St Patricks Home
November 14, 2016 Complaint Survey

Standard Health Citations

FF09 483.25(h):FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES

REGULATION: The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents.

Scope: Isolated
Severity: Actual harm has occurred
Citation date: November 14, 2016
Corrected date: November 15, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review conducted during an abbreviated survey, the facility did not provide proper supervision to ensure resident health and safety. Specifically, the facility did not respond appropriately to a door alarm. This was evident for 1 of 3 residents sampled for Quality of Care/Treatment (Resident #1). Resident #1 sustained multiple fractures, laceration and a hematoma, after opening and passing through an alarmed staircase door and subsequently falling down a flight of stairs (10 steps) in her wheelchair. Resident #1 was in the stairwell approximately 1 hour before being found by staff. Complaint # NY 706 The findings include: Resident #1 is an [AGE] year-old female, who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] identified Resident #1 with intact cognition. In addition, Resident #1 requires extensive assistance in all aspects of care. Section G of the MDS documented that Resident #1 requires extensive assistance of one person for walking in corridor and locomotion on unit. On 08/23/2016 at 11:00AM, Surveyor #1 and the Director of Communication/Security (D(NAME)S) viewed the facility's video surveillance camera of the 8th floor dated 08/19/2016. The surveillance camera showed Resident #1 self-propelling the wheelchair in the direction of stairwell C. No staff members or other residents were noted in the corridor. Resident #1 opened the door to stairwell C on the 8th floor at 6:42PM and passed through to stairwell landing. The door took approximately 10-11 seconds to close. (The D(NAME)S stated that the camera time stamped was off by 1 hour and 15 minutes. The actual recording time was approximately 7:53PM-8:00PM). Within a few seconds after the door was closed, Certified Nursing Assistant #1 (CNA#1), could be seen looking in the direction of stairwell C from the doorway of a resident room. As CNA #1 was looking in the direction of stairwell C, 14 seconds later, a resident in a wheelchair was seen coming out of the room that was next to stairwell C. CNA #1 walked in the direction of the resident, but did not go to the door of stairwell C. The surveillance camera showed CNA #2 coming out of a room and walked in the direction opposite of stairwell C. At no time did CNA #2 check the exit door at stairwell C. The security guard was seen on camera walking towards stairwell C exit door. As he approached the door of stairwell C, he looked through the glass window panel of the door. At no time did the security guard open the exit door at stairwell C. A nurse's note written by RN #1 on 08/19/2016 at 11:10PM, documented that while she was in the process of medication pass, CNA #2 approached her and informed her that Resident #1 was missing. The writer documented that she searched the high side of the floor and that she called the security guard at approximately 8:30PM to get further instructions on missing resident. The note documented that the security guard instructed the writer to thoroughly search. The writer documented that she checked the low side of the unit. No stairwell alarm heard at that time. The writer told the security guard to call 'Dr. Yellow' (missing resident) and connect her with the supervisor.The supervisor instructed the writer to search the floors then 'Dr. Yellow' was called. The writer further documented that as she went back to the floor, she heard an aide call out that Resident #1 was found in the stairwell. The writer went to the stairwell and stayed with Resident #1. The supervisor (RNS #2) immediately arrived. Resident #1 was observed lying on the landing of the stairwell between the 8th and 7th floor on her left side with the wheelchair rolled to the side. A small amount of blood was observed on the floor. RNS #2 called for cool compress and Normal Saline. Hematoma and laceration with depth that was unable to assess due to hair on left parietal side of the head. Tylenol 650mg was given for pain as evidenced by facial grimacing. More help was called to assist resident out of stairwell with the use of a full length backboard and the assist of eight staff. Resident #1 was placed in bed and the supervisor called the Emergency Medical Service (EMS). A nurse's note written by RNS #2 on 08/19/2016 at 9:24PM, documented that she received a call at 9:00PM from the nurse on