Park Nursing Home
October 22, 2018 Complaint Survey

Standard Health Citations

FF11 483.25(d)(1)(2):FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES

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: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 22, 2018
Corrected date: December 14, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews and record review conducted during an abbreviated survey, (NY 319), the facility did not ensure that a resident, who was at risk for elopement, received adequate supervision to prevent elopement. This was determined for 1 of 5 residents sampled for elopement (Resident #1). Specifically, Resident #1 was identified at risk for elopement and refused to wear a wander-guard. On 08/05/2018 at 6:43 PM, Resident #1 climbed the facility back gate and eloped from the facility without staff knowledge. The Registered Nursing Supervisor (RNS) was notified of the elopement on 08/05/2018 at 9:45 PM (approximately 3 hours after Resident #1 eloped from the facility). Resident #1 was located and returned to the facility at 11:45 PM. The Findings are: Review of the Facility's Elopement Prevention Policy dated 08/19/2016 documented that the facility maintains a process to assess each resident for the risk of elopement and to implement strategies based on identified risk factors. When a resident is at risk for elopement, the Registered Nurse Supervisor (RNS) will obtain a wander-guard device and place it on the resident. The RNS is responsible for initiating and updating the Elopement Risk Care Plan. (The Policy did not address monitoring or other interventions for refusal of wander-guard). Review of the Facility's Certified Nursing Assistant (CNA)) Responsibility Policy dated 01/2007, documented that the CNAs make rounds every 2 hours on 7-3 shift and 3-11 shift, and every hour during the 11-7 shift, check the statuses of residents and report any unusual findings to nurses. The Elopement Risk assessment dated [DATE] noted that Resident #1 was independently mobile, had an history of elopement and verbalized the desire to leave the facility and is a wanderer. The key explained that Resident #1 was considered at risk for elopement and required immediate prevention plan. In addition, it documented that Resident #1 refused the wander guard. Resident #1 was initially admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, a resident assessment tool) dated 06/29/2018, documented that Resident #1 has long/short-term memory problems and that Resident #1's Cognitive Skills for Daily Decision Making is moderately impaired (decisions poor; cues/supervision required). The resident required supervision for self-performance with walking in the corridor and with locomotion on and off the unit. A Wandering/Elopement Care Plan initiated on 03/26/2015 and updated on 04/25/2018, documented that Resident #1 walked off the unit without advising staff. The interventions included monitor resident location at intervals, provide picture at security station, redirect resident, engage him in activities of choice and Psychiatry evaluation. A care plan evaluation note dated 03/01/2018 documented that Resident #1 refused to wear wander-guard. The intervention documented ongoing encouragement. No other interventions noted. Review of the Facility's Occurrence Report dated 08/05/2018 documented that on 08/05/2018 at 9:45 PM, staff reported that Resident #1 was missing. Code E was initiated, and the staff searched the interior and exterior of the building. The Director of Nursing Service (DNS), the Administrator and the Physician were notified, and 911 was called. A CNA found Resident #1 and brought him back to the facility at around 11:45 PM. Resident #1 was assessed by the Supervisor and no injuries were noted. On 08/15/2018 at 2:15 PM, this Surveyor and the facility's Administrator reviewed the facility's surveillance camera dated 08/05/2018. The surveillance camera showed that on 08/05/2018 at 6:38 PM, Security Officer #2 was seen on the camera walking away from his post at the back door where he was stationed to monitor (the back door is located on the first floor and leads to a patio). At 6:39 PM Resident #1 was seen exiting the back door leading to the patio. Resident #1 took a chair from the patio (chairs were in a corner on the patio) and leaned it against the gate that leads into the yard of the facility's grounds. Resident #1 stepped on the chair and climbed over the gate at 6:44 PM, walked briskly towards the street and out of camera view. Observation of the patio doors was conducted on 8/15/2018, noted there were two doors leading to the back patio. The inner door was equipped with an alarm sensor and key pad. When the inner door is closed, one must enter the key code or the alarm will activate. The outer door (leads to patio) does not have an alarm or key pad. When Security Guard #2 walked away from his post on 08/05/2018, the inner door was left opened. A nursing progress note, by Licensed Practical Nurse (LPN) #6, dated 08/06/2018 documented that she was informed on 08/05/2018 at 9:45 PM that Resident #1 was not in his room, and not on the unit. Code E (used for missing resident) was called, a thorough search of the facility and outside of the building was done. The Director of Nursing, the Physician and 911 were called. A staff member found Resident #1 and brought him back to the facility. Resident #1 was transferred to the hospital for evaluation. Review of the Resident Nursing Instructions (for Resident #1) from 08/01/2018 to 8/5/2018, under safety instructions, documented elopement precautions. Resident #1 refused to wear wander-guard; observe for exit seeking behavior. No specific monitoring frequency was documented. Review of the International Safety Security Management (ISSM) Protective Services job description, signed by Security Officer #2 on 07/03/2017, stated that the Security Officer should not leave his post without face to face relief and to make sure that only authorized persons enter and leave the facility. Review of the Facility In-Service Records on Elopement revealed that no in-services were found for the Security Officers prior to the elopement on 08/05/2018. LPN #1 was interviewed on 08/15/2018 at 12:05 PM and stated that he was the regular day shift nurse on the unit where Resident #1 resided. He stated that Resident #1 was not on monitoring prior to eloping from the facility on 08/05/2018. LPN #2 was interviewed on 08/15/2018 at 12:22 PM and stated that Resident #1 walked around the unit and went off the unit independently. Resident #1 was assessed at risk for elopement, but refused to where a wander guard. Resident #1 was not on any specific monitoring. CNA #1 was interviewed on 08/15/2018 at 2:45 PM and stated that she was assigned to Resident #1 on 08/05/2018. She last saw Resident #1 on the unit before going on her break from 6:00 PM to 7:00 PM. Upon her return from break at 7:00 PM, she attended to another resident. She discovered that Resident #1 was missing sometime after 9:00 PM (not sure of the time) and she informed the nurse. LPN #6 was interviewed on 08/16/2018 at 1:20 PM and stated that she was assigned to Resident #1 on 08/05/2018 when he eloped from the facility. She gave Resident #1 his medications around 6:30 PM and between 8:00 PM and 8:30 PM (not sure of the time), CNA #1 informed her that she could not locate Resident #1. The staff searched for Resident #1 but the search was unsuccessful. The RNS was informed and Code E was activated. She stated that the residents were checked every hour or every two hours. In addition, Resident #1 was ambulatory and could leave the unit and roam around inside the building. The RNS was interviewed on 08/16/2018 at 7:59 AM and stated that he was on duty 08/05/2018 when Resident #1 eloped from the facility. At 9:45 PM, he was notified that Resident #1 was missing. They immediately conducted a search and called Code E. A CNA located Resident #1 and brought him back to the facility. Resident #1 was assessed with [REDACTED]. The RNS stated that prior to the elopement on 08/05/2018, all the residents were being monitored hourly. Security Officer #1 was interviewed on 08/17/2018 at 3:00 PM and stated that he was assigned to the back door on 08/05/2018. He had to leave his post around 6:20 PM and he asked Security Officer #2 to relieve him from his post. He went on to state that he returned to his post and relieved Security Officer #2 about 7:00 PM. He did not see Resident #1. This Surveyor attempted to interview Security Officer #2 on 09/24/2018 at 9:20 AM. He stated that he could not remember anything about Resident #1's elopement. However, Security Officer #2 provided the facility a statement via telephone on 08/06/2018. It stated that Security Officer #2 relieved Security Officer #1 from his post at the back door around 6:30 PM. Security Officer #2 stated that he temporarily moved away from the back-door post and went to the front lobby where he stayed for a few minutes and did not see when Resident #1 exited the back door. The Administrator was interviewed on 08/16/2018 at 3:20pm. He stated that he had been in the position for three weeks and that the facility uses a wander guard security system. An alarm with sensor is at every exit and only the staff has access to the keypad code. Cameras are on the 1st floor and outside the parameters of the building. Security Officers are stationed at both entrances to the facility during the day and evening. A Receptionist is also stationed at the front desk during the day. The Nursing Supervisor notified him around 11:00 PM that Resident #1 eloped from the facility. He reviewed the cameras and noted that Security Officer #2 left his post while the back door to the patio was open, resulting in Resident #1's elopement. Subsequent telephone interview was conducted with the Administrator on 10/17/2018 at 3:52 PM. He stated that the monitor at the front desk captures the back door and the patio. The Security Officer