The Grand Rehabilitation and Nursing at River Valley
January 6, 2017 Complaint Survey

Standard Health Citations


REGULATION: (d) Accidents. The facility must ensure that - (1) The resident environment remains as free from accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. (n) - Bed Rails. The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements. (1) Assess the resident for risk of entrapment from bed rails prior to installation. (2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation. (3) Ensure that the bed?s dimensions are appropriate for the resident?s size and weight.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 6, 2017
Corrected date: March 31, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review conducted during an abbreviated survey it was determined that the facility failed to provide adequate supervision, monitoring, and ensure that elopement prevention devices were utilized effectively to prevent potential serious accident for 1 of 3 residents who demonstrated exit seeking behaviors. Specifically, the Maintenance Worker deactivated a secured stairwell alarm which resident exited undetected to the main floor where his wander guard alarmed twice which receptionist turned off without responding. Resident was found by Police 50 minutes later on RT 9 in the median of a 4 lane highway about ½ mile from the facility. The findings are: Complaint # NY 180 Resident #1 was admitted to the facility on [DATE] at 7:30pm. His [DIAGNOSES REDACTED]. The Resident was assessed on admission as being alert and oriented to time, place and person, and assessed as being no risk for elopement. A review of the facility investigation dated 12/22/2016 documented the Resident was seen by nursing in his coat ambulating on the unit at approximately 7:45AM on 12/22/2016 and at that time the Register Nurse Supervisor (RNS) placed a wander guard on the Resident which was checked for functionality. It further documented that at approximately 8:20AM the Registered Nurse Unit manager (RNU) observed the Resident ambulating up and down the unit, offered him a chair in the hallway where he would be visible to the staff which he declined and continued to ambulate up and down the unit hallway. At approximately 8:40AM the RNU did not visualize the resident, after search of unit and Residents room. RNU was then told by a Maintenance Worker down the hall that he had let a man with a black coat who he thought was a family member into the stairway exit. RNU searched stairway then notified the Director of Nursing (DON) at 8:45AM and Code Orange (missing resident) was called. At 10:00 AM the Local Police notified facility that Resident was picked up and taken to the Police Station. The Assistant Director of Nursing (ADON) retrieved the Resident from the Police Station at approximately 10:30AM. A complete assessment found Resident without injury. Facility Policies and Procedures reviewed on 12/27/2016 in relation to elopement document: Wander Guard Sytem Bracelet / Transmitter Policy and Procedure, dated 2/2015, documented all facility employees in the immediate area are expected to respond to a sounding alarm, and check the immediate vicinity inside and outside the building to locate the Resident when an alarm is triggered. Code Orange Policy and Procedure, dated 12/18/2010, documented that police are to be called, and upon return of the Resident to the facility, there is to be documentation in the Nurses Notes. Elopement / Wandering Resident Policy and Procedure for Social Services dated 11/7/2011 documented the Staff Development Coordinator educates all staff on wandering / elopement residents, distributes an updated list of at risk Residents to all departments and the RNS notifies the Police. Review of the Residents Record on 12/27/2016 and 12/28/2016 contained no documentation regarding the resident's elopement, return to the facility or his assessment upon return to the facility. On 12/27/2016 at 11:37AM observation of the first floor west side door keypad (door resident exited) was tested and found to be not working. Surveyor was able to exit the building without using the keypad. This was demonstrated twice with the Maintenance Director present. The key pad was again tested on [DATE] at approximately noon and it was observed that after Maintenance entered the code the door would not open. At 4:30PM this date the malfunctioning key pad was replaced by the Alarm Company Technician. Review of the video surveillance tape of 12/22/2016, reviewed on 12/27/2016 shows the Resident triggered the wander guard sensor on the west first floor stairway at 8:29AM. The panel for the wander guard sensor at the front reception desk was triggered. It further reveals that the receptionist responded to the alarm and is seen looking at the monitor screen, then turning off the alarm. The second alarm sounding a few seconds later shows her again turning off the alarm with no regard to policy and procedure which requires staff to check the immediate vicinity inside and outside the building when an alarm is triggered. During an interview with the DON on 12/27/2016 at 9:30 AM the DON stated that the RNS had placed a wander guard on the Resident because she assessed him as being high risk for elopement due to him attempting to exit the building at the elevators early in the morning. The wander guard sensor alarms were functioning, however the Receptionist turned alarms off twice without checking the exit doors or the area for residents. She stated the Resident can be seen at the exit door on video and during the Code Orange review, which was called by RNS, staff searched inside and outside, but could not find resident. At 10 something AMthe Police called and advised them that they located a resident of theirs who was wearing a device. She stated that, It is the facility policy to call the police, the doctor and family, but did not know why the police were not called right away. My ADON went to pick up the Resident from the Police Station, and when they returned the RNU did a full body check and found no injury or harm. During an interview via telephone on 12/28/2016 at 4:00PM with the facility Receptionist, she stated that she was going to get paper when she heard the wander guard alarm. She glanced at the monitor and did not see anything. She stated she has been a Receptionist for 14 ½ years and the facility has never been given an in-service regarding the policy and procedure for the wander guard sensor, or what to do. She further stated, I would stop someone if I saw them leaving or maybe call someone, but I didn't see anyone. During an interview with the Administrator on 12/27/2016 at 9:45AM he stated that he is aware of the problems with the alarm system that led to the elopement. He was not aware if all staff had been in-serviced regarding the facility's policy for Elopement and was unable to produce in-service education documentation for ancillary staff on elopement policy and procedures. Administrator further stated that the wander guard system is maintained and monitored for functionality by having the bracelets monitored by nursing, if the bracelet is working the system is working. During an interview with the Director of Maintenance on 12/27/2016 at 10:20AM he stated the only time that the key pad alarms are checked is when there is a problem, they do not monitor or keep a log of monitoring the functionality for wander guard sensor system or key pad alarms. He further stated he did not have in-service records for his staff for monitoring of alarms or elopement policy and procedures. During an interview via telephone with the Maintenance Worker on 12/28/2016 at 12:45PM, he stated, It was an odd situation since no one notified anyone that he was a Resident. Everyone thought he was a visitor, and the Nurses were having a hard time keeping him off of the elevator. He further stated, I used the key pad to access the 4th floor and was not paying attention, so I never saw the Resident go through the door. He states he has never had a facility in-service on elopement, and does not check the door alarms for functionality. During an interview on 12/28/2016 at 2:00PM with the RNS she stated she observed Resident #1's exit seeking behavior. She stated, The resident did have a coat on and was attempting to exit building through the elevator which is why I assessed him as being a high risk and placed the wander guard that was working at the time. I started the care plan and informed the Certified Nurse Aides on the unit but did not notify the reception area of the change in his status. The Director of Nursing and the Administrator were unable to provide any in-service documentation on elopement training to any of ancillary staff. 415.12(h)(1)

