REGULATION: §483.25(d) Accidents. The facility must ensure that - §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: October 31, 2018
Corrected date: January 8, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interview conducted during a recertification / abbreviated survey (#NY 761), the facility did not provide adequate supervision to prevent elopement for 1 of 4 residents (#30) with cognitive impairment reviewed for accidents. Specifically, the facility did not ensure that electronic devices functioned effectively to alert the staff, prevent unsafe wandering and elopement. Resident #30 was able to bypass an alarm device (WanderGuard) and was able to exit the facility without the staff's knowledge. (A WanderGuard is designed to prevent residents at risk from leaving a facility unless they are accompanied. The system tracks the resident using a wrist or ankle band and automatically locks doors or alarms if the resident moves outside a defined area without being accompanied by an authorized staff/person.) Additionally, the facility did not provide an environment that is free from accident hazards. Specifically, multiple areas in both resident units (1 and 2) had poorly maintained flooring, including but are not limited to cracked linoleum floors in resident bathrooms and buckled (having waves or wrinkles) carpets in resident areas that are potential trip hazards for residents, staff and visitors. The findings are: 1. Resident #30 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS; a resident assessment tool) completed on 10/01/18, with assessment reference date starting on 9/24/18, indicated that the resident had moderately impaired cognitive skills for daily decision making, required limited assistance of one person with bed mobility, transfer, locomotion and walking in room and corridor, was not steady walking and only able to stabilize with human assistance, used a walker and wheelchair as mobility devices, and had no behavior or mood problems. The elopement risk assessment conducted on 9/24/18 documented that the resident was high risk for elopement secondary to history of wandering, cognitive impairment with poor decision-making skills, confusion, and/or disorientation. The reassessment section of this elopement risk assessment record documented to continue with WanderGuard to reduce the risk of elopement. A person-centered care plan titled Wandering Behavior was initiated on 9/24/18 and indicated the resident is high risk for elopement related to dementia, confusion, and acute illness per risk assessment. Interventions included but are not limited to apply WanderGuard bracelet and check for placement per policy, door alarms/ WanderGuard system on exit doors and check quarterly, the front door alarm tone is changed quarterly, and reassess elopement risk. The physician's orders [REDACTED]. The Nurse's Notes of 9/27/18 at 6.30 AM, documented the resident wandering in the hallway and was assisted back to her room. On 9/29/18 at 8.30 PM, the resident attempted to exit the facility through the front door and the WanderGuard alarm triggered. The Nurse's Notes on 10/9/18 at 6:55 AM documented that the was noted to be in bed at 6:15 AM, and at 6:45 AM the resident was found outside the building and was fully dressed. The facility conducted an investigation of the incident on 10/9/18. The facility concluded that the resident was alert with confusion regarding why she is at the facility. The resident exhibited self-initiated acts/behavior as part of the quality of life routine and has been assessed as an elopement risk from admission. The resident eloped on 10/9/18 despite adherence to all safety interventions and all plans of care consistently implemented. The above care plan was reviewed and revised after the above incident on 10/9/18. Interventions added were to maintain resident in staff sight when awake. Based on the physician's orders [REDACTED]. The 11-7 night shift nurses documented the placement and functioning of the WanderGuard bracelet. Certified Nurse Aide (CNA) #1 was interviewed on 10/25/18 at 2:52 PM and stated that on 10/09/18 at approximately 6:40 AM, she saw the resident standing at the entrance to the facility just before the highway (Route 17). She stated the resident was standing next to the car of a housekeeping staff who was trying to get resident to return to facility. At that time, another staff member, a Licensed Practical Nurse (LPN #1) who was coming in to work drove up to where they were located and with her assistance, was able to convince the resident to return to the facility and immediately notified the nursing supervisor. The 11-7 night shift Registered Nurse (RN #1) was interviewed on 10/26/18 at 9:45 AM and she stated that she was made aware of the resident's elopement via a phone call made by CNA #1 at 6:45 AM on 10/09/18. RN#1 stated she assessed the resident upon return and kept her on 1:1 monitoring. (The 1:1 monitoring was done until the Director of Nursing arrived to further investigate the elopement incident.) She stated that the resident told her that she went for a walk. RN #1 was unable to state as to how the resident was able to exit the facility without being detected by the night shift staff, including her. CNA #2, one of the two unit CNAs on duty at the time of elopement was interviewed on 10/26/18 at 12:55 PM and stated that she did not know that the resident had eloped until she was informed by the night nurse. CNA #2 stated she did not hear any alarm. LPN #1 was interviewed on 10/29/18 at 1:45 PM. She stated that on her way to work between 6:45 AM and 6:50 AM on 10/9/18, she witnessed the resident standing next to CNA #1 on the entrance to the facility near the service road off Route 17. CNA #1 stated she heard the resident say that she's not going back to the facility and would like to talk to her son. LPN #1 stated it took approximately 10 to 15 minutes before they were able to convince the resident to go back to facility. The environmental supervisor (ES) was interviewed on 10/29/18 at 2:30 PM and he stated that the video camera was viewed for several hours after the elopement but they were only able to see the resident returning to the facility with a staff member at 6:19 AM and not when she was leaving. The ES stated that an employee was assigned to check the alarmed doors at night. The camera room located on the independent living side of the building revealed the resident returning and was not seen leaving the facility. The camera recording was viewed with the ES at this time and revealed a discrepancy between the time the staff brought the resident back in and the time on the camera recording when the resident returned. The camera recording indicated that the resident was returned at 6:19 AM contrary to the statement of the staff members who found the resident in the driveway