assigned to the front desk job responsibilities includes monitoring the monitors. On inquiry he stated that the facility is responsible for In-servicing Security Officers on Elopement Prevention. However, he could not say if the Security Officers had prior In-services on Elopement Precautions. The DNS was interviewed on 08/16/2018 at 2:40 PM and stated that residents are assessed for elopement risk on admission, readmission and as needed. The residents are monitored by the staff every two hours during the day and evening shifts, and every hour during the night shift. They cannot hold the residents on the unit, the residents are allowed to go down (1st floor) to the dining room independently. The residents were not allowed to go to the patio without supervision. Residents who are at risk for elopement and refused to wear a wander-guard were monitored every two hours. The facility did not have an official form to document the monitoring. She added that there was a breach in security and that the staff who worked on the unit were also accountable. Subsequent telephone interview was conducted with the DNS on 10/22/2018 at 3:35pm. She stated that Resident #1's name was placed on a Refusal of Wander Guard List which is kept at the Security desk. He was not exhibiting exit seeking behavior and was not placed on 30 minutes monitoring. She further stated that the facility does not have any Elopement In-service attendance records for the Security Officers prior to the elopement. 415.12(h)(2)

Plan of Correction: ApprovedNovember 19, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Immediate Corrective Action for Resident affected:
Resident #1
1) As noted in the SOD, the Resident was located and returned to the facility on [DATE] at 11:45 PM. Immediately the resident was assessed by the RN and the PM was contacted and recommended that the resident be transfer to ED for evaluation.
2) Resident was transferred to ED and returned to the facility on [DATE] with not noted findings.
3) On return to the facility the Resident was;
a) placed on 24-hour constant monitoring with a staff member rotating around the clock for until 9/14/18. On 9/14/18 the resident was placed on Q 30 minutes monitoring and continues to be on the same monitoring schedule to date. The wander guard is being checked every shift for placement by the Certified Nursing Assistants. The 11:00 PM-7:00 AM RN Supervisor is responsible to check the function of the wander-guard on a weekly basis.
b) provided with a wander guard, which was placed on his Left wrist, as he was agreeable to the use of the wander guard on return from the hospital. The wander guard continues to be in place, at this time.
c) on 8/6/18, the DNS updated the resident?s Care Plan and CNAAR to reflect the use of the wander guard and the constant monitoring for safety.
4) Security Officer #2, who left his post, was terminated from his employment at the facility as of 8/6/18. To date all security personnel have been in-serviced.
5) All new and existing security personnel were immediately in-serviced regarding never leaving their post unattended by the DNS on 8/6/18-8/11/18. Copies of the lesson plan and sign-in sheets are retained on file as validation.
6) The security post at the back door was changed from being manned only during the day to a 24-hour on 8/17/18 and will continue to be manned 24-hours going forward.
7) On 8/20/18 the facility installed an alarm to the outer door (leading to the patio), that is active at all times and controlled by a keypad. It is only deactivated, with a key held by the recreation supervisor, during an outdoor activity. At this time the area is under constant supervision and will be under the supervision of the activities staff during that time. During non- activity time the door is under constant supervision by the security officer assigned to the back door. The Maintenance department is responsible to check that all alarmed doors are functioning properly on a daily basis.
8) An elopement risk binder of residents wearing wander guards or refusing to wear is also located at the back door.
9) The inner door continues to be under constant supervision and has the wander guard censor in place.
10) On 8/6/18 the Director of Maintenance removed all chairs from the patio area that were stored near the door and moved them to a different location that was not easily accessible by residents.
11) On 11/16/18 the Director of Maintenance safeguarded all the chairs located in the patio area so that they cannot be easily moved by residents and used as an enabler to scale the fence.
12) On 11/19/18 the assigned CNA received an educational counseling, for failure to provide rounds, and check every resident, every two hours as per the established facility P&P. The copy of the educational counseling has been retained on file as validation.

II) Identification of other Resident:
1) The facility respectfully states that all resident at risk for elopement could have been potentially affected.
