Promenade Rehabilitation and Health Care Center
May 2, 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: May 2, 2018
Corrected date: May 31, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review conducted during an abbreviated survey (NY 269), the facility did not ensure that a resident under its care and responsibility received adequate supervision to prevent elopement. This was evident for 1 out of 4 residents reviewed (Resident #1). Specifically, Resident #1, who was at risk for elopement, was escorted to a clinic appointment at the hospital on [DATE] where she eloped. Resident #1 was found and brought back to the facility on [DATE]. The findings include: An undated facility's Policy and Procedure titled CNA-HHA-Transporter/Escort which documented that any Escort assigned to accompany a resident to a clinic visit is to ensure that they keep the resident at arm's length at all times, except while supervised by a staff member of the health care organization the resident is attending. They are also to ensure that they did not leave the resident unless directly relieved by a staff member of the health care organization the resident is attending. An undated Escort Policy and Procedure which documented that the assigned Escort will receive report from the licensed nurse who is caring for the resident, and collect the required document placed in an envelope and carry with the resident to appointment. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS 3.0, an assessment tool) dated 03/14/2018, documented that a brief interview for Mental Status (BIMS) was conducted and scored 8 out of 15 which identified Resident #1's cognitive ability for daily decision making as Moderately Impaired (where 00-07 is severely impaired; 07-12 is moderate impairment and 13-15 is cognitively intact) with long/short term memory problems. A Comprehensive care plan (CCP) dated 03/07/2018, documented that Resident #1 will not have any episode of elopement within 90days. The care plan specifically documented that Resident #1 should be redirected as needed whenever she made any attempt to elope. A hospital security camera recording dated 3/27/2018, revealed that the assigned Escort was distracted and did not supervise Resident #1 closely while they were both in the lobby area of the hospital. A facility's in-house investigation report dated 4/2/2018, documented that the assigned Escort was negligent in her supervisory conduct during the clinic visit on 03/27/2018. The report also documented that prior to the elopement, the assigned Escort had on two separate occasions on 03/27/2018 left Resident #1 unattended. The assigned Escort went out of the hospital building for a total of approximately 10 Minutes, leaving Resident #1 by herself. Resident #1's assigned Escort was interviewed on 3/29/2018 at 2:35PM. She stated that prior to leaving the facility for the clinic appointment, the Licensed Practical Nurse (LPN) on duty at the time did not give her a formal report about Resident #1. She stated that she was given an envelope to take with Resident #1 to the clinic appointment and that the envelope contained the Escort Check List that she was supposed to fill out in the facility before leaving for the clinic appointment. She stated that she never filled out the Escort Check List before leaving the facility because no one ever informed her that she needed to do so. She stated that what happened on 3/27/2018 was that after the consult visit was over, she and Resident #1 went down to the lobby area to wait for their transportation. She stated that while in the lobby area, she left Resident #1 unsupervised for approximately 5 Minutes and went out of the hospital building to buy Donuts. She stated that she was sitting next to Resident #1when she decided to use her phone to check on their transportation arrival time. She stated that at that point, Resident #1 got up to get rid of her trash in the garbage bin close by. She stated that suddenly, she missed the resident and started searching for her. She stated that she called the facility and in her panicky state told facility staff that she had handed over Resident #1 to an unidentified hospital nurse to assist the resident to use the bathroom. She stated that because Resident #1 had wander guard in use she knew it was for elopement risk but never thought that the resident would elope. She stated that no one told her Resident #1 had dementia and had she known, she would not have left the resident by herself alone for any length of time. She also stated that she was never formally in-serviced by the facility with respect to her escort duties and elopement prevention. Her signature was on the attendance sheets because she was present during the in-services but left early to accompany a resident to clinic appointment. The LPN was interviewed on 03/29/2018 at 4:27PM, and stated that she informed the assigned Escort that she needed to watch Resident #1 closely. She further stated that she did not specifically tell the assigned Escort that Resident #1 was at Risk for elopement. She stated that she gave the assigned Escort the clinic visit envelope which included an escort check list that was supposed to be filled out by the assigned Escort in the facility before leaving for the clinic appointment. She stated that she did not see the Escort filling out the check list. She stated that the act of filling out the check list provided Escorts the opportunity to reconfirm their awareness of the resident status. The Assistant Director of Nursing (ADNS) was interviewed on 03/29/2018 at 12:52PM and stated that she reviewed the hospital's security camera recording and noticed that the assigned Escort was distracted and not attending to Resident #1 when she eloped. The Director of Nursing (DNS) was interviewed on 05/02/2018 at 1:30PM. She stated that facility's Policy is that any Escort going out on Clinic assignment with a resident is given a report by the nurse on duty at the time and an envelope that contains a Consult Form with all the pertinent information about the clinic visit and an Escort Check List. She further stated that the Escort must sign the Escort Check List in the facility before leaving and that the Escort's signature in the Check List validates that the resident's needs and special instructions were explained by the nurse on duty and understood. The facility Escort Policy did not document that the Escort must sign the Escort Check List in the facility before leaving the facility. 415.12(h)(2)

Plan of Correction: ApprovedMay 16, 2018

I. Immediate Corrections: Res. #1
1. The Facility did a complete and thorough investigation relative to the elopement of Res #1 from Wycoff Hospital. Based on the investigation the following actions were taken:
a. The Police were immediately notified
b. The residents family was notified
c. The Escort was interviewed regarding the elopement
d. The Hospital camera was reviewed
2. Based on the investigative findings it was identified that the Escort did not follow Facility Policy for maintaining the safety of the resident. Subsequently, the Escort was terminated from the Facility.
3. The LPN who failed to complete the escort checklist for res#1 was counseled by the DNS. A copy of the counseling was retained for validation.
4. The Resident returned to the facility on (MONTH) 1. The Attending Physician evaluated the Resident.
II. Identification of Other Residents:
1. The DNS and or RN supervisors have checked all residents that have gone out for clinic appointments to ensure that the Escort Checklist was in place and fully implemented.
2. There were no quality issues from this review and same remains ongoing.
III. Systemic Changes
1.The DNS has revised the Escort Checklist to include validating signatures that the list was reviewed with the escort. Both the Nurse and the Escort must sign the checklist to ensure that care plan directives are reviewed with the escort, and understood to ensure safety of the residents
2.A copy of the checklist will be sent with the escort and signed upon return and kept in the medical record for validation.
3. All licensed Nurses and CNAs/Escorts have been inserviced on the revised Escort Checklist by the DNS. A copy of the attendance has been retained for validation.
4. Any resident scheduled to go out of the Facility with an escort will be entered on the 24 hr report and discussed at the morning meeting.
IV. QA Monitoring:
1. The DNS has developed an audit Checklist Log tool to track that the Escort Checklist is being reviewed with the escort prior to any resident leaving the Facility.
2. Each unit will maintain a Audit Checklist Log and the resident and escort information will be entered into the Log by the Charge Nurse to validate that the checklist was documented, reviewed and provided to the Escort.
3. The Log will be reviewed by the DNS/RN supervisor daily when noted resident had an outside appointment scheduled.
4. Any quality issues identified will have onsite corrective actions by the DNS or RN supervisor for compliance.
5.Audit findings will be reviewed at QA quarterly meetings for follow up and evaluation as indicated.