that the resident was found on the driveway at around 6:45 AM and returned at 6:50 AM. This was pointed out to the ES who stated that the camera was very old and needed a replacement. During this interview, it was noted that there was only one camera being used for both the nursing facility and the independent living section of the building. This camera was pointed at the front door of the nursing facility. During environmental rounds during the survey, it was observed there were eight possible exit doors in the building. CNA #3, the primary CNA assigned to the resident on the day of the incident, was interviewed on 10/30/18 at 9:15 AM. She stated that she last saw the resident sleeping in bed at 6:20 AM. She stated that she provided morning care to other residents because she was assigned to take six residents out of bed. CNA #3 stated that she kept the residents' doors ajar when providing care so that she could hear the phone and the doorbell, or see any resident wandering. She claimed she did not see or heard any alarm indicating that this resident with a Wanderguard bracelet was exiting the facility at that time in order to prevent her from exiting the facility. The housekeeping staff was interviewed on 10/30/18 at 12: 20 PM and she stated that she saw the resident by herself at 6:45 AM standing on the other side of the entrance to the facility just before the service road leading to Route 17. She stated that she stopped and asked the resident what she was doing there. The resident stated she wanted to call her son. The Director of Nursing (DON) was interviewed on 10/30/18 at 12:35 PM. The DON stated that on 10/9/18 at 6:45 AM, she was called by RN #1 stating that resident was seen by CNA #3 at 6:15 AM sleeping in bed. (CNA #3 stated during a previous interview that she saw the resident in bed at 6:20 AM.) The resident's room area was quiet and nobody called for assistance. Then at 6:45 AM, she was called by RN #1 stating that resident was found on the facility's driveway. She stated that RN #1 stated that CNA #3 checked the resident's room and found it was empty but the bed was still warm. The DON stated that when resident was brought back to the facility the WanderGuard alarm triggered. The DON interviewed the resident and stated that she felt going for a walk and needed to call her son. The resident stated that she used to walk all over where she used to live and that she doesn't know why she can't walk in the facility. The investigation conducted and concluded by the facility was unable to identify as to when, how and on which of the possible exit doors in the building that the resident was able to exit. None of the unit staff members including the two CNAs and the nurse in charge that the resident had exited the facility without their knowledge. 2. An initial tour of the facility was conducted on 10/23/18 at 10:00 AM and throughout the survey dates until 10/31/18. The following conditions were observed and were identified as possible trip hazards for residents, staff and visitors: Unit 1: - buckled linoleum floors were observed in bathrooms located within the resident rooms #7, 15, 16, 17, and 9; - torn and buckled carpets were observed in hallways located near resident rooms #2, 4, 6, 7, 9, 16 and 19; - cracked linoleum floor was observed in a bathroom located in resident room [ROOM NUMBER]; - lifted and unsecured carpet seam was observed on the doorway located outside a hallway bathroom. Unit 2: - buckled linoleum floors were observed in bathrooms located within the resident rooms #27, 29, 32, 34 - buckled carpets were observed in hallways located near resident rooms #28, 30, and 31 - cracked linoleum floor was observed in a bathroom located in resident room [ROOM NUMBER]. The facility administrator was interviewed on 10/31/18 at 12:30 PM and she stated that the facility is aware of the issues regarding the linoleums floors and torn carpets. She stated that these issues are already on the list of things that needed to be done. Interviews were conducted on 10/31/18 at 2:44 PM with multiple nursing staff members. They stated that they have repeatedly reported and complained about the condition of the linoleum and carpets and nothing had been done as of yet. These staff members stated they felt these conditions could cause a resident to trip and fall. 415.12(h)(2)

Plan of Correction: ApprovedNovember 9, 2018

I 1)An over-door alarm has been installed in residents (#30) room to alert staff of room exit 10/9/18. A staff member has been assigned to monitor the front door and other exit doors daily from 9PM to 7AM Additional Wanderguard door check performed at midnight by Environmental Services Estimates are being sought for additional enunciators for Wanderguard alarm in each resident care area(nourishment area -mid point of each unit) Estimates are being sought for an upgraded camera and DVR system The Wanderguard Company has been notified of failed alarm system on 11/8/2018 2)A Wanderguard technician will assess and evaluate the facility to determine the need for upgrading or enhancing the system. Residents identified to be at risk for elopement will have their care plans reviewed and revised as necessary by the IDCP team by 11/16/2018 3)A staff member will continue to be assigned to monitor the front door and all other exit doors until the Wanderguard assessment is complete. Elopement and Wandering Risk Policy and Procedure has been reviewed and revised to increase the Wanderguard bracelet checks for function twice daily (every 12 hours) beginning 11/12/2018. All staff will be re-educated on wandering behaviors using the Elopement Resource manual distributed by NYSHFA, CCLC and HANYS by 11/30/2018 4)All residents are assessed for wandering risk on admission and reviewed by IDCP team at comprehensive careplan meeting, and with any change in their mental, emotional or ambulation status. Assessments will be monitored by the DON. An Audit will be conducted by the DON/designee to ensure Wanderguard bracelet function checks are performed twice daily. Results will be reported to QAPI committee for 3 months, for additional recommendations II 1)Estimates are being obtained 11/8/2018 for carpet repair/replacement for rooms # 2,4,6,7,9,16,19,28,30,31 and the doorway located outside a hallway bathroom. and Estimates are being obtained 11/8/2018 for linoleum flooring repair/replacement for rooms #7,15,16,17,9,27,29,32,34,22 and 40. 2)A full house evaluation will be conducted to ensure any other areas requiring replacement are included in the repair by 11/16/2018. 3)An audit will be completed by the Maintenance Dept on a monthly basis to ensure the carpeting and bathroom flooring is free of tears, buckling and cracks. 4)The results of the audit will be presented to the QAPI committee at each monthly meeting x3 months for further recommendations.