cms_GA: 7658
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| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 7658 | NORTHRIDGE HEALTH AND REHABILITATION | 115714 | 100 MEDICAL CENTER DRIVE | COMMERCE | GA | 30529 | 2014-02-20 | 282 | K | 1 | 0 | LWSQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, facility staff interview, hospital ED Nursing Record review, hospital ED Discharge Instructions review, and facility Follow-Up Report review, the facility failed to ensure resident supervision for elopement/wandering behavior, in accordance with the Care Plan which specified WanderGuard bracelet use to address elopement/wandering behavior, by failing to ensure that the WanderGuard system provided protection which included a set of double doors located in one (1) first floor corridor which was accessible to Unit B and Unit C residents, and which exited the nursing facility into an adjoining hospital facility. The failure of the facility to ensure WanderGuard alarm protection on the double doors contained within this unsecured corridor allowed this corridor to serve as an unsecured route of exit for one (1) resident (#1) who eloped through this corridor, and as a potential unsecured route of exit for four (4) additional residents (#5, #11, #12, and #14), whose Care Plans specified the use of WanderGuard bracelets to address known elopement/wandering behavior, on the total survey sample of fourteen (14) residents. Resident #1 subsequently accessed this unsecured corridor on 02/09/2014 without the knowledge of facility staff, exited the facility through the corridor, and eloped through the adjoining hospital. Resident #1 traveled along a street for approximately one-half mile, fell on to the pavement, was taken to the hospital Emergency Department (ED), and was found to have facial abrasions, a nasal laceration requiring sutures, a nasal fracture, and a fractured right knee cap. This resulted in a situation in which the facility's non-compliance 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 and Director of Nursing were informed of the immediate jeopardy on February 18, 2014 at 9:30 a.m. The non-compliance related to the immediate jeopardy was identified to have existed on February 9, 2014 (the date Resident #1 eloped from the facility via the unlocked, unalarmed, and unsecured doors located within a corridor which lead from the nursing facility to an adjoining hospital), continued through February 18, 2014, and was removed on February 19, 2014. The facility implemented a credible allegation of jeopardy removal related to the immediate jeopardy on February 18, 2014. During this survey, it was determined that Resident #1, who had a history of [REDACTED]. In addition to Resident #1, Resident #s 5, 11, 12, and 14, who all had cognitive impairment and whose Care Plans all specified the use of WanderGuard bracelets for known elopement/wandering behavior, also resided on Unit B or Unit C, and all had direct access to these unlocked, unalarmed corridor doors which lead directly to the hospital. During an interview conducted on 02/14/2014 at 11:50 a.m., the Administrator acknowledged that the set of unlocked corridor doors located in the corridor leading from the nursing facility into the hospital did not have a WanderGuard alarm. An allegation of jeopardy removal was received on February 19, 2014. Based on the corrective plans which had been developed and implemented by the facility, the immediacy of the deficient practice was determined to have been removed on February 19, 2014, and the facility remained out of compliance at a lower scope and severity of E while the facility completed a process which involved the retraining, via staff in-service, of available nursing staff related to procedural revisions made to ensure adequate supervision for residents at risk of wandering/elopement, but continued to provide in-service training to staff who were initially unavailable for training, as they reported to work. In-service materials and records were reviewed. Interviews were conducted with staff to ensure they were knowledgeable about the monitoring of residents requiring supervision related to the risk of wandering/elopement. Observations were made to assess staffs' performance of care and supervision of these residents. Findings include: During a tour of the facility's first floor conducted on 02/14/2014 at 12:30 p.m., observations were made in first floor Unit B and Unit C. Observation during this tour revealed that the facility utilized a WanderGuard alert system to allow for the supervision of residents at risk for elopement/wandering. A WanderGuard alarm was observed on the nursing facility's main entrance/exit doors located at the front of the facility, and a WanderGuard alarm was observed on doors located at the terminal end of the Unit C front corridor which opened into a corridor of the adjoining hospital facility. However, observation of Unit B revealed a corridor which turned off the end of the B Hall of Unit B and lead into the adjoining hospital facility. This corridor which connected the nursing facility and the hospital was noted to contain a set of double doors which did not have a WanderGuard alarm. These doors were not locked, and opened upon pressing a wall-mounted button. This corridor containing these unalarmed, unlocked doors lead from the nursing facility to the adjoining hospital, continued through the hospital and exited through the hospital's main front entrance/exit doors. During this observation, it was noted that the nursing facility's Unit B and Unit C adjoined, and that residents of both units could travel between units, thus allowing residents of both units to have access to this corridor which exited from Unit B and which contained these unalarmed, unlocked double doors leading into the adjoining hospital. During an interview conducted on 02/14/2014 at 11:50 a.m., the Administrator acknowledged that the double doors located in the corridor leading off of Unit B had no WanderGuard alarm and were not locked. 