Huntington Hills Center for Health and Rehabilitation
August 14, 2018 Complaint Survey

Standard Health Citations


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: August 14, 2018
Corrected date: September 28, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F 689 D [MEDICAL CONDITION] Hills Based on observation, interviews and record review during an abbreviated survey (Complaint Number NY 362), the facility did not ensure adequate supervision for one of three residents reviewed for elopement (Resident #1). Specifically, Resident #1 was assessed with [REDACTED]. On [DATE], the resident exited the building through the main entrance door undetected by the facility staff. He was found sitting on the sidewalk outside the facility's main entrance door near his wheel chair. The exit door did not alarm. Upon assessment by the Registered Nurse (RN) the resident complained of pain to his left arm. Subsequently, the resident was diagnosed with [REDACTED]. The findings were: The facility policy and procedure titled Elopement dated (MONTH) (YEAR), documented all residents would be accounted for at all times and Certified Nursing Assistants would check on all residents on their assignment when they came on their shift and again at meal times and when care was to be provided. On admission/readmission all residents would have an identification photo visible in the Electronic Medical Record (EMR). As means of prevention photos of residents that have been identified at high risk for elopement would be posted at the front reception desk. The facility policy and procedure titled Wanderguard dated ,[DATE] documented the Licensed Nurse was responsible to check the placement of the wander guard every shift and the night supervisor was responsible for ensuring transmitter testing was conducted nightly. Resident#1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS- an assessment tool) dated [DATE] documented moderately impaired cognition for Resident#1. The resident required extensive assistance of one person for locomotion on and off the unit and extensive assistance of two persons for transfers. The resident utilized a manual wheelchair for locomotion. No impairment for the upper extremities including shoulder, elbow, wrist and hands. The Order Summary Report (Physician orders) for Resident #1 dated [DATE] documented to check location of the wander guard to right lower extremity (RLE) every shift. The Occupational Therapy (OT) evaluation and plan of treatment dated [DATE] documented both upper extremities range of motion was within functional limits for the resident. The elopement risk evaluation dated [DATE] documented the resident was an elopement risk related to wandering and a wander alert device was placed on the resident. The Comprehensive Care Plan (CCP) titled elopement risk dated [DATE] documented the resident wandered. Wander guard to the RLE. The CCP was updated on [DATE] and documented the resident was found on floor by entrance of the facility, no injuries noted. Wander guard was replaced immediately. The Equipment Readings Log Sheet dated [DATE] at 6:15AM documented the Main entrance door and the wander guard for the resident were checked as a routine check on [DATE] (prior to the incident) and were found to be functioning appropriately. The wader guard testing roster dated [DATE] documented the night nurse initialed that all wander guards were checked and functioning including the resident's wander guard. The Nursing Progress Note (NPN) dated [DATE] at 20:03 and facility accident report dated [DATE] documented that, at 6:15 PM, the Concierge alerted the Supervisor that Resident #1 fell outside the main entrance. The resident was found outside the main entrance by the sidewalk sitting on his buttocks in front of the wheelchair. The resident stated he followed his wife outside the main entrance and he slid out of the chair on his butt. He did not hit his head. Body check completed, and no injuries observed. Upon range of motion to all extremities the resident complained of left upper extremity pain. The Nurse Practitioner (NP) ordered x-ray of the left upper extremity. A new wander guard was placed on the residents' right ankle. Tylenol given, ice pack applied with mild effect, MD aware. Telephone order to give [MEDICATION NAME] 5 mg (pain medication) one dose. Left elbow noted with small excoriation, site cleaned, bandage applied. The facility's summary of investigation dated [DATE] documented the resident was found by a visitor sitting on his buttock, next to the wheelchair, by the entrance of the building by the sidewalk. The security doors did not alarm, the resident wheeled himself past the front doors and outside on the sidewalk. The left wheel of the wheelchair came off the curb and the resident suddenly fell over to the left side and out of his wheelchair. The facility concluded that this incident was a failure of the wander guard to activate the alarm at the door due to the battery dying. The facility lacked documented evidence of a signed education attendance record related to prevention of unsafe wandering and wander guard/door alarms for receptionist #27 and the concierge. The Radiology report dated [DATE] at 20:14 documented no evidence of fracture or dislocation, left humerus no fracture or dislocation. The NPN dated [DATE] at 12:07 documented X-ray showed no evidence of fracture or dislocation. Abrasion to left elbow noted, no complaints of pain upon assessment. The NPN dated [DATE] at 14:54 documented the family requested hospital evaluation. The resident was transferred to the hospital emergency room for evaluation for left arm pain secondary to fall. The NPN dated [DATE] at 00:47 documented the resident returned to unit at midnight from the hospital with a sling to left arm. The Medical Progress Note dated [DATE] documented resident seen for follow up status [REDACTED]. The hospital MRI dated [DATE] of the left shoulder documented a full thickness full width shoulder muscle tear with retraction; a full thickness biceps tendon tear with retraction and the deltoid muscle contusion (bruising). The NPN dated [DATE], [DATE] and [DATE] documented resident complained of mild discomfort to the left, sling remains in place. Administrator #8 was interviewed on [DATE] at 9:30 AM and stated the wander guard alarm did not sound because the resident's wander guard battery failed (died ). The reason for the wander guard system was to keep residents from getting out of the facility. The receptionist and the concierge were retrained to visually check the door at all times, to ensure no resident leaves the facility. The Administrator stated If the main door would have alarmed the receptionist and or the concierge would have gone to the front door to investigate the audible sounding wander guard alarm. The alarm did not sound, and the resident was then found outside. The Concierge #14 was interviewed on [DATE] at 4:03 PM and she stated she was on duty on [DATE] and recalled the resident. She was trained to observe the facility front door. She did not see Resident #1 wheel himself out of the building, she was not at her desk and had notified receptionist#15 that she left her desk and went to the admissions office. When she returned she did not get any report that Resident #1 left the facility. At times Concierge #14 sat at her desk and performed other function such as clothing inventory and may not see who goes in and out of the facility. On [DATE] a visitor came to her at approximately 5:00PM and said somebody was outside on the ground. Resident #1 was sitting on the floor and the wheelchair was next to him. He had a wander guard on his ankle. She did not see Resident #1 in the lobby or at the front door on [DATE] prior to the incident. The wander guard alarm was working for other residents and she was not sure why the wander guard did not trigger for Resident #1. The RN (Registered Nurse) Supervisor #16 was interviewed on [DATE] at 4:42PM, and the RN stated she was on duty [DATE]. At 6:15 PM she was called by Concierge #14 who reported the resident fell outside the facility. The RN was unsure if the wander guard alarmed when the resident was brought back in to the facility after the incident. The Licensed Practical Nurse (LPN) #18 was interviewed on [DATE] at 5:20 PM, and stated she was on duty on [DATE] and the LPN stated when she came on duty she made rounds and she saw the resident in his room in wheelchair and wife present and the resident was wearing his wander guard on his ankle. The Maintenance Supervisor (MS)#21 was interviewed on [DATE] at 10:31AM and stated the wander guard monitoring system was checked twice a day by the maintenance department. If a resident with a wander guard approached the lobby front door area, the inside doors would close, and if the door is opened then the alarm would sound. On [DATE] the front door wander guard system was checked and was functioning. After the incident the doors were checked again, and no issues were identified with the wander guard system. The Receptionist #27 was interviewed on [DATE] at 12:15PM, and stated she was on duty on [DATE] from 5:00PM-8:30PM, there was concerige#14 also present. She was trained to observe the facility front door. On [DATE] she did not see Resident #1 go out of the facility. The wander guard alarm did not sound at any time that evening. The admission office closed at 5:00 PM and the Receptionist #27 performed the functions of the admitting office. If any resident was being admitted he/she would be brought to the front desk for admission. Receptionist #27 was then responsible to obtain information such as paper work, she calls the unit, takes a photo and then the resident is directed to the unit. She did not recall if any new residents were admitted to the facility on [DATE] after 5:00 PM. She was at the front desk and people (could not recall who) were standing at the front desk. Receptionist #27 did not clearly remember what she was doing at the time the resident left the facility. There was a book at the front desk that had pictures of the residents identified to be at risk for elopement. The receptionist did not look in the book and was not sure if the resident's picture was in the book. The Medical Doctor (MD) # 29 was interviewed by phone on [DATE] at 2:44 PM and stated the resident had no complaints of shoulder pain when he was admitted . MD #29 stated the resident complained of shoulder pain and had an MRI of the left shoulder that showed a partial tear, but it was not possible to state if the tear was a new or old problem for the resident. 415.12(h)(1)