the unit (RN #1), who stated that Resident #1 has been missing for a while and a thorough search already been done by staff without success. Writer came to unit and assisted in search for Resident #1 without success. Writer instructed security to initiate 'Dr. Yellow' for missing resident. While staff were already responding to 'Dr. Yellow,' received a call from staff, come quickly Resident #1 on stairway. Found Resident #1 lying on her left side on the floor at the bottom of stairwell C on the 8th floor with her wheelchair rolled next to her. Resident #1 was alert and responsive with confusion. No change in mental status. Noted moderate amount of bleeding to left parietal. Pressure dressing applied with cold compress with effect. Noted facial grimacing upon palpation to left parietal and left shoulder. Tylenol 650 mg by mouth given with effect. Resident assisted off the floor with the assistance of eight staff using first aid body board to transfer to bed. Body assessment done. Hematoma with laceration with depth to left parietal. Unable to assess laceration due to hair. 911 called arrived at 10:00AM (10:00PM not 10:00AM) and Resident #1 was transferred to the hospital. Review of the Facility's Internal Investigation, revealed that on 08/19/2016 at approximately 9:15 - 9:20PM, Resident #1 was found on the stairwell landing between the 8th and 7th floor. Resident #1 is wheelchair bound, went through the exit door (stairwell C) and fell down the stairs. Stairwell C is alarmed. The alarm did sound but was ignored by staff who heard it go off. The investigation also documented that after CNA #2 was unable to find Resident #1, she informed RN #1 and a coworker. Staff began searching. The supervisor (RNS #2) was notified and 'Dr. Yellow' was announced. They searched for some time, she then went back to the unit and a resident told her (CNA #2) that she thought somebody in a wheelchair went through the door. CNA #2 said she then went through the door (stairwell C) where she found Resident #1 lying on the landing next to her wheelchair. CNA #2 said she then screamed out to alert staff that she found Resident #1. Investigation concluded that CNA #1 and CNA #2 failure to respond to alarm did result in resident's injury. This was negligence on their part. Review of the nurse's progress note dated 08/23/2016, revealed that Resident #1 was readmitted from the hospital at 8:00PM. [DIAGNOSES REDACTED]. Noted with dry cut on the top of left of head with 4 staples. Complained of pain when move in bed. On Tylenol 650mg every 6 hours. Vital signs temperature 97.0, Pulse 74, Respiration 18, Blood Pressure 120/64. Also noted, Resident #1 on oxygen 2L/ML via nasal cannula. Oxygen saturation 99%. No distress noted. The hospital document dated 08/23/2016 documented the following: Scalp Laceration, left Pneumothorax (PTX) - trace bubble, Left Hemothorax (HTX)- trace, Left Clavicle Fracture, Left 6 Rib Fractures - #1,2,4,5,7 & 8. Resident admitted to Intensive Care Unit (ICU) also on pain management. Review of the hospital discharge medications revealed that Resident #1 received and was discharged on the following medications: [REDACTED]. The Doctor's Order Summary Report dated 08/23/2016 documented Acetaminophen Tablet 325mg give 2 tablet by mouth every 5 hours for chronic pai[DIAGNOSES REDACTED] and Lidocaine Patch 5% apply to left rib cage topically every 12 hours related to chronic pai[DIAGNOSES REDACTED]. The Medication Administration Record (MAR) of 08/24/2016, documented that Resident #1 started on Lidocaine Patch 5% to left rib cage topically in AM and removed at bedtime and Acetaminophen Tablet 325 mg give 2 tablet by mouth every 5 hours . The Acetaminophen Tablet 325mg was discontinued on 08/26/2016. The Physician Examination assessment dated [DATE] at 12:03 PM, documented that Resident #1 was status [REDACTED]. No new complaints. Pain controlled. The documentation further revealed that Resident #1 was assessed for pain and was on Lidoderm Patch. On 08/23/2016 at 6:26PM a telephone interview was conducted with CNA #2, who worked on the 3-11 shift on 08/19/2016. She stated that after she had completed caring for all her residents, she started looking for Resident #1 and was unable to find her. She also stated that she informed RN #1 who instructed her to search again. She also stated that when they did not find Resident #1, RN #1 called the supervisor. CNA #2 was asked if she had checked the stairwell as the door alarm was activated and she replied, No, I didn't check the stairways because I don't think she could open the door. When CNA #2 was asked if she had heard the door alarm, she