The Plaza Rehab and Nursing Center
January 24, 2019 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: January 24, 2019
Corrected date: March 27, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review conducted during an abbreviated survey (NY 011), the facility did not prevent a resident from eloping the facility. This was evident in 1 out 3 residents sampled for elopement (Resident #1). Specifically, on 01/04/2019 at 3:21 AM, Resident #1 walked out of the facility through the back loading-dock door undetected by staff. Staff discovered that Resident #1 was missing around 4:00 AM. The Hospital notified the facility on 01/04/2019 at 11:35 PM, that Resident #1 was in the emergency room (RM). Findings: The Facility's Policy and Procedure on Elopement and Unsafe Wandering initiated on 12/27/2016 and revised on 08/28/2018, documented that all residents will be assessed on admission, readmission, and return from the hospital to determine their level of risk of elopement/unsafe wandering. All residents will be routinely assessed quarterly and after actual elopement occurs. A resident is determined to be at risk with a score of 3 negative responses or the team believes the resident is at risk even with a low score. An Elopement occurs when a resident leaves the premises or a safe area without authorization (an order for [REDACTED]. Review of the Security Guard's Job Description with revised date of 05/2018, revealed that the Security Guard's essential job function included performing access control duties for the facility, understanding/operating the wander guard system; notifying the departments of concerns; providing direction; monitoring the closed-circuit television system and responding to security alarm conditions. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, an assessment tool) dated 11/10/2018, documented that Resident #1 had a Brief Interview for Mental Status (BIMS, used to determine attention, orientation and ability to recall information) score of 0/15, associated with severe impairment of cognition (00-7 severe impairment, 08-12 moderate impairment and 13-15 cognitively intact). Resident #1 required supervision of one staff with locomotion on and off the unit. Review of the Falls Hourly Monitoring sheet from 11/04/2018 through 01/04/2019, revealed that Resident #1 was on hourly monitoring and was last seen in the facility on 01/04/2019 at 3:00 AM, awake in her room. Review of the Security Guard Supervisor's log dated 01/04/2019, revealed that on 01/04/2019 at 3:21 AM, the loading dock door alarm was activated and was disarmed at 3:21 AM. Surveyor #1; Surveyor #2; the facility's Administrator and Director of Nursing Services (DNS) reviewed the facility's surveillance camera of the elopement on 01/07/2019. The camera revealed that on 01/04/2019 at 3:10 AM, Resident #1 was seen on the unit entering the elevator that was located on the left side of the nursing station. Resident #1 exited the elevator at 3:37 AM on the first floor (lobby) of the East building and walked towards the double doors that lead to the back-loading dock. Resident #1 pushed opened the double doors and exited to the loading dock at 3:38 AM (time discrepancy of 17 minutes ahead displayed on the camera confirmed by the DNS and the Administrator). At 3:41 AM, Resident #1 reentered the facility through the front lobby (where SO #1 was posted) and interacted with SO #1. At 3:43 AM, Resident #1 was seen exiting the lobby. Review of the Nurse's Progress Note dated 01/04/2019, revealed that the staff was unable to locate Resident #1 and the Registered Nurse (RN) was informed at 4:30 AM. Security was also notified. Review of the Nurse's Progress Note dated 01/05/2019 at 12:39 AM, revealed that the facility administration was notified that Resident #1 was brought to the Hospital by the Emergency Medical Services (EMS) for disorientation. The nurse's note at 12:53 PM documented that the RN called the Hospital to ascertain the resident's disposition and was told that the resident was discharged with a family member. Review of the Emergency Department (ED) Medical Doctor's (MD) note dated 01/05/2019 at 1:00 AM, documented that Resident #1's primary [DIAGNOSES REDACTED]. Resident #1 was found confused in a coffee shop. Security Officer #1 (SO #1) was interviewed on 01/08/2019 at 3:00 PM and stated that he was stationed at the East Desk Lobby during the time Resident #1 eloped from the facility. His responsibilities included controlling entrances; sign visitors in/out; direct visitors to the right floor; and sign out Residents. On 01/04/2019 around 3:00 or 4:00 AM (does not recall exact time) the back-loading dock door alarm was triggered, and he disarmed the alarm without radioing the relief SO to check the location of the alarm that was triggered. A female came into the lobby through the front door and told him that she was visiting with her niece or nephew (not sure) and that she was going to get something to eat and he let the female out of the building. CNA #1 was interviewed on 01/08/2019 at 2:11 PM and stated that she was assigned to Resident #1 when the resident eloped from the facility. She said that she last saw the resident in her room awake talking with the roommate at 3:00 AM. She went on her break and when she returned at approximately 4:00 AM, the Charge Nurse informed her that Resident #1 was missing. RN #2 was interviewed on 01/11/2019 at 12:33 PM and stated that she last saw Resident #1 at approximately 3:00 AM. The resident was in her room sitting up in bed awake chatting with her roommate. She was at the nurse's station and did not see when Resident #1 entered the elevator. At 3:40 AM, CNA #2 returned from her break and a few minutes later (not sure of time), the CNA informed her that she was unable to find Resident #1. RN #2 instructed the staff to search the unit, and she informed the Supervisor at around 4:00 AM (not sure of time) that the resident cannot be found in the unit. The DNS was interviewed on 01/08/2019 at 4:00 PM and stated that there was no deviation from the resident plan of care. The staff searched the unit and alerted the security when they were unable to locate the resident. The security officer did not follow the protocol. He disarmed the system that was in place to prevent exit and did not follow the training and protocol. 415.12 (h) (1)

Plan of Correction: ApprovedFebruary 25, 2019

F689: Free of accidents/ devices/ supervisor/ devices

I. Plan of correction for affected residents
- Resident # 1 located and transferred to the hospital for further evaluation, she was released without admission and discharged home with family.
- Security officer # 1 terminated.
II. Plan to identify other residents potentially affected by this deficiency
- Elopement risk assessments conducted on all residents and plan of care reviewed and revised accordingly.
III. System changes and measures to prevent recurrence
- All staff re-educated on Elopement policy.
- Security re-education on elopement prevention, code orange, dementia tips and alarm activation's and response.
- Security staff re-educated to notify nursing supervisor after midnight of all visitors.
- Facility implemented elopement drills monthly x 3 then quarterly.
- Policy and procedure reviewed and revised to include assessment upon significant change in condition.
- Elopement risk identifier revised, binder with identified at risk residents kept at security desk. Picture of resident triggering alarm displayed on security computer
-IDT team will review residents that trigger for elopement at weekly Risk management meeting.
IV. Plan to monitor effectiveness of corrective actions
- Audit elopement assessments for timeliness and accuracy weekly x 4 and then monthly x 3.
- Results of elopement drill findings will be report to QAPI committee for review and recommendation monthly.
Director of Nursing/ Designee will be responsible for monitoring compliance.