St Luke Residential Health Care Facility Inc
February 19, 2019 Complaint Survey

Standard Health Citations

FF11 483.12(c)(2)-(4):INVESTIGATE/PREVENT/CORRECT ALLEGED VIOLATION

REGULATION: §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated. §483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 19, 2019
Corrected date: April 19, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview during an abbreviated survey (NY 623), the facility did not ensure a thorough and complete investigation was conducted for 1 of 3 residents (Residents #1) reviewed for elopement. Specifically, Resident #1 was found outside of the building and the facility did not complete a thorough investigation to determine where the resident exited the facility. Findings include: The 3/2014 revised Reporting Elopement and Unsafe Wandering Policy documented all reports of resident elopement and unsafe wandering shall be promptly and thoroughly investigated. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 7/12/18 Minimum Data Set (MDS) assessment documented the resident had severely impaired cognition, had wandering behaviors, required supervision for locomotion on the unit, and was not steady with walking but could stabilize without staff assistance. The 7/5/18 comprehensive care plan (CCP) documented the resident had exit-seeking behaviors and she would state she had to go home. A wander alert device (a device that alerts when a resident approaches an exit with a sensor) was placed on the resident on 7/5/18. The 7/9/18 nursing progress note documented the resident was first noticed not to be in her room by CNA (certified nurse aide) #17 at 7:35 PM. The unit was searched and a missing resident code (an overhead page alerting staff) was called at 7:40 PM. The resident was found outside the building by the dishwashing room doors (door #1) and brought back to the unit in a wheelchair. She arrived on the unit at 7:50 PM. The 7/9/18 Resident Incident Report Form and Alleged Resident Abuse/Neglect/Crime Investigation Report Form documented the resident eloped outside near the kitchen and was observed in the back parking lot by the dishwashing room near the maintenance truck. The resident was noted to be off the floor at 7:35 PM, the supervisor was called at 7:40 PM, and the resident was found at 7:45 PM. She was escorted back to the building and had no apparent injuries. CNA #15 found the resident while she was outside on a break. The CNA's statement documented she saw someone standing on the other side of the truck and found the resident when she went over to look. The resident had a wander alert device placed on 7/6/18 prior to the incident and had set off the wander alert system earlier in the shift. The 7/10/18 update documented maintenance checked all the doors and the resident's wander alert device, all which were functioning. The resident's wander alert device did not sound to alert staff she had left the building. The administrator signed off on the investigation on 7/10/18. The 7/10/18 Nursing Home Incident Report documented all the facility cameras were reviewed and it was not clear as to which door the resident exited. When interviewed on 1/30/19 at 6:40 PM, CNA# 15 stated she was outside on break on 7/9/18 at 7:45 PM when she heard a noise and saw papers falling to the ground. She looked behind the maintenance truck and saw a little lady stumbling around. She called inside to the supervisor who brought a wheelchair to bring the resident back inside. The CNA did not know what door the resident used as the resident was already outside when she came out on break. On 1/31/19 at 8:15 AM, the outside area where the resident was found was observed. Two doors leading to the general vicinity were observed (doors #1 and 2). The cameras could not be seen in the area the resident was found. A diagram of the building grounds documented door #1 (near dishroom) was equipped with a wander alert system without a maglock (alarms locally at door and A/B Wing nursing station) and an intrusion alarm system (alarms to A/B Wing nursing station). Door #2 (near offices) was equipped with a maglock system (alarms locally at the door) and a wander alert system with maglock (alarms locally at door and A/B Wing nursing station). Door #3 (near adult day care) was equipped with a stop sign device system (alarms locally at door) and an intrusion alarm system. Door #4 (South stairwell) was equipped with a stop sign device system and an intrusion alarm system. When interviewed on 1/31/19 at 10:35 AM, the Director of Maintenance stated the wander alert systems on the doors and the monitors were checked every month. All the doors had an alarm on them. Alarms went to the panel on the A and B wing and staff there announced the location of the wander alert alarm to the rest of the building by an overhead page. Staff had to be on the wing to see where the alarm was and the door would alarm until staff manually turned it off. During the interview, the Director of Maintenance checked the wander alert sensors on doors #3 and door #1 and they were both functioning. Door #3 locked if a wander alert device was nearby and did not alarm until someone breeched the doorway. Door #1 alarmed as soon as the wander alert transmitter neared it. The Director of Maintenance stated there was a camera on the roof that could see that area if pointed in the right direction. The Director stated the cameras were an electronic system that automatically erased old data and he did not have a copy from the date the resident exited the building. He did not remember the event or if anyone asked him to check the cameras. He showed the wander alert bracelet band which was strong and would need to be cut off to be removed. When interviewed on 1/31/19 at 11:50 AM, cook #18 stated the doors to access the kitchen were locked around 7:45 PM. The kitchen closed at 8:00 PM and all employees left at that time. She stated residents occasionally came in to the kitchen but never made it past the doorways and never made it near the dish room. Residents did sometimes wander down the hallway past the kitchen towards the South stairwell. Door #4 at the end of the hallway was between the Riverview Room, used for activities, and the kitchen. When interviewed on 1/31/19 at 12:55 PM, RN Supervisor #17 stated the resident was found behind the maintenance truck near the dishwasher doors. She stated she thought the resident exited the building from door #4. The alarm was on the outside door and there was a fire door to the stairwell from the building which diluted the sound of the alarm. She stated she told the Administrator that it was hard to hear the alarm unless you were in the stairwell or close to the fire door. The RN stated door #4 was alarming the night the resident went missing which she told the Administrator. On 2/1/19 at 9:30 AM, maintenance staff #13 and the surveyor went to the exit at door #4 and opened the door. The maintenance worker stated the door had a Stop Sign alarm which would sound whenever the door opened and a key was needed to stop it from sounding when opened. The door was not accessible to staff. The Food Service Director's office was on the other side of the door. The maintenance worker stated he used to work in the kitchen and said kitchen staff would respond to the alarm if they heard it. The alarm would likely not be heard from the dish room since the dishwasher was loud. He had never heard of a resident getting out from this exit. The alarm stopped when the door was closed. On 2/1/19 at 9:30 AM, another surveyor stood down the hallway from door #4 as maintenance staff #13 opened the door and set off the alarm. The alarm was barely audible on the other side of the Food Service Director's door. On 2/1/19 at 9:35 AM, a surveyor set off the alarm to door #4 while another surveyor stood in the kitchen doorway. The alarm could not be heard from the kitchen doorway and it stopped when she released the push button on the door. When interviewed on 2/1/19 at 9:36 AM, the Food Service Director stated he could hear the alarm when he was in his office. He stated some residents wandered back near door #4. When interviewed on 2/8/19 at 2:22 PM, the Administrator stated he looked through the resident's chart to see what happened and stated he was unsure what door the resident exited from. He thought maybe the resident exited via door #3. He said the cameras were reviewed and stated door #3 was visible on the cameras. He said it was unlikely that the resident exited through door #4 as the door was heavy and the door alarmed whenever opened, not just with the wander alert device, and staff would have heard it. He thought the alarm could be heard from the hallway. The Administrator stated he was unsure where the resident exited from, he did not know where the additional notes for the investigation were, and he would review the incident with nursing staff on 2/11/19. When re-interviewed on 2/11/19 at 1:35 PM, the Administrator stated door #4 had two security devices including a Stop Alarm and an Intruder Alarm. The Stop Alarm emitted a loud noise at the exit and the Intruder Alarm triggers to the A wing. With the Stop Alarm, the alarm continued to sound until maintenance or a supervisor shut it off with a key. He was unable to find additional notes regarding the resident's elopement and said they were unable to come up with her point of exit since nothing alarmed. When re-interviewed on 2/19/19 at 10:17 AM, RN #17 stated she was notified by CNA #15 that a resident was outside. CNA #15 stayed with the resident while someone went outside to get the resident. Per the RN, she did not know door #4 was there before the event and it was the only time she had used that door. She could not hear the door alarming until she was past the firewall door and in the stairwell to door #4, which she told the Administrator. She stated there was a wanderguard alarm panel on the A and B wing, there was no alert on 7/9/18, and no one called a wanderguard on that evening. RN #17 thinks the resident left the building from door #4. In summary, the investigation was incomplete and did not determine how Resident #1 had exited the facility. A root cause analysis did not identify door #4 as a possible exit point for a resident wearing a wander alert device and corrective measures were not implemented to prevent reoccurance. 10NYCRR 415.4(b)

