cms_WV: 8715
Data source: Big Local News · About: big-local-datasette
| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 8715 | PIERPONT CENTER AT FAIRMONT CAMPUS | 515155 | 1543 COUNTRY CLUB ROAD | FAIRMONT | WV | 26554 | 2013-04-29 | 323 | G | 1 | 0 | LRUF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon observation, medical record review, review of the facility's abuse and reporting information, review of staff in-services, and staff interview, the facility failed to ensure the resident environment remained as free from accident hazards as possible for two (2) of two (2) residents reviewed for safety issues, in a facility sample of fourteen (14). The facility failed to ensure Resident #98 received adequate supervision and assistance devices to prevent accidents. The facility failed to monitor this resident who eloped, and sustained injuries during the elopement. His whereabouts were unknown for an hour, until notified by emergency responders, that he was found and was undergoing emergency treatment. In addition, the facility failed to repair a damaged wall which Resident #42 may have been ingesting. Resident identifiers: #98 and #42. Facility census: 95. Findings include: a) Resident #98 Medical record review revealed Resident #98 was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. According to the facility's abuse/neglect reporting information, reviewed on 04/22/13 at 10:07 a.m., this resident eloped from the facility on 04/09/13. During the survey, an investigation of exit doors was conducted as to their design, their function, the types in use, and their maintenance and testing. Review of maintenance logs and tests, on 04/23/13 at 2:30 p.m., found no documented concerns to suggest there was a malfunction on the afternoon of 04/09/13. There were three (3) doors designed to automatically lock when approached by a resident wearing a WanderGuard device, such as the one ordered for Resident #98. In addition, if a resident wearing a WanderGuard followed someone out an already opened door, an audible alarm sounded. These doors were at the main entrance, a door leading outside from the main dining room, and a door that was located on the hallway toward the assisted living unit, where staff exited to the outside to smoke. If the WanderGuard was not in place, was not functioning, and/or the doors were disarmed, Resident #98 could have exited, without being noticed, any of the three (3) doors designed for automatic locking. All the remaining doors, when armed, were of the type that required one to push the panic bar type of release, wait fifteen (15) seconds, and the door would open, whether or not one was wearing a WanderGuard. A loud audible alarm sounded as soon as the bar was touched, and did not stop until reset by a key pad. If one went out these doors, he/she could not get back inside unless someone reset the door from the inside. The resident's closed medical record was reviewed, beginning on 04/23/13 at 4:10 p.m. Prior to the elopement incident, Resident #98's care plan included a focus item for the risk of elopement due to dementia and cognitive loss. One of the interventions was to utilize and monitor the resident's security bracelet according to protocol. His care plan indicated he could ambulate independently. Review of physician's orders [REDACTED]. The treatment administration record (TAR) indicated the placement of his WanderGuard was not checked by the assigned nurse on the day shift or the afternoon shift of 04/09/13, the date of the elopement. Restorative nursing documentation contained documentation of weekly checks to ensure the units were operating and batteries were sufficiently charged. Such a check was documented for Resident #98 on 04/09/13. Also contained in this restorative information was a hand written note stating (as written): (Resident #98) document on cutting wander guards off. A second handwritten note stated (as written): Cuts wander guard off Hosp 3/14 Multiple recordings in the incident report, the facility's investigation, and nurses' notes concerning the elopement stated the WanderGuard was in place. The incident report completed by a former registered nurse (RN), Employee #196, stated (typed as written): (local rescue squad) called to inform us that the resident was discovered. Wanderguard was in place to left ankle. A nurse's note, also by Employee #196, dated 04/09/13 at 4:54 p.m., stated (typed as written): Resident exited the facility by himself, UTD time of elopement. He was discovered at (local country club). Facility was called at 1500 by (local rescue squad). Was informed by staff at the field club that the resident had fallen and was found in the golfing area by two golfers. the golfers placed the resident on their golf cart and took him to the office. This nurse went to visualize the resident and his current status. Resident was noted to be lying on the stretcher, verbal and confused. Emergency treatment was provided by (local rescue squad). Transported to (local acute care hospital) by (local rescue squad). (Name) MPOA, was called at 15:15. Wanderguard was noted to be in place to the left ankle. Medical record review revealed a summary of the situation completed by the social worker, Employee #37 (typed as written): At approximately 3:00 pm on 4/9/13, it was reported that (Resident #98) had eloped from the facility and was found by golfers at the (local golf club) down the road. He was found lying on the ground, and (Local Rescue Squad) was called and notified the facility upon recognizing the resident. It was reported that his wander guard was in place on his left ankle. The resident was noted as having a superficial laceration to his face and low blood sugar, but he was not seriously injured. According to staff statements, the resident was last seen at approximately 2:00 p.m. that afternoon attending an activity in the assisted living area of the facility. A band was playing from 2-3:00 pm, the time during which the resident eloped. Since his wander guard was in place and working, we can only assume that the door alarm was not heard. b) The facility's investigation regarding the resident's elopement included two (2) pertinent statements: 1) A statement from an activities staff member, Employee #56 (typed as written) included: Resident 320 Bed 2. Had come to the 2 oclock activitie music in Chessey (the assisted living unit within the facility). He stayed about 5, maybe 10 mins. Then came up back to the front 2) A statement from a registered nurse (RN), Employee #148 (typed as written) included: On April 9th 2013 at approximately 2pm, I saw and spoke with (Resident #98). He stated he was going to go take a nap because his roommate was quiet (Resident #98) walked towards his room and I went to lunch He was in his room. I did not hear any door alarms other than the aide going out for oxygen. Statement #1 and #2 call