| 10113 |
JENNIE M MELHAM MEDICAL CENTER |
28A056 |
P O BOX 250, 145 MEMORIAL DRIVE |
BROKEN BOW |
NE |
68822 |
2013-03-20 |
323 |
J |
1 |
0 |
RYUO11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER: 175 NAC 12-006.09D7. Observation, record review and interviews revealed the facility failed to provide supervision of 1 sampled resident (Resident 37) to prevent the resident from exiting the facility through the secured door late at night. The resident was unable to return to the facility through the secured door or alert staff the resident had left the facility without the staff's knowledge. The facility census was 38 and the sample size was 5. Findings are: A. Review of Resident 37's CARE PLAN, dated 12/10/2013, revealed the resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Further review of Resident 37's CARE PLAN revealed Resident 37 was alert but had confusion. The resident experienced short and long term memory loss and was cognitively impaired in the ability to make decisions. The resident was forgetful and required cueing and supervision frequently and needed reminded of safety issues often due to his forgetfulness. Review of Resident 37's medical record on 3/7/2013 found no documented evidence an assessment for wandering with a risk for elopement had been completed. Review of the MDS (Minimum Data Set; a federally mandated comprehensive assessment tool used for care planning) dated 12/10/12 revealed the following: -cognition showed a short term memory problems, -the BIMs (Brief Interview for Mental Status) was scored 7 out of 15, - No behaviors, -Limited one assist for bed mobility, transfer, personal hygiene, -Supervision with walking, used a wheelchair in the corridor, and -Wandered. B. Review of the facility report entitled ADULT ABUSE REPORT FOR LICENSED/CERTIFIED FACULTIES, dated 3/5/2013, revealed Resident 37 was very forgetful but alert. Resident 37 had poor eyesight, was hard of hearing, transferd self and got around the facility without assistance. Resident 37 went outside to check the weather, the door locked behind the resident and he/she couldn't get back in. The incident occurred on 3/4/2013 at 11:00 PM. The outside temperature was 23 with a windchill of 6.3 degrees (F) Fahrenheit at 10:52 PM. At 11:53 PM the outside temperature was 21.9 with a windchill of 2.9 degrees F. On 3/7/2013 about 9:45 AM, the facility security video was watched to reveal the following incident on 3/4/2013 when Resident 37 left the building: -At 2300 (11:00 PM), Resident 37 was seen self-mobile in the wheelchair through the ALF (Assisted Living Facility) door, then through it to the entry way and through the outside door. The resident was wearing a shirt, jeans, shoes, a light jacket, and a cap. -At 2303 (11:03 PM), Resident 37 was seen to enter the entry way in the wheelchair. Resident 37 pulled on the locked door. -At 2304 (11:04 PM), the resident was seen leaving the wheelchair in the entry way and walked outside. -At 2306 (11:06 PM), the resident came back into the entry way, pulled on the door, then pounded on the window of the door. -At 2307 (11:07 PM), the resident walked back outside and came back in knocking on the door. The resident was unsteady on feet looking around. -At 2309 (11:09 PM), Resident 37 walked back outside. -At 2311 (11:11 PM), Resident 37 walked back into the entry way. -At 2313 (11:13 PM), Resident 37 sat in the wheelchair in the entry way, then opened the door and looked out. -At 2314 (11:14 PM), Resident 37 checked the locked door again. -At 2318 11:18 PM), Resident 37 went out the entry way door to the outside in the wheelchair. Interview with the DON (Director of Nursing) on 3/7/2013 revealed the dispatcher indicated a call was received from a passer by notifying the dispatcher of a resident and wheelchair in the ditch. This call was received at 11:59 PM. The Sheriff arrived at the scene at 12:05 AM on 3/5/2013. The resident was brought to the emergency room at 12:15 AM on 3/5/2013. Interview with the Administrator and the DON on 3/7/2013 at 9:15 AM revealed the resident likes to go outside to check the weather. The resident always goes out the front door and this night 3/4/2013 the resident went out the ALF exit door. Also, Per the Sheriff, the resident was 3 blocks away from the facility. Based on the previous evidence from the security tape video and the DON interviewing, the resident went out the secured door of the facility on 3/4/2013 at 11:00 PM and was brought back to the hospital emergency roiagnom on [DATE] at 12:15 AM a total of 1 (one) hour and 15 minutes. Review of Resident 37's NURSES NOTES, dated 3/4/2013 at 2245, revealed the resident was noted in the hallway outside the room at change of shift. Staff talked to the resident and encouraged the resident to return to the room with personal affects. The resident was compliant with the suggestion and noted to have closed the door to the room. At 2400, a call was received from the acute care asking Are you missing anyone? The staff had not noted any missing residents. Acute responded that a resident was reported to have been seen on Memorial Drive in a wheelchair. A room search was initiated to find Residen 37 missing. At 2415, Acute phoned and stated (Resident 37) was picked up and delivered to the emergency room . At 2435, Acute phoned to state the resident would be held overnight for observation. Review of the hospital history and physical revealed Resident 37's core rectal temp was 95 degrees Fahrenheit as there was trouble getting an auxiliary or tympanic temperature. It was reading in the 92-93 range. The resident received 2 liters of warm saline. A bear hugger was used to warm the resident. The Doctor monitored the vital signs and labs before the resident returned to the Nursing Home. C. Observation of the resident on 3/7/2013 revealed the following regarding continued wandering behavior: -The resident was sitting in the wheelchair in the dining room at 9:30 AM, -At 10:15 AM, the resident was roaming in the hall down the middle hall and to the conference room in the south west corner of the building, -At 3:20 PM, the resident was in the room then self mobile in the hall and back to the conference room. Tour of 5 (five) exit doors of the facility on 3/7/2013 found no way to notify the staff that a resident was outside the secured door or for the resident to get back inside the building. ABATEMENT STATEMENT Based on the following, the facility has removed the immediacy of the situation: 1) Assessments regarding wandering and a risk for elopement have been completed on the residents in the facility. 2) Door bells have been installed on all the exit doors to notify staff a resident needs to get back in the facility. 3) The wanderguard alarms have been changed to sound when anyone goes through the door to alert staff that a resident has gone out an exit door without staff knowledge. Because the immediacy was removed, but the deficient practice not totally corrected, the severity is lowered from a J to a D. |
2016-03-01 |