Plan of Correction: ApprovedMarch 16, 2019

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** PLAN OF CORRECTION
ST. LUKE HEALTH SERVICES
SURVEY EXIT DATE: 2/19/2019
F 610 483.12(c)(2)-(4) ? INVESTIGATE/PREVENT/CORRE ALLEGED VIOLATION
Preparation and/or execution of this plan do not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility?s credible allegation of compliance.
1. Corrective action(s) will be / have been accomplished for those residents found to be affected by the deficient practice:
Resident #1: Resident was discharged on [DATE]. A complete and thorough investigation of the 7/9/2018 incident was completed by the Administrator and it was determined that the resident had exited the facility at door # 5 (Health Information). We came to this conclusion with the addition of the following information:
An additional interview and statement was obtained from the RN Supervisor #17 on 3/1/2019 regarding the elopement. Supervisor #17 clarified her knowledge / statements regarding door #4, which she was unclear whether or not an alarm was sounding.
A routine scheduled testing of Door #4 on 7/2/2018 by the Maintenance Department was performed and the results showed the outside door was functioning properly and the alarm system was working appropriately. All other outside doors were tested on [DATE] and found to be functioning properly and alarming appropriately.
The resident could not give a concise statement of how they had exited the building. When interviewed on 7/9/2018 the resident told #17 RN supervisor that she wanted to go home to take care of the dog. She refused to sign her statement. After a review of the resident?s medical record we concluded that the resident physically could not have exited door #4 as the resident did not have enough physical strength to open two heavy doors (the fire door to the south stairwell and then door #4) within such a short distance ([MEDICAL CONDITION] feet). The resident?s gait was unsteady; had poor safely awareness; weighed 100 pounds; and limited dexterity.
We conducted a root cause analysis of all outside egress doors that included door number #1, #2, #3, #4 and #5 (Health Information) and determined the root cause was door # 5 (Health Information Area). We concluded Door #5 (Health Information) was the least secure and the most likely exit point of all of the outside doors. The determination was made that it needed to be made more secure. Door #5 (Health Information) was provided extra security on 7/11/2018.
All outside doors had a routine scheduled testing on 8/3/2018 and all were functioning properly and alarm systems were working appropriately.
Completion date: 3/4/2019