2) On 11/12/18 the DNS/designee developed a list of all Residents currently at risk for elopement. The
The list was used to ensure that all residents are; a) provided with a wander guard.
b) Residents refusing to wear a wander guard are care planned for and have specific interventions developed for frequent monitoring.
c) The CNAAR reflects all established interventions for residents at risk for elopement.
d) Residents with wander guards and residents refusing to wear wander guards have pictures placed in elopement risk binders located at both security check points.
e) The Medical Alert in the Electronic Medical Record (EMR) is reflecting the resident?s risk status for elopement and that all residents have a pink star on the wrist band that identifies them as being at risk for elopement.

III) Systemic Changes made so the deficiency will not reoccur:
1) On 11/15/18 the DNS reviewed and revised the current facility P&P for Elopement. The revised P&P will be in-serviced to all facility staff by the DNS/Designee as of 12/07/18. The lesson plan concentrated on the following;
a) Once it has been determined that a resident is an elopement risk the Interdisciplinary Care Plan Team (IDCP) will:
b) Ensure that an elopement risk assessment has been completed.
-Develop/update the Elopement Prevention care plan, document in the progress notes and ensure that the resident is carried on the 24- hour report for discussion at the next morning/QA meeting.
-Contact the MD and obtain an order for [REDACTED].
-Once the wander guard is in place, the RNS will complete a Wander Guard Functionality Check Form and place it in the designated location in the RNS? office.
-Update the CNAAR with regards to the placement of the wander guard and ensure that instructions are added for placement checks of device Q shift by the CNA.
-Will inform the Social Worker so that the facility wide Elopement Risk Lists and security Elopement Binders can be updated. When the Social worker is not in the facility the RNS will manually update the lists and the books.
-Will inform the Recreation Director/Designee so a photo of the resident can be taken immediately and placed in the Security Elopement Binders. If the Recreation Director/Designee is not in the facility, the RNS will take a picture using the camera that is kept in the Nursing Supervisor?s office and place the picture in the binders.
-Will update the Medical Alert in the EMR, by selecting the Pink Star Elopement Identifier and reprint a new armband/wrist band with the elopement alert identifier and place it on the resident.
For Residents Refusing to wear a Wander guard
c) Once it has been determined that a resident is an elopement risk and is refusing to wear a wander guard, the RNS will;
-Place the resident on q 30 minutes monitoring.
-Update the CNAAR to reflect all established monitoring intervention, and document that resident is an elopement risk refusing to wear the wander guard.
- Will inform the Social Worker so that the facility wide Elopement Risk Lists and security Elopement Binders can be updated, and counseling provided to the resident as applicable. When the Social worker is not in the facility the RNS will manually update the lists and place them in the Elopement Binders located at the security check points.
-Will inform the Activities Director/Designee so a photo of the resident can be taken and placed in the Security Elopement Binders. If the Activities Director/Designee is not in the facility, the RNS will take the pictures using the camera that is kept in the Nursing Supervisor?s office and place them in the Elopement Binders located at the security check points.
-Will update the Medical Alert in the EMR, by selecting the Pink Star Elopement Identifier and reprint a new armband with the elopement alert identifier and place it on the resident.
A copy of the lesson plan and sign-in sheets will be kept on file as validation. Any newly hired employees or employees returning from vacation post 12/07/18 will be in-serviced prior to the start of their work day.

2) On 11/16/18 the facility created a new P&P for CNA Visual Monitoring. The newly established P&P will be in-serviced to all Nursing staff as of 12/07/18 by the DNS/Designee. The lesson plan will concentrate on the following;
a) CNAs will be responsible for making rounds every 2 hours on 7-3 shift, 3-11 shift and every hour during the 11-7 shift.
b) During rounds they must check the resident?s status and report any unusual findings to the licensed nurse immediately.
c) Validation of rounds conducted must be documented in the EMR, and in the CNAAR under the monitoring sections.
d) Residents on visual monitoring for elopement prevention and other behaviors placing the resident or others at risk will be monitored and validated on the established visual check forms (Q 15, Q30 and continues monitoring/one to one.).
A copy of the lesson plan and sign-in sheets will be kept on file as validation. Any newly hired employees or employees returning from vacation post 12/07/18 will be in-serviced prior to the start of their work day.

3) On 11/19/18 the Administration and the Director of Nursing Services reviewed and revised the facility?s Job Description/Responsibilities for Security Officers. The revised Job Descriptions will be in-serviced to all Security Officers by the DNS/Designee as of 12/07/18. The lesson plan concentrated on the following;
-Security Officers should never leave the post without face to face relief.