into question the social worker's conclusion that the resident exited from the assisted living unit while the band was playing and therefore, staff may not have heard the alarm. It appears just as likely the last place any staff saw the resident was in his hallway. The acute care medical record of Resident #98's emergency room visit was reviewed at the hospital on [DATE] at 8:15 a.m. These hospital medical records revealed the resident sustained [REDACTED]. During the investigation, a visit was made to the local rescue squad, on 04/25/13 at 10:30 a.m. The two (2) emergency medical technicians (EMTs) who had responded to the call were interviewed. They said Resident #98 was found lying face down on a putting area of the golf course. They said the location was about a half mile from the facility. When asked if the resident had on a Wander Guard, EMT #1 said they cut the resident's pants off, as he was wet and covered in mud, to determine the extent of his injuries. EMT #1 said he knew what a wander guard was, and Resident #98 definitely did not have one on his leg. Other information obtained during the complaint investigation gave rise to additional questions about the actual circumstances which may have provided the opportunity for Resident #98 to elope undetected by facility staff: Review of the facility's in-servicing of staff in elopement procedures and one-on-one care for Resident #98 following his elopement led to the discovery of in-servicing of staff related to the disarming and propping open of doors. An interview with the RN staff educator, Employee #59, on 04/24/13 at 1:48 p.m., found there had been concerns with staff disarming and propping open doors so they could go outside to procure portable oxygen and get back in on their own without sounding any alarms. A document was presented that showed nineteen (19) staff members still had not been in-serviced as of 04/24/13. A trip around the building confirmed there were two (2) doors used by staff to obtain oxygen. One (1) was at the end of one of the hallways in assisted living. The other was at the end of the hallway on the unit where Resident #98 resided. This doorway lead in the general direction of the country club. The elopement and the investigation were discussed with the administrator, Employee #45, on 04/26/13 at 9:40 a.m. She confirmed adequate supervision was not provided, and the resident was injured as a result. She confirmed the facility did not know where the resident was, how he eloped, or what exit was used. It was verified no one saw the resident for approximately an hour and the facility was unaware he was not in the building until called by rescue personnel. At the close of the complaint investigation, there was still no conclusive evidence regarding what happened; however, several questions were raised during the investigation as to the presence of the wander guard and the consistent, correct use of the doors in the facility. b) Resident #42 Observations of Resident #42 were made on 04/22/13 at 1:00 p.m., 04/22/13 at 4:30 p.m., 04/23/13 at 9:10 a.m., 04/23/13 at 2:00 p.m., and 04/23/13 at 3:00 p.m. Resident #42's bed was placed with one side against the wall of the room. He was always found lying on his right side with his face within a foot of the wall. There were two (2) main areas where the wall was damaged. Those areas were around four (4) inches in diameter, and the outer finished layer of the wall was gone. Toward the center, the depth of the damage increased, to include the inside of the wall itself. There were several, eighteen (18) to twenty (20) small areas where small pieces of the outer finish layer of the wall were missing and the inside of the wall material was exposed. These were roughly circular and ranged from around one fourth inch (?) to one inch (1) in width. Also noted were many marks on the wall around and through these damaged areas, that appeared to be linear scratches. These were jagged in appearance, not perfectly straight marks. All of this damage was adjacent to the area where Resident #42's face and hands were observed. He appeared debilitated, perhaps contracted, nearly in a fetal position, but was seen to be restless and moving about in his bed. Resident #42's medical record was reviewed on 04/23/13 at 9:12 a.m. He was admitted to the facility on [DATE]. He had a [DIAGNOSES REDACTED]. A goal was in place for no episodes of choking or aspiration. He was to be kept at a ninety (90) degree upright position when swallowing food or drink. The resident was also at risk for respiratory infections due to respiratory infiltrate. A registered nurse (RN), Employee #148, was interviewed on 04/23/13 at 3:15 p.m. She was asked to observe the damage to the wall in Resident #42's room. She was asked if she knew how the damage occurred. Employee #148 stated Resident #42 picked at the wall all the time. She also said the resident had been observed putting some of the pieces in his mouth. When asked if any other staff members were aware of this, she said she had spoken to the unit manager about it, and she said the two (2) of them went to the director of nursing (DON), Employee #133, either the beginning of last week, or the end of the week before and informed him of this situation. According to Employee #148, the DON said he would take care of it. A nursing assistant (NA), Employee #51, was interviewed on 04/23/13 at 4:13 p.m. She was asked to observe the damage to the wall in Resident #42's room. She was asked if she knew how the damage occurred. She said the resident gets mad and hits the wall. Employee #51 stated the resident made the two (2) big places hitting it. According to Employee #51, the resident picked at the wall a lot. She was asked if the nursing assistants had told anyone about this. She said she had told the nurses, and that all the afternoon shift nurses knew about it. Maintenance work orders were requested from the maintenance supervisor, Employee #134, on 4/22/13 at 1:00 p.m. Review of these work orders found no work orders for March or April 2013 involving the wall in Resident #42's room. The director of nursing, Employee #133, was interviewed on 04/24/13 at 9:30 a.m. He was asked about the wall damage, and the concern that Resident #42 may be placing debris from the wall in his mouth. He said he had no knowledge of the situation; that if he did, he would have taken care of it immediately. He denied any meeting with any nursing staff had ever taken place on the subject. During the day, on 04/24/13, after the condition of the wall was brought to the facility's attention during the survey, the facility placed a wall covering on the affected wall and rearranged the layout of the furniture in the resident's room, in an attempt to ensure a safe, comfortable sanitary environment for Resident #42, and to ensure Resident #42 did not ingest non-food items. | 2016-04-01 |