Hornell Gardens, LLC
May 1, 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: May 1, 2017
Corrected date: June 1, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews conducted during an Abbreviated Survey (complaint # NY 619) completed on 5/1/17, it was determined that for one (Resident #1) of three residents reviewed for elopement, the facility did not ensure that a resident received adequate supervision to prevent potential accidents. The issue involved lack of adequate monitoring or supervision resulting in an elopement from the building. This is evidenced by the following: Resident #1 has [DIAGNOSES REDACTED]. The Certified Nursing Assistant (CNA) Care Plan, documented on 8/8/16, that the resident is at risk for elopement (ARFE), and to follow policy and procedure. The Minimum Data Set Assessment, dated 2/23/17, revealed the resident's cognition is severely impaired. The Comprehensive Care Plan, dated 2/28/17, documented the resident wanders in her wheelchair, is an elopement risk, and is difficult to redirect at times. Interventions included discouraging the resident from lingering at the doors leading to the outside and diversionary tactics such as puzzles/games as needed. Review of the Report of Incident or Accident, dated 4/24/17, documented that at 10:45 a.m. a visitor brought the resident to the nursing unit desk and asked the Licensed Practical Nurse (LPN) if the resident was allowed outside by herself. The LPN documented that the visitor reported that a newspaper delivery person let the resident out of the building, and the resident followed her to her car in the front parking lot (about 40 feet). The Facility Investigation, dated 4/25/17, revealed that the newspaper delivery person allowed the resident outside, assuming she was looking for a visitor in the parking lot. The Summary of Review Form, dated 4/27/17, revealed that interventions had been modified and recommended safety checks every 15 minutes. The safety checks were documented as completed on 4/27/17 from 7:00 a.m. to 9:30 a.m. Interviews conducted on 4/27/17 included the following: a. At 9:15 a.m., the Director of Nursing (DON) stated that on 4/24/17, the resident was last seen at 10:40 a.m. in the lobby area by the front door. She said a visitor returned the resident to the nurses' station at 10:45 a.m. The DON said the resident was out of view of the facility staff for approximately five minutes. The DON stated that the resident had a previous elopement in (MONTH) (YEAR) when a family visitor let her out of the building. The DON stated that ARFE, as documented on the CNA resident care plan, means the resident is at risk for elopement. b. At 9:25 a.m., the Administrator agreed that the resident was out of the facility staff's view for five minutes. c. At 10:00 a.m., the receptionist stated that she was not able to see the resident between the two exit doors or exiting the building because the exit doors are not in her sight. d. At 10:05 a.m., the Charge Nurse stated that the resident was returned to the nurse's station close to 11:00 a.m. The Charge Nurse stated that no changes have been made because of this elopement except the resident is going out with her daughter more often. The Charge Nurse stated that the resident was placed on 15 minute checks immediately following the elopement on 4/24/17, however, this was not started until 4/27/17 at 7:00 a.m. The Charge Nurse said that she did not hear this intervention discussed at the 4/24/17 team meeting. e. At 10:25 a.m., CNA #1 stated she was assigned to the resident on 4/24/17 and heard about the elopement after lunch. CNA #1 stated that, after the elopement, she could not recall being directed to do anything different for the resident. CNA #1 stated that she did not have the resident that day and did not know the resident was currently on 15 minute checks. f. At 10:45 a.m., the DON stated the 15 minute checks were supposed to be initiated immediately after the 4/24/17 elopement, as recommended by the team. The DON said the checks were not done, and it was her responsibility to ensure the checks were in place. The DON said the elopement assessments are completed quarterly and the resident's assessment was due in (MONTH) (YEAR), but had not been done. Interviews conducted on 5/1/17 included the following: a. At 10:50 a.m., the Nurse Manager stated that staff are notified of a resident's elopement by the Charge Nurse. She said it is also documented on the 24-hour sheet. b. At 11:20 a.m., the DON stated that she reviewed the 24-hour sheets for 4/24/17 through 4/27/17, and there is no documention about the resident's recent elopement. (10 NYCRR 415.12(h)(2))

Plan of Correction: ApprovedMay 21, 2017

The preparation and execution of this plan of correction does not constitute admission or agreement with the facts alleged or conclusions set forth in this statement of deficiencies. This plan of correction is executed solely because it is required by provision of Federal law.
Resident #1 was placed on security checks to ensure her safety. After review by the Interdisciplinary Care Team, it was determined to be prudent to move resident #1 to the other unit to increase her safety and eliminate her access to the lobby and doors to the outside. After her move, her care plan and CNA care card were updated to reflect the move and to further monitor her behavior.
All residents who had been determined to be an elopement risk were review by the Interdisciplinary Care Team and their care plan and CNA care cards were revised where necessary. A list of all residents at risk for elopement was updated and distributed to all departments. Those residents determined to be at high risk for elopement were reviewed by the committee and, where is was felt to be prudent,were transferred to the other unit to increase their safety and to remove their access to the lobby and outside exit doors.
Facility policies and procedures for the prevention of elopement of residents at risk have been reviewed and revised as necessary. The Staff Development Coordinator and/or her designee will inservice all staff members on the Facility policy and elopement prevention procedures.
Safety measures instituted to protect the safety of all residents determined to be at risk for elopement will be audited by the Nurse Managers or their designee weekly for four weeks then monthly and then intermittently as determined by the Quality Assurance Committee after the review of the audits.
The Director of Nursing is responsible for the correction of this deficiency.