| 13 |
BENEFIS SENIOR SERVICES |
275012 |
2621 15TH AVE S |
GREAT FALLS |
MT |
59405 |
2018-05-17 |
689 |
D |
0 |
1 |
FGZ511 |
Based on observation, interview, and record review, the facility failed to provide adequate supervision to keep a resident safe from six elopements and two falls (one with minor injuries), for 1 (#131) of 28 sampled residents. Findings include: Record Review of resident #131's Interdisciplinary Notes and Care Plan showed resident #131 eloped three times: a. 5/21/17 at 11:08 p.m., resident #131 left the doors from Eastview. Staff asked resident #131 to come back and stay on the unit. Resident #131 attempted to leave again out the unit doors by the nurse's station. Staff stopped him again. Resident #131 had clothing hidden under his coat. A review of the Care Plan showed, the intervention established was: resident #131 is monitored frequently by the staff. His room is checked frequently to see if he is in and if not to be sure of his where about's. In this case our monitoring and diligences prevented him from leaving the unit with clothing hidden under his coat. b. 6/4/17 at 2:00 p.m., resident #131 walked alone to the north tower information desk. The north tower staff called to alert the staff. Resident #131 was assisted back to the unit via wheelchair. Resident #131 was seen by the nurse in the dining room around 1:40 p.m. A review of the Care Plan showed, the intervention monitor frequently was established before this elopement. The new intervention method established was We have been told by the Clinical Engineering that the Wanderguard system is coming and then they will install it. We are not sure of the date. Until the system is installed, staff are doing half hourly checks in resident #131 when he is awake (sic). c. (no time or date) Resident #131 was found in the lobby during nightly rounds. During the walk back to his room resident #131 stated that he was going to leave tomorrow. He was escorted back to his room and the Eastview staff were notified.[NAME]remains on hourly checks, he had been checked and noted to be in his room several times before we were notified he was at the security station. A review of the Care Plan showed the intervention method was doing half an hour checks on resident #131 when he is awake. The new intervention method put in place on the Care Plan was This is a repeated elopement for resident #131 and as per his usual pattern walks to the north/south security desk. The manager will follow-up with Security regarding the auto door lock in the north egress after 9 pm daily. Administratively, we are evaluating the cost of the Wanderguard System to purchase with contingency funds (sic). d. 7/3/17 at 9:20 p.m., resident #131 was reported to be walking by her husband's window. When the floor nurse went to go get resident #131 he could not be seen. Upon searching for him, another family member recognized him and had walked with him back to the Eastview front entrance. Resident #131 was reported to have been around the corner heading toward another medical facility building. A review of the Care Plan showed the previous intervention method was follow-up with security regarding auto door lock on the north egress after 9 p.m. daily. The new intervention method was A one to one is being assigned to resident #131 until the Wanderguard system can be installed. e. 7/29/17 at 9:55 p.m., CNAs discovered that resident #131 was gone from his room after they told him they would be back to assist him to get changed for bed. They immediately went searching for him and found him half way down the hall leading to the hospital. A review of the Care Plan showed the pervious intervention method established was A one to one is being assigned to resident #131 until the Wanderguard system can be installed. This intervention was not care planned and there was not a new intervention put in place for the event to protect the resident from eloping. f. 9/1/17 at 2:00 p.m., resident #131 was found outside the facility, by the bus driver, laying on his back on the ground near the parking area of Eastview. He was witnessed by the truck driver to fall on the grassy area near the parking lot. He was assessed and was found not to have obvious injuries from the fall. He was returned to Eastview by staff. A review of the Care Plan showed the intervention method established on 9/3/17 was A one to on is being assigned to resident #131 until the Wanderguard system can be installed. There was no new intervention method established for future protection from elopements. g. 9/26/17 at 6:50 p.m., resident #131 was found in the long hallway of the facility, near the trash compactor area. A housekeeping employee who knew resident #131 found him, called Eastview staff, and stayed with resident #131 until staff came and got him. Resident #131 stated I was just taking