1. Resident #1's Minimum Data Set (MDS) Assessment of 02/06/2014, for an admission of 01/30/2014, documented diagnoses, in Section I - Active Diagnoses, which included [MEDICAL CONDITION] Fibrillation, [MEDICAL CONDITION] Disorder, and Non-Alzheimer's Dementia, and Section C - Cognitive Patterns indicated severe cognitive impairment, with a Brief Interview for Mental Status (BIMS) Summary Score of six (06). Section E - Behavior documented that Resident #1 had exhibited wandering behavior 1 to 3 days during the look-back period. Resident #1's Nursing Admission Care Plan, dated 01/30/2014, identified that the resident was at risk for elopement, and was also at risk for falls. This Nursing Admission Care Plan identified an Approach which specified the use of a WanderGuard alarm to address Resident #1's risk for elopement, with the indicated Goal being that the resident would remain free of injuries and falls. A Nurse's Notes (NN) entry of 02/09/2014 for the 7:00 a.m.-7:00 p.m. shift documented that at around 3:45 p.m., Resident #1 had been seated in the Day Room for an activity. However, a subsequent 02/09/2014, 5:00 p.m. NN documented that Resident #1 had been found at the side of a road by a previous neighbor and was being taken to the hospital. Resident #1's hospital ED (Emergency Department) Nursing Record of 02/09/2014 documented lacerations/abrasions to the face, nose, and forehead, and that the resident had been found by a previous neighbor in the highway outside of the resident's former home. Resident #1's ED Discharge Instructions form of 02/09/2014 documented [DIAGNOSES REDACTED]. A 02/14/2014 facility Follow-Up Report (FR) documented that at 3:45 p.m. on 02/09/2014, Resident #1, who resided on first floor Unit B, had left the facility's Day Room sometime after 4:00 p.m. and eloped, almost reaching his/her former home located 0.83 mile from the nursing facility. This FR documented that the facility believed Resident #1 could have eloped through a set of double doors located in a corridor which lead to the adjoining hospital. As indicated in the 02/14/2014, 12:30 p.m. tour observation referenced above, the corridor which lead off the B Hall of facility Unit B, to which Resident #1 had direct access, contained unlocked double doors which had no WanderGuard alarm, were not locked, and continued into the adjoining hospital facility, passed through the hospital, and exited through the hospital's main entrance/exit doors. During an interview conducted on 02/14/2014 at 11:50 a.m., the Administrator acknowledged these corridor doors off of the Unit B corridor were not locked and did not have a WanderGuard alarm. The Administrator stated that it was thought that on 02/09/2014, Resident #1 walked down the B Hall corridor, passed through the unalarmed double doors, entered into the hospital and eloped through the hospital's front main entrance/exit doors. Based on the above, despite the facility's system for supervision of residents at risk of wandering/elopement involving the use of WanderGuard bracelets, and despite Resident #1 having severe cognitive impairment and a known history of wandering behavior, thereby requiring the use of a WanderGuard bracelet as specified by the Nursing Admission Care Plan, the facility failed to ensure that the unlocked double doors located in the corridor leading from the Unit B hall where Resident #1 resided were equipped with a WanderGuard alarm, to thus ensure WanderGuard bracelet supervision as specified by the Care Plan. Resident #1 then exited the nursing facility through the unalarmed, unlocked corridor double doors and then exited the hospital through the front entrance/exit doors and eloped. Resident #1 then traveled approximately one-half (1/2) mile, fell and sustained facial abrasions, a nasal laceration requiring sutures, a nasal fracture, and a fractured right knee cap. Cross refer to F323, example 1, for more information regarding Resident #1. 