stated that she heard the alarm when she was in a resident room. She also stated that she could not leave the resident in the bathroom. She also stated that after she had completed caring for the resident, she saw the security guard on the unit and the alarm was not sounding. She further explained that she found Resident #1 at the end of the stairs, lying on the floor with her wheelchair next to her. In addition, she stated that she alerted others by screaming. On 08/23/2016 at 6:37PM, a telephone interview was conducted with RN #1 who was assigned to the 8th floor on the 3-11 shift on 08/19/2016. She stated that she was away from the unit for approximately 10 minutes and that she returned to the unit at approximately 8:10PM. In addition, she stated that as she was in the process of medication pass, CNA #2 approached her at approximately at 8:30PM reporting that she was unable to find Resident #1 and that she had searched for Resident #1 for approximately 5-10 minutes. RN #1 stated that she reported to the security guard and RNS #1 that Resident #1 was missing and Code Yellow was subsequently announced. She affirmed that after Resident #1 was discovered on the stairs, she became aware that the alarm on the 8th floor at stairwell C had been activated. On 08/26/2016 at 10:02AM, a telephone interview was conducted with RNS #2, who worked on the 7:00AM to 7:00PM shift on 08/19/2016. She stated that RN#1 called her to the 8th floor on 08/19/2016 at approximately 9:00PM stating that they were unable to find Resident #1. She stated that she went to the 8th floor and extended the search to other floors. She also stated that she was informed that Resident #1 was located (RNS #1 unable to recall the time) and that she should go to the 8th floor stairwell C. She stated that Resident #1 was observed lying on her left side with blood on the left side of her head and the wheelchair was next to her. Further body assessment revealed that Resident #1 sustained laceration to the left parietal with hematoma. RNS #1 also stated that Resident #1 grimaced when her left shoulder was touched and she was given pain medication. Treatment was also done and 911 was also called. On 08/23/2016 at 3:41PM, the security guard, who worked on the 3-11 shift on 08/19/2016 was interviewed. He stated that he returned from break at approximately 7:48PM and the alarm was activated on the panel between 7:51PM and 7:53PM indicating stairwell C. He stated that a call was already made to the 8th floor, but there was no answer. He stated that when he went to the 8th floor, he heard an audible alarm and went towards stairwell C. He spoke with CNA #1 asking her, who tripped the alarm and she stated, it's ok, it's the lady in the wheelchair and she is fine. He also stated that he asked the CNA if the resident was good, and she responded ok. He also stated that, based on CNA's answer, he looked through the glass panel on the door and saw no one, therefore he reset the alarm by punching in the code. He stated that he proceeded to do his rounds by starting from the roof to the basement. He asserted that he utilized the elevator stopping on each floor, only checking the functioning of the door alarms. The security guard responded to a question regarding checking the stairwells. He stated that he did not check the stairwells and that he did not check the 8th floor stairwell C as he had already done it. In a subsequent telephone interview with the security guard on 09/23/2016 at 2:10PM, he stated that when he returned to the front desk, the panel was still sounding at approximately 8:01PM. The security guard responded to a question regarding the time he received the first phone alerting that Resident #1 was missing. He stated that RN #1 called him between 8:30PM and 8:40PM informing him that Resident #1 might be missing. He asserted that he instructed RN #1 to double check the unit first before calling Code Yellow. In addition, he stated that RN #1 called him back at approximately 9:00PM informing him that they were unable to find Resident #1 and to connect her to the nursing supervisor. He stated that the supervisor came down stairs to him asking if Resident #1 was found and when he said no, she instructed him to call 'Dr. Yellow' between 9:02PM and 9:05PM. He stated that between 9:10PM and 9:15PM he received a call stating that Resident #1 was found. On 10/18/2016 at 4:25PM, a telephone interview was conducted with the receptionist. She stated that on 08/19/2016 when the door alarm was activated on the 8th floor, it showed stairway C. She stated that she made three phone calls to the unit, but that no one answered. The receptionist