Plan of Correction: ApprovedMarch 13, 2017

I. Corrective Action
1. All facility staff were inserviced by the Director of Nursing or Assistant Director of Nursing regarding facility policy and procedures regarding elopement
2. The Maintenance Worker and Receptionist were disciplined appropriately for violation of facility policies and procedures regarding elopement
3. All exits to the stairwells and to the street were inspected by an external alarm company. In the event of any systems found to be malfunctioning, repairs were made by the alarm company.
4. Extra supervision was placed on any external exit door on a 24 hour basis until their alarms were repaired
5. All RN were inserviced by the Director of Nursing regarding documenting a full assessment for any resident after each Incident and/or Accident
6. All wanderguard bracelets were inspected and found to be in working order
7. The Wanderguard System Bracelet/Transmitter Policy and Procedure were reviewed. Revisions were made as needed.
8. The Code Orange Policy and Procedure were reviewed. Revisions were made as needed.
9. All personnel that work at the Front Desk were inserviced regarding appropriate response to any door alarm.
II. Residents at Risk for the Same Practice
All residents in the facility that meet the criteria for requiring a wanderguard bracelet are considered to be at risk for the same deficient practice.
III. Systemic Changes to Prevent Recurrence
1. All exit doors to both the stairwells and the street will be checked three times a day by the Maintenance Department/Security Officer. The results of these checks will be kept in a binder
2. The policies on Elopement Response including notification of the Police, were all updated. All Staff were inserviced on the new policy.
3. All residents are assessed upon admission for elopement risk. Any resident meeting criteria for being at risk will be given a wanderguard bracelet. Their photo will also be circulated to all Units and kept at the front desk and updated as needed.
IV. Monitoring of Systems
1. An audit tool has been created to reflect the results of the daily checks on all Wanderguard bracelets currently in use by residents. The results of these audits will be presented by the Director of Nursing/Designee on a quarterly basis to the QAPI team for one year
2. The Maintenance Department has created an audit tool to reflect the results of the daily checks of the door alarms being made three times per day between the Maintenance Department and the Security Officer. The Director of Maintenance will present the results of these audits on a quarterly basis to the QAPI team for one year.
V. People responsible and Date of Correction
The People responsible are the Directors of Nursing and Maintenance and the Date of Correction is (MONTH) 31, (YEAR).