2. Resident #12's MDS of 11/11/2013 documented diagnoses, in Section I - Active Diagnoses, which included Hypertension and Dementia, and Section C - Cognitive Patterns documented a BIMS Summary Score of seven (7), indicating severe cognitive impairment. Review of Resident #12's Care Plan revealed that the resident resided on Unit B of the facility. An entry on this Care Plan, indicated as a Problem/Need and originally dated 12/31/2013, identified Resident #12 to have wandering behavior. Approaches listed on Resident #12's Care Plan to address this wandering behavior included the use of a WanderGuard bracelet to be applied at all times, and to redirect the resident as indicated. The Goal for these Approaches identified on Resident #12's Care Plan included that the resident would not leave the facility unescorted. However, as indicated in the 02/14/2014, 12:30 p.m. tour observation referenced above, the corridor leading to the adjacent hospital facility, and located at the end of the B Hall of Unit B where Resident #12 resided and to which Resident #12 had direct access, contained double doors which were unlocked and not equipped with a WanderGuard alarm. This corridor continued into the hospital facility and exited through the hospital's main front entrance/exit. Based on the above, despite the facility's system for supervision of residents at risk of wandering/elopement involving the use of WanderGuard bracelets, despite Resident #12, who resided on Unit B, having Dementia and severe cognitive impairment and having been assessed to have a history of wandering behavior, and despite the resident's Care Plan specifying the use of a WanderGuard bracelet and that staff redirect the resident as indicated, the facility failed to ensure that double doors located in the corridor which exited Unit B and lead directly into the adjoining hospital were WanderGuard alarm equipped. By failing to ensure WanderGuard alarm placement on the unlocked double doors contained within this corridor leading from the nursing facility to the hospital, and which served as a direct route of egress from the nursing facility, the facility failed to ensure that the WanderGuard bracelet utilized by Resident #12, as specified by the Care Plan, would allow redirection of the resident as indicated, also as specified by the Care Plan, by alerting staff to wandering/elopement attempts through this unsecured corridor. This presented a wandering risk for Resident #12. Cross refer to F323, example 2, for more information regarding Resident #12. 3. Resident #14's MDS of 01/06/2014 documented diagnoses, in Section I - Active Diagnoses, which included [MEDICAL CONDITION], Hypertension, [MEDICAL CONDITION], Dementia, [MEDICAL CONDITION] Disorder, and a [MEDICAL CONDITION], and Section C - Cognitive Patterns documented severe cognitive impairment, with a BIMS Summary Score of ninety-nine (99). Resident #14's Care Plan identified that the resident resided on Unit C. The Care Plan also identified, as a Problem/Need originally dated 04/18/2013, that Resident #14 was at risk for elopement from the facility. The Care Plan referenced Approaches to address Resident #14's elopement risk which include the use of a WanderGuard bracelet at all times, and for staff to provide redirection as indicated. However, as indicated in the 02/14/2014, 12:30 p.m. tour observation referenced above, Resident #14, who wore a WanderGuard bracelet for elopement-risk and resided on Unit C, had direct access to Unit B, where observation revealed the corridor which lead off of Unit B and contained the double doors which were not locked or equipped with a WanderGuard alarm, and lead to the hospital facility that adjoined the nursing facility, exiting through the hospital's main front entrance/exit. Based on the above, despite the facility's system for supervision of residents at risk of wandering/elopement involving the use of WanderGuard bracelets, despite Resident #14 (who resided on Unit C and had direct access to Unit B) having Dementia and severe cognitive impairment, despite the resident having been assessed to be at risk for elopement, and despite the resident's Care Plan specifying the use of a WanderGuard bracelet for this elopement-risk and that staff redirect the resident as indicated, the facility failed to ensure WanderGuard alarm placement on the unlocked double doors located in the corridor which exited Unit B, lead directly into the adjoining hospital, and allowed nursing facility egress. By failing to ensure WanderGuard alarm placement on these unlocked double doors, the facility failed to ensure that the WanderGuard bracelet utilized by Resident #14, as specified by the Care Plan, would allow redirection as indicated, also as specified by the Care Plan, by alerting staff to elopement attempts through this unsecured corridor. This presented an elopement risk for Resident #14. Cross refer to F323, example 3, for more information regarding Resident #14. 4. Resident #5's MDS of 11/19/2014 documented diagnoses, in Section I - Active Diagnoses, of [MEDICAL CONDITION], Heart Failure, Hypertension, [MEDICAL CONDITION], Diabetes Mellitus, Arthritis, a history of [MEDICAL CONDITION], and Dementia. Section C - Cognitive Patterns documented that Resident #5 had moderate cognitive impairment, with a BIMS Summary Score of twelve (12). The Care Plan of Resident #5 identified that he/she resided on facility Unit B. Resident #5's Care Plan also identified, as a Problem/Need originally dated 11/20/2013, that the resident had the potential for elopement related to both episodes of confusion with wandering and a history of wandering. This Care Plan identified Approaches to address Resident #5's elopement-risk which included the use of a WanderGuard at all times, and also staff redirection as indicated. However, as indicated in the 02/14/2014, 12:30 p.m. tour observation referenced above, the double doors located within the