responded to a question regarding how long it took between the time she called the unit and the time the security went up to the 8th floor. She stated that it took approximately 5-7 minutes. On 08/23/2016 at 10:49AM, a telephone interview was conducted with CNA #1 who worked on the 3-11 shift on 08/19/2016. She stated that she was in a resident room when she heard the door alarmed. The CNA did not recall the time she heard the alarm. CNA #1 was asked if she had responded to the alarming door and she stated that she I looked through out the door from the room that she was in, but that she did not see anybody by the door. She further stated, I did not go towards the door because I could not leave the resident I was caring for in the bathroom. She also stated that she saw the security guard going towards the door and that she assumed he would take care of it. CNA #1 stated that the security never spoke to her when he came to the unit. On 08/23/2016 at 10:00AM, an interview was conducted with the Director of Nursing (DON). She stated that she was informed that Code Yellow was activated on 08/19/2016 at approximately 9:00PM. She also stated that the facility's investigation revealed that the alarm on the 8th floor at stairwell C was activated at approximately 7:45PM for 2-3 minutes. In addition, she stated that the investigation revealed that prior to Resident #1 being found lying in the stairwell on the 8th floor, the security guard, CNA #1 and CNA #2 did not report that the alarm was activated. She also stated that during her interview with the staff, CNA #2 stated that she observed Resident #1 going to the elevator on 08/19/2016 but didn't tell the nurse. When the DON was asked how staff should respond to an alarming door, she stated that staff is supposed to go and check the stairway. In a subsequent telephone interview with the DON on 09/23/2016 at 9:37AM, she stated that when the alarm is activated staff should check up and down the stairs and if staff cannot be sure no one went through the door at that time, they do headcount. The Facility's Policy and Procedure on Wandering/Elopement Risk Assessment Procedure did not mention how staff should respond to an alarming door. On 10/27/2016 at 1:15PM, a telephone interview was conducted with Resident #1's readmitting physician. He stated that he examined Resident #1 upon her return from the hospital and she was in stable condition. He further stated that she had staples to the occipital area that was dry and no treatments were ordered. He also stated that she had pain that was controlled. 415.12 (h)(1)(2)

Plan of Correction: ApprovedNovember 30, 2016

Resident #1 was re-evaluated upon re-admission from the hospital and determined to be stable both medically and psychologically. However, as an extra precautionary measure the resident was transferred to a secure unit where staff can closely monitor her movement throughout the unit. Family was advised of the proposed transfer and agreed to the re-location.
Administrative and supervisory staff met with all staff on each unit in the facility and emphasized the expectation that once an alarm is triggered staff must respond. The facility evaluated a number of environmental interventions to address potential unsafe wandering. All residents identified based on their care plans as at risk for wandering have been re-assessed and care plans updated where required.
The current Wandering Policy was reviewed and reference to checking the stairwells have been incorporated into the policy. All alarms were checked for functionality. The staff that did not follow the policy and failed to respond to the alarm when it was activated have been terminated.
For all new admissions and for all current residents any episodes of unsafe wandering or any expressions that would indicate a likelihood that the resident might elope or wander (i.e. expressing desire to leave, change in cognitive status related to wandering)will be reflected in the 24-Hour report book and will result in the current interventions being evaluated.
The facility has developed a series of comprehensive audit tools that will determine whether staff fully understands and carries out policies as required. Audits include Staff response to Alarms and Care Plans related to Wandering and Elopement.
Additionally, all supervisory staff will monitor units to ensure staff is following the care plans and to identify potential situations that impact on a culture of safety.
Audits are done weekly and all findings will be reported to the QA monthly and to the QAA quarterly.
Responsible Person: Nursing Supervisor/Designee
Date Completed: 11/15/2016