a stroll. A review of the Care Plan showed the pervious intervention method established was A one to on is being assigned to resident #131 until the Wanderguard system can be installed. The new intervention method established was Resident #131 is very frequently monitored - including one on one as frequently as possible. h. 10/30/17 at 6:00 p.m., a CNA went into resident #131's room for a routine check and he was not there. The CNA notified the floor nurse and a search was initiated. A CNA coming on shift notified the staff he was on his way back with a security guard. The security guard found him in the south tower of the hospital and escorted him back. A review of the Care Plan showed the previous intervention method established was Resident #131 is very frequently monitored - including one on one as frequently as possible. The new intervention method established was We will cont. the very frequent monitored - including 1:1 frequently as possible (sic). The interventions had shown to be ineffective to protect the resident from elopement. i. 3/30/18 at 7:00 p.m., another resident's family notified the facility that the resident was in the orthopedics parking lot with the fire department. The resident was warmed with blankets for 25 minutes and given a warm shower due to the cold temperature outside. Resident #131's left fingers had minor scrapes, and the resident complained of right hip pain. A review of the Care Plan showed the previous intervention method established was, We will cont. the very frequent monitored - including 1:1 frequently as possible (sic). The new intervention method established was We will cont. the very frequent monitored - including 1:1 frequently as possible, until the Wanderguard can be installed (sic). Record Review of resident #131's Care Plan showed one-on-one as an intervention method and one-on-one intervention frequently as possible. During an interview on 5/17/18 at 9:15 a.m., staff member F stated that resident #131 was supposed to have a one-on-one 24/7 (24 hours a day/7 days a week), unless he was in bed sleeping. During an interview on 5/15/18 at 9:00 a.m., staff member F stated, usually someone checks on resident #131 every hour and then when he has had an elopement they check on him every 15 minutes, and then every half an hour during the night. There is usually someone with him during the day at all times, but he is alone during the night. During an interview on 5/16/18 at 2:03 p.m., staff member U stated resident #131 was supposed to have one-on-one supervision, however it is hard for that to happen every day. Staff member U stated that when the resident eloped he was unpredictable. Staff member U stated in (MONTH) (2018) when he left the building in the cold we were just more relaxed that day. Staff member U recalled resident #131 saying I saw you weren't watching so I left (sic). During an interview on 5/16/18 at 2:20 p.m., staff member S stated that she was on shift when resident #131 eloped out of the building in (MONTH) of (YEAR). Staff member S stated she was washing dishes when she got a call that resident #131 could not be located. Staff member S stated the resident was found outside and brought back in. Staff member S stated that the CNA staff watching resident #131 had to leave to check on another resident. When they went back to check on resident #131 he was gone. During an interview on 5/16/18 at 2:30 p.m., staff member R stated resident #131 was very fast when he wants to leave. He is supposed to be a one-on-one and we cannot, and do not, provide that all the time because we do not have enough staf. Staff member R stated, she was there the night he eloped out of the building in March. Staff member R stated, she was not watching resident #131 when he left the building because there was an incident with another resident she had to help with. Staff member R stated there were only three CNAs and one nurse on that night. During an observation on 5/17/18 at 7:56 a.m., resident #131 had his door shut to his room, and no one-to-one was being provided. During an interview on 5/17/18 at 8:05 a.m., staff member C stated that she thought resident #131 was in his room. She said she would check to make sure, then stated Yep, he's still here. Staff member C stated that staff do not usually check on him when he was sleeping. During an interview on 5/17/18 at 8:30 a.m., staff member D stated staff did not see resident #131 leave the building in (MONTH) of (YEAR) because there was an incident with another resident. We did one-on-ones for a while after his elopement in (MONTH) (2018) for about a day and a half until he was back to normal. Staff member D stated currently staff were just checking in on him or getting visuals of him. We usually try to check in on him every hour and then get a visual of him every half hour. |
2020-09-01 |