corridor which lead off of Unit B, where Resident #5 resided, were unlocked and were not equipped with a WanderGuard alarm. This corridor within which these unlocked, unalarmed double doors were located was accessible by Resident #5, lead into the adjoining hospital facility, and exited through the hospital's main front entrance/exit. Based on the above, despite the facility's system for supervision of residents at risk of wandering/elopement involving the use of WanderGuard bracelets, despite Resident #5, who resided on Unit B, having Dementia and cognitive impairment and having been assessed to have the potential for elopement due to confusion and a history of wandering behavior, and despite the resident's Care Plan specifying the use of a WanderGuard bracelet and that staff redirect the resident as indicated, the facility failed to ensure that double doors located in the corridor which exited Unit B and lead directly into the adjoining hospital were WanderGuard alarm-equipped. By failing to ensure WanderGuard alarm placement on the unlocked double doors within this corridor which served as a direct route of egress from the nursing facility, the facility failed to ensure that the WanderGuard bracelet utilized by Resident #5, as specified by the Care Plan, would allow redirection of the resident as indicated, also as specified by the Care Plan, by alerting staff to wandering/elopement attempts through this unsecured corridor. This presented an elopement risk for Resident #5. Cross refer to F323, example 4, for more information regarding Resident #5. 5. Resident #11's MDS assessment of 01/06/2014 documented in Section I - Active [DIAGNOSES REDACTED]. The Care Plan of Resident #11 identified that the resident resided on facility Unit C. The Care Plan also identified, as a Problem/Need originally dated 07/16/2013, that Resident #11 had the potential for wandering behavior, with a history of wandering in the hallways. Care Plan Approaches to address Resident #11's risk for wandering included the use of a WanderGuard bracelet at all times and for staff to redirect the resident as indicated. However, as indicated in the 02/14/2014, 12:30 p.m. tour observation referenced above, Resident #11, who utilized a WanderGuard bracelet and resided on Unit C, had access to the corridor which exited off of Unit B, contained the double doors which were unlocked and were not equipped with a WanderGuard alarm, and which lead from the nursing facility to the adjoining hospital and exited through the hospital's main front entrance/exit. Based on the above, despite the facility's system for supervision of residents at risk of wandering/elopement involving the use of WanderGuard bracelets, despite Resident #11 (who resided on Unit C and had direct access to Unit B) having Dementia/severe cognitive impairment and having been assessed with [REDACTED]. Unit B, lead directly into the adjoining hospital, and allowed nursing facility egress. By failing to ensure WanderGuard alarm placement on these unlocked doors, the facility failed to ensure that the WanderGuard bracelet utilized by Resident #11, as specified by the Care Plan, would allow redirection as indicated, also as specified by the Care Plan, by alerting staff to resident wandering in this unsecured corridor. This represented a wandering risk for Resident #11. Cross refer to F323, example #5, for more information regarding Resident #11. The immediate jeopardy was determined to have been removed on February 19, 2014, at which time the facility had presented and implemented a credible allegation of jeopardy removal with the following interventions: A. On February 9, 2014, after learning of Resident #1's elopement, the facility conducted a full resident audit to assure the presence of all residents. B. On February 9, 2014, all doors exiting the nursing facility were checked to ensure the proper working order of the WanderGuard alarm system. All existing WanderGuard alarms were functioning properly. C. On February 9, 2014, a procedure was put into place by which a facility employee was placed at the doorway, located in the corridor leading from the nursing facility to the hospital, which was not equipped with a WanderGuard alarm. A scheduled was developed reflecting specific employees who were assigned to be in place at the unalarmed doorway, at specific times and continuously around the clock, until a WanderGuard alarm was installed on the doorway. D. On February 9, 2014, chart audits for all current facility residents were conducted to ensure that all residents who demonstrated a potential for elopement had been accurately identified by the facility. During these chart audits, no new residents were identified to have the potential for elopement. E. On February 9, 2014, Care Plan reviews were conducted for residents assessed to be at risk for elopement to ensure that a comprehensive approach to address this risk was in place. During these Care Plan reviews, no problems were identified. F. On February 9, 2014, in addition to daily WanderGuard bracelet checks completed by the Activities Director which were in place prior to Resident #1's elopement, the facility implemented audits of the door alarms through the preventative maintenance program. The door alarms would be checked weekly, on each Tuesday, by