identified the resident. The Policy indicated that this information would be collected on admission, updated as needed, and may include, but was not limited to, the following items: the attending and alternate Physician’s name and telephone number.

On 2/2/17 at 11:41 A.M., Surveyor #4 called the phone number of the Physician documented on Resident #4 and Resident #7’s Face Sheet. The person who answered the phone identified himself/herself as a Staffing Coordinator who said the number Surveyor #4 called was for the local hospital and that the Physician no longer worked at that location. The Staffing Coordinator said this Physician had not worked at that location for over 3 years, and did not have a current phone number for the Physician.

Surveyor #4 interviewed the Interim Director of Nurses (DON) at 11:52 A.M. on 2/2/17. The Interim DON said she was not aware that the Physician’s contact phone number was not updated on Resident #4 and Resident #7’s Face Sheet. The Interim DON said that up-to-date telephone numbers for all of the Physicians and Nurse Practitioners were located at each of the Nurses’ station.

Failed to train all employees on what to do in an emergency, and carry out announced staff drills.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interviews and records reviewed, the Facility failed to develop and implement an effective emergency preparedness plan for resident elopement for 1 out of 3 sampled residents (Resident #1), and 5 non sampled residents, when Resident #1, who had cognitive impairment, eloped from the Facility, and was found approximately 2 miles from the Facility, outside exposed to temperatures between 30 to 37 degrees Fahrenheit, for approximately 90 minutes, and sustained abrasions to his/her right knee, pain in both hips, a body temperature of 96.2 degrees F, and fatigue.

Findings include:

Facility policy titled Elopement Guideline, dated 10/2015, indicated, in the event of a missing resident who cannot be located on his/her respective unit, the staff person in charge will initiate a search of all areas of the Facility and external premesis, and all available employees will continue to participate in searching all areas of the Facility, as directed by the staff person in charge. If the missing person cannot be located, staff were to notify the resident’s family or responsible party, notify the police, notify the resident’s attending physician, complete the Missing Resident Profile, and attach a current photograph of the resident.

Resident #1’s [DIAGNOSES REDACTED]. After the incident of elopement, his/her spouse revealed he/she had a history of [REDACTED]. A Minimum Data Set (MDS) assessment, dated 11/14/16, indicated Resident #1 was cognitively impaired, and required minimal assist with ambulation.

A Plan of Care, dated 11/20/16, indicated, Resident #1 was identified at risk for wandering, and a wander alert bracelet (a device which causes an alarm to sound when a person is close to an exit) was applied.

Resident #1 was discharged from the Facility before this investigation, therefore, the Surveyor was unable to observe his/her care. A Nurse Progress Note, dated 11/18/16, indicated, Resident #1 was wandering, exit seeking, and went to the exit door and elevator several times.

A Nurse Progress Note, dated, 11/21/16, indicated, Resident #1 had eloped from the Facility some time right after 7:00P.M., an internal search was conducted, and he/she was found at or around 8:35 P.M., by a staff member, approximately 2 miles from the Facility, had sustained abrasions to his/her right knee, was complaining of pain in both hips, had a body temperature of 96.2 Fahrenheit, Nurse Practitioner #1 was notified, and orders for X-rays of the sites to rule out fractures was obtained. A Police Report, dated 11/21/16, indicated, it was reported to the Police at 7:52 P.M., that Resident #1 was missing from the Facility (approximately 52 minutes after Resident #1 was first noticed missing), on 11/21/16, and was located 30 minutes later by Facility staff.

Nurse #1 was interviewed at 1:37 P.M., on 12/12/16. Nurse #1 said Resident #1 was known to wander, was exit seeking, and a wanderguard bracelet was in place. Nurse #1 said he noticed Resident #1 was not on the unit some time around 7:00 P.M., he walked to the other 3 units of the Facility to ask if anyone had seen Resident #1 before making an announcement over the intercom. Nurse #1 said he could not recall what announcement he had made over the intercom. Nurse #1 said a search of the interior, exterior, and surrounding neighborhood was conducted by staff. Nurse #1 said he called the local Police Department about 15 minutes after first noticing Resident #1 was missing, (This was inconsistent with the Police report). Nurse #1 said Resident #1 was found, by CNA #1 around 8:35 P.M., (approximately 90 minutes after he/she was missing), walking along a main road, and was returned to the Facility.

CNA #1 was interviewed at 3:27 P.M., on 12/12/16. CNA #1 said he Nurse #1 told him Resident #1 was missing around 7:00 P.M., on 11/21/16, and he aided in searching for Resident #1. CNA #1 said there was not an announcement made over the intercom to alert staff that there was a missing resident. This was inconsistent with Facility policy and inconsistent with Nurse #1’s statement. The Staff Development Coordinator (SDC) was interviewed at 4:03 P.M., on 12/14/16. The SDC said in the event of a missing resident, after a ten minute search has been conducted, the person in charge at the Facility should announce Code 10 to alert staff that a resident is missing. The Surveyor requested a written policy regarding the Facility’s Code 10 procedure, however it was not produced.

The Assistant Director of Nurses(ADON) was interviewed at 11:08 A.M., on 12/12/16. The ADON said the procedure when there is a missing resident is for the person in charge at the Facility to announce over the intercom system (name of resident) please return to your floor to alert staff throughout the building that a resident is missing, and to initiate a search, however she was unaware if there was a written protocol to this effect. This was inconsistent with the SDC’s statement. The ADON said she was not aware of the Missing Resident Profile form, as mentioned in the Facility’s Elopement policy.

CNA #4 was interviewed at 11:17 A.M., on 12/14/16. CNA #4 said at or around 7:00 P.M., on or around 11/21/16, Resident #1 eloped from the Facility, and Nurse #1 notified staff by walking to the units, asking if staff had seen Resident #1. CNA #4 said there was not an announcement made over the intercom to alert staff of a missing resident. This was inconsistent with Facility policy, and Nurse #1’s statement. CNA #4 said she did not know what Code 10 indicated.

A review of the Facility’s Elopement Book, which was located at the front desk, indicated, there were 11 residents identified at risk for elopement. The Administrator said the Elopement Book is updated weekly, however, 7 out of 11 of the residents identified at risk for elopement did not have a photograph documented for identification purposes. This was inconsistent with Facility policy. Each of the 11 residents identified at risk for elopement had a printed face sheet filed in the book, however, 4 out of the 11 face sheets were printed on the date of the survey, after the book was requested by the Surveyor. The Business Office Manager said it was the responsibility of the SDC to update the Elopement Book. The SDC said it was not her responsibility to update the Elopement book, and that it used to be the responsibility of a nurse who was once an evening shift supervisor, but now works day shift. Unit Manager #1 said the ADON and the SDC were responsible to update the Elopement Book. The ADON said she did not know whose responsibility it was to update the Elopement Book. The DON said she did not know whose responsibility it was to update the Elopement Book, and the Facility did not have a functioning camera available to update photographs.

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Page Last Updated: November 18, 2017

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