-Making sure that only authorized persons enter and leave the facility.
-Report any unusual activity or unsafe behaviors immediate to the RNS.
-Making sure that the outer door leading to the patio is always alarmed if patio is not actively being used for an activity.
A copy of the lesson plan and sign-in sheets will be kept on file as validation. Any newly hired employees or employees returning from vacation post 12/07/18 will be in-serviced prior to the start of their work day.
4) On 11/19/18 the Administrator established a new P&P/Criteria for Keeping the Back Door, leading to the patio, Alarmed. The newly established P&P will be in-serviced to Facility Department Heads by the Administrator as of 11/20/18. All Department heads will in-service their departmental staff on the policy as of 12/07/18. The lesson plan will concentrate on the following;
-Back door, leading to the patio, must always be kept alarmed. It is controlled by a key pad and it is only deactivated with a key that is held by the recreation supervisor.
-The only time it can be deactivated is when there is a scheduled activity in the patio area that is under constant supervision by a designated facility staff member.
-The Alarm can also be deactivated, for 20 seconds only, by entering the designated code into the key pad located on the side of the door.
-Staff deactivating the alarm by entering the code into the key pad must ensure that there are not residents exiting behind them and that the door is fully closed, and the alarm activated prior to leaving the area.
A copy of the lesson plan and sign-in sheets will be kept on file as validation. Any newly hired employees or employees returning from vacation post 12/07/18 will be in-serviced prior to the start of their work day.
5) On 11/19/18 the Administrator developed a criterion and a form for conducting daily visual rounds of the back-patio area. Rounds will be conducted by the Maintenance Director/Designee to ensure that the patio is free of any unsecured chairs/ other items that can be used by residents to scale the fencing in the patio area and that all alarms in the patio area are working properly. The daily visual rounds criteria and form was in-serviced to the Maintenance Director by the Administrator on 11/20/18. The Lesson plan concentrated on the following;
-Daily rounds must be conducted in the back patio to ensure that the area is maintained safe and clean.
-Any unsecured chairs or other items that can be used for scaling the fencing must be immediately secured or removed from the area.
-All door alarms leading to or out of the patio area must be checked to ensure that they are functioning properly. Any identified issues must be immediately corrected and reported to the Administrator or DNS.
-Validation of the above noted tasks must be documented on the established form.
A copy of the lesson plan and sign-in sheets will be kept on file as validation. Any newly hired employees or employees returning from vacation post 12/07/18 will be in-serviced prior to the start of their work day.
IV) Monitoring of the Corrective Action/Quality Assurance:
1) On 11/19/18 the DNS developed a QA audit tool to monitor the facility?s compliance with developing and implementing appropriate interventions for elopement risk residents.
The audit will be completed by the Director of Nursing (DNS)/designee for residents identified at risk for elopement and for those refusing to wear wander guards monthly x 3 months and quarterly thereafter. All negative findings will be immediately corrected by the DNS/designee. Initial auditing is scheduled to be completed by 12/14/18
All audit findings will be reported to the Administrator and QA Committee monthly x 3 months and quarterly thereafter for follow-up and input as needed. Next QA meeting is scheduled for 12/18/18.
2) On 11/19/18 the Administrator developed a QA audit tool to monitor the Security Officers knowledge of their job description specific to leaving their assigned post. Audits will be completed by the Administrator/Designee for 2 randomly selected Security Officer monthly x 3 months and quarterly thereafter. Initial auditing will be completed by 12/07/18. Any negative findings will be immediately corrected.
All audit findings will be reported to the Administrator and QA Committee monthly x 3 months and quarterly thereafter for follow-up and input as needed. Next QA meeting is scheduled for 12/18/18.
3) On 11/19/2018 the Administrator developed a QA audit tool to track the facility?s compliance with maintaining the outer door, leading to the patio, always alarmed unless patio is being used and that all furniture in the patio are secured and cannot be used for scaling the fencing. Audits will be conducted by the Administrator/designee monthly. Any negative findings will be immediately corrected. Initial auditing is scheduled to be completed by 12/7/18.
All audit findings will be reported to the Administrator and QA Committee monthly x 3 months and quarterly thereafter for follow-up and input as needed. Next QA meeting is scheduled for 12/18/18.
V) Responsibility:
Director of Nursing