cms_AK: 98
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 |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
98 | PROVIDENCE TRANSITIONAL CARE CENTER | 25018 | 910 COMPASSION CIRCLE | ANCHORAGE | AK | 99504 | 2018-07-13 | 689 | D | 1 | 1 | FK4811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview the facility failed to ensure the safety of 1 Resident (#2) who resided in the facility. Specifically, the facility failed to ensure the Roam Alert Resident Safety (RARS- a door alarm system intended to alert staff of elopement/wandering from the building or a designated area of the building) was checked regularly for proper functioning that resulted in resident #2 leaving the facility unsupervised. This failed practice placed the resident at risk being without medical supervision and unsafe environment conditions. Findings: Based on a closed record review of an elopement the facility is cited for past non-compliance for elopement of resident #2. Upon the Resident's return to the facility, the facility found no system in place for checking the monitoring device and had developed a protocol for monitoring and recording this information on the Residents Treatment Administration Record. Record review of a closed record from 7/10-13/18 revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #2's care plan dated 4/2/18, revealed NEED/PREFERENCE .I LIKE: to wander about and sometimes go outside .I SHOW THIS BY: going outside at times, without telling staff .APPROACH .I need my nurses to---chart on my behavior in regards to the wander guard that I wear .GOAL .MY GOAL IS TO: stay safe while I'm moving about . Record review revealed no documentation of the Resident using the RARS and no documentation of staff checking the system. Further review of the medical record revealed no documentation of resident eloping in the medical record. Review of the facility report incident dated 5/24/18, revealed the facility reported the elopement to the state agency (Health Facilities Licensing & Certification). During an interview with Nursing Supervisor (NS) #1 on 7/13/18 at 12:05 pm, when asked for documentation in the medial record of Resident #2's elopement the NS stated he/she could not find any documentation. Further review on site revealed a protocol Wander Guard Sensors-Care and Management of the Resident dated 5/28/18 was developed, 4 days after Resident #2 had eloped. During an interview on 7/13/18 at 1:39 pm, with the Director of Nursing (DON) and Quality Director (QD), when asked about Resident #2's elopement the DON stated Resident #2 monitor had not alarmed and was gone from the facility about 3 to 4 hours. When the Resident was brought back to the facility, entering the building, the monitoring system did not alarm. The monitor Resident #2 was wearing was replaced 5/29/18. The DON further stated the Licensed Nurse did not document in the medical record of the Resident as it was reported to the State Agency and did not need further documentation. Review of the facility policy titled AMA (Against Medical Advice) and Elopement revision date 12/14 revealed .Elopement .e. A thorough documentation of the elopement is made in the medical record by appropriate clinical disciplines . | 2020-09-01 |