| 2023 |
ORCHARD HEALTH AND REHABILITATION |
115522 |
1321 PULASKI SCHOOL ROAD |
PULASKI |
GA |
30451 |
2017-10-08 |
278 |
J |
1 |
0 |
UU0Y11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and record review, the facility failed to accurately assess one resident (R) #1, as high-risk for elopement on admission (resident had a known history of elopement and attempted elopement) resulting in the resident successfully eloping on [DATE]. The facility failed to re-assess the resident and his elopement risk after his return. He eloped again on [DATE] with his remains found on [DATE]. The Sample size was six residents. On [DATE] a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Administrator, Director of Nursing (DON), and the Regional Vice President (RVP) were informed of the immediate jeopardy on [DATE] at 6:45 p.m. The noncompliance related to the immediate jeopardy was identified to have existed on [DATE]. The immediate jeopardy continued through [DATE], and was removed on [DATE]. The facility implemented a Credible Allegation of Compliance related to the immediate jeopardy on [DATE]. The immediate jeopardy is outlined as follows: Resident #1 (R#1) was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident had a Brief Interview for Mental Status (BIMs) score of 6 indicating that the resident was severely cognitively impaired. The resident's functional status was documented that the resident's locomotion (walking) on the unit required supervision meaning oversight encouragement or cueing. Record review revealed that on [DATE], R#1 eloped from this facility and walked about one mile down the highway. The resident was found by staff and returned to the facility. Further record review revealed that after the resident eloped on [DATE], that the facility failed to update the resident's care plan and failed to put new care plan interventions in place to prevent the resident from eloping from the facility again. On [DATE], R#1 eloped from the facility between the hours of 10:30 a.m. and 1:30 p.m. The resident was last seen in the morning exercise class scheduled on [DATE] from 10:00 a.m. to 10:30 a.m. The facility realized that the resident was missing at approximately 1:10 p.m. when the kitchen staff observed that the resident's lunch tray was still on the serving cart. The resident's family, physician, and police were notified. Foot patrols were begun by the Sheriff's office and nursing home volunteers. Additional searches were conducted until [DATE], at approximately 1:30 p.m. when R#1 was found approximately a quarter of a mile from the facility, deceased . The immediate jeopardy was related to the facility's noncompliance with the program requirements at F 278 SS=J 483.20(g)-(j) Assessment Accuracy/Coordination/Certified, F280 S/S: J 483.10(c)(2)(i-ii,iv,v)(3),483.21(b)(2) Right to participate in planning care - Revise care plan, F 323 SS=J 483.25(d)(1)(2)(n)(1)-(3) Free of Accident Hazards/Supervision/Devises F 490 SS=J 483.70 Effective Administration/Resident well-being. Additionally, Substandard Quality of Care was identified with the requirements at F 323 SS=J 483.25(d) (1) (2) (n) (1)-(3) Free of Accident Hazards/Supervision/Devices. A Credible Allegation of Compliance was received on [DATE]. Based on observations, record reviews, interviews and review of the facility's policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice were removed on [DATE]. The facility remained out of compliance at a lower scope and severity of D while the facility continued management level staff oversight of resident assessments related to elopement, updating and revising care plans, systematic review of residents and the physical environment for elopement risks. In-service materials and records were reviewed. Observation and interviews were conducted with staff to ensure they demonstrated knowledge of facility Policies and Procedures. Resident records were reviewed to ensure that resident care and treatment, including assessments and care plans were current and accurate. The IJ was removed on [DATE]. Findings include: Clinical record review for R#1 revealed the resident had the following diagnoses, including but not limited to: unspecified [MEDICAL CONDITION], generalized anxiety disorder, adjustment disorder, unspecified dementia, [MEDICAL CONDITION], and dementia with behavior disturbance. Review of R#1's Minimum Data Set (MDS) annual review dated [DATE] revealed under Section C - Cognition, that resident is severely cognitively impaired. Under Section [NAME] - Behaviors, R#1 is not coded for wandering behavior, but his previous MDS assessments from [DATE] through [DATE] were coded for wandering. Resident also had delusions, exhibited verbal behaviors ,[DATE] days of the review period and exhibited other behaviors ,[DATE] days of the review period. Under section G- Functional Status, the resident required supervision for most activities of daily living, but needed extensive assistance to dress and maintain personal hygiene. Review of 'Interdisciplinary Progress Notes' dated [DATE] recorded by nursing staff revealed an assessment for a fall that occurred on [DATE] with an additional notation that read: 'also, at 4:35 p.m. staff member alerted nurse that (R#1) had left the premises. Nurse writer and 3 other staff members went outside to search for him. Resident had waked (sic) about 1 mile down HWY 46 and was returned to facility by staff member. Resident had no injuries noted to body, appeared to be in no distress. Resident showed nurse writer how he had gotten out. Apparently, while the heating and air service men were working on the unit they left the door open and resident walked outside. Resident stated, I'm sorry, I was just trying to get home'. Continuing review of the 'Interdisciplinary Progress Notes' related to the elopement reveals there was no follow-up documented or re-assessment recommended. Review of R#1's current 'Plan of Care' for wandering/elopement revealed it originated on [DATE] and had not been updated or revised related to the elopement on [DATE]. Problem 004, on page 4 of the plan of care reads as follows: Resident has the potential for leaving the facility grounds due to poor decision making skills. He requires supervision and redirection throughout the day. Under 'Goals', dated [DATE], it reads: Resident will not leave the facility grounds without an escort through next review. There are 4 'Interventions' listed to meet this goal, all dated [DATE], that read as follows: 1. Cue & Redirect as needed 2. Involve resident in activities as a diversion, encouraging resident to attend activities of preference. 