Plan of Correction: ApprovedSeptember 13, 2018

1. What corrective action will be accomplished for those residents found to have been affected by the deficient practice.
Resident #1 had wander guard changed after incident. Resident #1 wander guard verified in place daily per policy. No recurrence following issuance of new wander guard. Resident #1 discharged home on[DATE].
2. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken.
Because of failure of 1 wander guard in Resident #1 incident, all residents with wander guards were identified to be at risk for similar, although unlikely, incident. All existing wander guards were replaced with new models that indicate expiration date of each device on each device. Each device will be replaced at individual expiration date. Each shift, every day, the unit nurse on that shift verifies the wander guard is in place on each resident on that unit. This X3 daily check is documented in the resident's T.A.R. Each night, the Nursing Supervisor verifies the function of each wander guard device using a monthly record for each resident which includes resident name, wander guard number, and proper function. Proper function is verified by using a testing device supplied by manufacturer. Policy has been updated to reflect this testing and logging procedure. All unit licensed staff will be inserviced on wander guard policies by 9/28/18.
3. What measures will be put in place or what systemic changes will you make to ensure the deficient practice does not recur.
The wander guard system has 2 separate components; the sensor at the front door and the individual wander guards.
-Plant Operations preventive maintenance rounds include testing of the front door sensor twice daily. Proper function is noted on their daily records and maintained in the Plant Operations office. If malfunction is detected, inspecting staff will initiate repairs necessary, or seek assistance from supervisor.
-Noted in #2 above, all wander guards were changed to newer models after this incident. Nursing Supervisor checks each wander guard daily in the PM and records name, number, testing and function. The record is maintained in the Nursing Supervisor's office. Licensed staff checks placement of wander guard every shift and documents on TAR.
-Staff in front lobby area, (Receptionists, Concierge, Administrator, Administrative Assistant, and Admissions staff), have been re-inserviced on being aware of wander risk residents' photos at front reception desk, to watch for residents approaching the front doors, and to check wander-risk resident photos at the start of each shift. Staff will approach any resident who is attempting to leave, unattended, via the front door. In-service document will be signed by the lobby staff and maintained in Administration.
4. How the corrective actions will be monitored to ensure deficient practice will not occur.
Plant Operations will submit a monthly summary of front door sensor system operation to monthly QAPI meeting, via Administrator, for 3 months. If any malfunction has been discerned, problem will be rectified by Plant Operations staff and problem and remedy will be noted on the monthly report. Nursing will submit monthly PM check record to monthly QAPI meeting, via DNS, for 3 months. Any problems or malfunctions and remedy will be noted. Reception and Concierge staff will sign for review of potential wandering residents photos daily. Log will be submitted to Administrator weekly for 3 months.
5. The date for correction and the title of the person responsible for correction of each deficiency.
Person responsible: DNS
Date: 09/28/2018