the Maintenance Director, and these door alarm checks would be documented via computer data entry. The door alarm test would include a check of the power indicator light to ensure proper function, and also a check for battery condition. A sensor button was to be used to test each door alarm, with the alarm to sound when within six feet of an alarmed doorway. If a door alarm did not initially sound, the test was to be repeated with a different sensor button. Any deviation from full working order found during these weekly door alarm checks would be reported to the Administrator for immediate correction. The Administrator or DON would monitor the results of these weekly door alarm audits, conducted by the Maintenance Director, by reviewing the computer data entered as a result of the door alarm checks weekly for four (4) weeks, then monthly for three (3) months, then quarterly thereafter. The results of these supervisory audits will be submitted to the Quality Assessment/Performance Improvement (QA/PI) Committee for their review. G. On February 9, 2014, the facility contacted the Medical Director to inform him of the elopement of Resident #1. Additionally, a meeting which consisted of some members of the QA/PI Committee, including the Administrator, DON, and Director of Maintenance, was held to review the elopement event and the actions which had been taken by the facility, and to identify any additional actions that were needed. H. On February 15, 2014, the corridor doorway, which lead from the nursing facility to the hospital and which had previously lacked a WanderGuard alarm, was equipped with a WanderGuard alarm. I. On February 18, 2014, the facility continued to provide staff in-service training to facility staff, including licensed nurses, CNAs, and maintenance/housekeeping staff. This in-service training served to both reinforce current facility protocols involving the routine monitoring of residents having WanderGuard bracelet devices and also to provide staff training on newly-implemented protocols related to the facility's WanderGuard alarm system. As of February 18, 2014, 116 of the facility's total 118 employees had received this in-service training. The two (2) remaining staff members, who were on Family and Medical Leave Act leave at the time this in-service training was provided, will received the training upon their return to work. J. On February 18, 2014, the QA/PI Committee met to review the elopement event involving Resident #1, to review the actions taken by the facility as of that date, and to review the monitoring systems put into place as a result of the elopement. The QA/PI Committee will review the results of WanderGuard bracelet monitoring and door alarm audits weekly for four (4) weeks, then monthly for three (3) months, then quarterly thereafter to ensure ongoing compliance with the systemic measures implemented to correct the identified issue and prevent recurrence. The information will be analyzed by the QA/PI Committee, and subsequent plans of correction will be developed and implemented as needed. This will be an ongoing process. Based on these corrective actions which had been developed and implemented by the facility as outlined above, the immediacy of the deficient practice was removed on February 19, 2014. However, the effectiveness of the corrective action plans could not be fully assessed to ensure ongoing application and completion. On February 9, 2014, the facility implemented a weekly audit of WanderGuard door alarms to be accomplished through the preventative maintenance program by the Maintenance Director. These weekly WanderGuard door alarm audits would check for the proper function of all facility WanderGuard door alarms, and were to be documented via computer data entry. However, these weekly WanderGuard door alarm audits had been initiated only on February 9, 2014, and had occurred only twice prior to the February 20, 2014 exit date of this complaint survey. Therefore, ongoing staff compliance with this newly implemented procedure involving routine, scheduled WanderGuard door alarm monitoring could not be entirely assessed at the time of survey completion, and will thus need future evaluation. Additionally, by February 18, 2014, the facility had completed in-service training for 116 of its 118 facility employees, to include licensed nurses, CNAs, and maintenance/housekeeping staff, regarding both existing and newly-implemented protocols involving the monitoring of residents with WanderGuard bracelets and the WanderGuard alarm system. However, two (2) remaining staff members, who were on leave and had been unavailable for training, will need to receive this training upon returning to work, and this training will thus need future evaluation. Additionally, the QA/PI Committee was to include the review the results of WanderGuard bracelet monitoring and door alarm audits in future meetings, but the Committee had met on On February 18, 2014, only two (2) days prior to the February 20, 2014 exit date of this complaint survey, to begin this process. Thus, the QA/PI Committee's ongoing process of facility procedural oversight could not be evaluated at the time of survey completion. Therefore, the non-compliance continues, but the scope and severity is reduced to the E level. | 2017-02-01 |