3. Observe resident's location & redirect as needed 4. Notify MD (Medical Director) as needed. Under 'Start Date' for the 'Interventions' are two handwritten dates, [DATE] and [DATE], but no additional interventions or revisions are recorded. Interview on [DATE] at 11:10 a.m. with the DON who confirmed that the resident had previously eloped in (YEAR) under similar circumstances. She further states that the facility made a policy change requiring that the security codes on the doors be changed monthly after R#1's elopement in (YEAR). There was no follow-up investigation or tracking tool used to measure effectiveness of this intervention and no re-assessment of this resident or other residents at risk for elopement. Continuing interview with the DON revealed the facility had no formal assessment tool for elopement. The DON was not aware that the resident attempted to 'catch' doors before they closed, but was aware that he had entered other resident's rooms and was known to observe staff entering the code to open the secured doors and agrees that these should have been on the resident's care plan. The facility implemented the following actions to remove the Immediate Jeopardy 1. On [DATE] the Regional Nurse (RN), Director of Nursing (DON), Assistant Director of Nursing (DON) and one Resident Care Coordinator reassessed all patients to determine elopement risk using the elopement risk assessment tool. Fifteen out of eighty-one residents were identified as high risk. Care plans for these patients were reviewed and updates made as indicated by Resident Assessment Instrument (RAI) Coordinator, ADON, DON, two Resident Care Coordinators and Regional Nurse Consultant. 2. On [DATE], the remaining care-plans that had been reviewed for elopement/wandering risk but were not high risk were reviewed for medium and low risk patients and were updated as indicated by RAI Coordinator, Restorative Nurse, ADON, DON, two Resident Care Coordinators and Regional Nurse Consultant. 3. On [DATE], the Administrator and Director of Nursing educated the RAI Coordinator, Restorative Nurse, Assistant Director of Nursing, and two Resident Care coordinators on ensuring wandering risk, communication of any patient reviewing and revising patient care plans as patient's conditions change and their roles in the interdisciplinary team assessment and care planning process. 4. Education will be provided to licensed nurses on this process. There are currently nineteen on staff. This education will be provided by the Director of Nursing and will be completed by close of business on Friday, [DATE]. The education will begin at 4:00 p.m. and will end at 4:30 p.m. If all 19 licensed nurses do not participate, education will be provided to those who were unable to attend by Director of Nursing via telephone. Each nurse will be required to receive the education prior to providing patient care. 5. Newly hired nurses will be provided education on elopement risk assessment during orientation by the Director of Nursing or Assistant Director of Nursing. 6. Policy review was performed by the Vice President of Clinical Practice on [DATE]. Policy is being revised and will be implemented on [DATE] for center to perform elope risk assessments at least monthly due to patient population. 7. Patients will begin receiving elopement risk assessments at least monthly by licensed nurses with the baseline risk assessments being those performed on [DATE]. 8. All findings were entered into the QAPI program by the Administrator. This will continue to be reviewed by the Quality Assurance Performance Improvement (QAPI) team members during the monthly QAPI meetings until compliance is achieved and sustained. The State Survey Agency validated removal of the Immediate Jeopardy as follows: 1. Elopement Risk Assessment Tool was used for assessment of all residents resulting in 15 high risk residents identified. Elopement Risk Assessment Tool will be the new base-line going forward for assessment and re-admissions. 2. On [DATE] copies of the new care plans were reviewed for all residents in the high, medium, and low risk categories. All care plans had been updated as indicated by RAI Coordinator, Restorative Nurse, ADON, DON, two Resident Care Coordinators and Regional Nurse Consultant. Review of updated care plans reveals appropriate new interventions have been added. 3. On [DATE] and [DATE], the Administrator and Director of Nursing educated the RAI Coordinator, Restorative Nurse, Assistant Director of Nursing, and two Resident Care coordinators using a printed Power Point tool that expanded on the interventions used for wandering risk, communication, reviewing and revising patient care plans as patient's conditions change and their roles in the interdisciplinary team assessment and care planning process. Review of the training tool on [DATE] at 11:55 a.m., review of the signatures page, and interview with RAI Coordinator confirmed that the training had been done and the RAI coordinator was able to verbalize the training material. 4. All staff have been educated in person or by telephone by [DATE]. Interview with Licensed Practical Nurse (LPN) Charge Nurse RR who confirms that training on [DATE] and ,[DATE] /17 was completed on [DATE] between 2:30 p.m. and 3:00 p.m. Review of the training sheet and the staff records reveals that all staff have received the specified training either in person or by phone. 5. Interview on [DATE] at 2:40 p.m. revealed that the Director of Nursing or Assistant Director of Nursing have provided a copy of the new elopement risk assessment tool to be incorporated into the training packet for all new nurses. 6. Interview and review with the Vice President of Clinical Practice on [DATE] at 1:35 p.m. reveals that the policy is being revised and will be implemented on [DATE] for the entire center to perform elope risk assessments at least monthly due to the patient population. 7. Interview on [DATE] at 9:15 a.m. with Social Service Director (SSD) who confirms that high risk residents were assessed on [DATE] and will be assessed monthly, all other residents will be assessed quarterly, annually, as needed or based on significant change, and new or re-admissions will be assessed on admission. 8. Review of QAPI plan, tools initiated and staff interviews on [DATE] at 4:40 p.m. with DON, ADON and the RVP confirm this process as of [DATE]. |
2020-09-01 |