2. Identification of other residents having the potential to be affected by the same deficient practice and corrective action taken:
All doors will be inspected by the Maintenance staff to ensure all security systems in place are functioning appropriately which includes those that have wander guard. Completion date: 4/19/2019 and ongoing.
All RN?s and RN Supervisors will have a tour of the facility by the Director of Maintenance to show them all of the outside doors to ensure they are aware of all of the outside door security systems in place and how they function. Completion date: 4/19/2019 and ongoing
RN Unit Manager/ Designee will review all incident reports of residents who have had elopements since 2/19/2019 to ensure a thorough investigation has been completed, a root cause analysis has been performed and corrective measures have been implemented to prevent reoccurrence. Completion date: 4/19/2019 and ongoing.
The Reporting Elopement and Unsafe Wandering policy and procedure will be reviewed by the Administrator / Designee to ensure it contains all of the steps to a complete and thorough investigation, in order to determine a root cause so that corrective measures can be implemented to prevent reoccurrence (ie. egress doors are functioning properly and alarm systems are working appropriately). Completion date: 4/19/2019 and ongoing.
The Quality Assurance Incident Reports policy and procedure will be reviewed by the Director of Health Information / QA Director / Designee to ensure it contains all of the steps to a complete and thorough investigation, in order to determine a root cause so that corrective measures can be implemented to prevent reoccurrence (ie. egress doors are functioning properly and alarm systems are working appropriately). Completion date: 4/19/2019 and ongoing.
3. Measures put in place to ensure that the deficient practice does not recur:
All doors leading to the outside will be inspected by the Maintenance staff to ensure all security systems are in place and are functioning appropriately. This includes those that have wander guard on them. This will be done on a monthly basis. Completion date: 4/19/2019 and ongoing.
All RN?s will be in-serviced by the In-service Coordinator regarding the Quality Assurance Incident Report Policy and Procedure. This includes performing a thorough and complete investigation, a route cause analysis, determining corrective actions and implementing measures to prevent reoccurrence. Completion Date: 4/19/2019 and ongoing.
The RN Night Supervisor will complete rounds all outside doors to ensure they are securely shut. Completion date: 4/19/2019 and ongoing
All RN?s will be in-serviced by the In-service Coordinator regarding the Quality Assurance Incident Report Policy and Procedure. This includes performing a thorough and complete investigation, a route cause analysis, determining corrective actions and implementing measures to prevent reoccurrence. Completion Date: 5/19/2019 and ongoing.
All RN?s will be in-serviced by the In-service Coordinator regarding the Reporting Elopement and Unsafe Wandering policy and procedure. This includes performing a thorough and complete investigation, a route cause analysis, determining corrective actions and implementing measures to prevent reoccurrence. Completion Date: 4/19/2019 and ongoing.
All licensed nursing staff will be in-serviced by the In-Service Coordinator regarding the Quality Assurance Incident Report Policy and Procedure as well as the Reporting Elopement and Unsafe Wandering policy and procedure. This includes their role in ensuring a thorough and complete investigation, route cause analysis, determining corrective actions and implementing measures to prevent reoccurrence. Completion date: 4/19/2019 and ongoing.
4. How the Corrective Actions will be monitored by to ensure the practice will not recur:
A QA monitor will be implemented to ensure all doors leading to the outside will be inspected to ensure all security systems are in place and are functioning appropriately. This includes those that have wander guard on them. The audit will be done monthly for three months, then quarterly for six months by the Director of Maintenance / Designee with further frequency of monitoring to be determined by the QA committee. Threshold: An expected compliance will be 85%. Completion Date: 4/19/2019 and ongoing.
A QA monitor will be implemented to ensure incident reports of elopement are thorough and complete, have root cause analysis performed and corrective measures implemented to prevent reoccurrence. The audit will be done monthly for three months, then quarterly for six months by Employee Health Nurse / Designee with further frequency of monitoring to be determined by the QA committee. Threshold: An expected compliance will be 85%. Completion Date: 4/19/2019 and ongoing.
A QA monitor will be implemented to ensure nightly rounds are being completed by the RN Night Supervisor to ensure all outside doors are securely shut. The audit will be done monthly for three months, then quarterly for six months by Employee Health Nurse / Designee with further frequency of monitoring to be determined by the QA committee. Threshold: An expected compliance will be 85%. Completion Date: 4/19/2019 and ongoing.
5. Date for Correction: 4/19/2019 and ongoing
6. Person Responsible for Correction: Director of Nursing