| 12421 |
GOOD SHEPHERD LUTHERAN HOME |
285148 |
2242 WRIGHT STREET |
BLAIR |
NE |
68008 |
2010-06-10 |
323 |
E |
1 |
1 |
P9FH11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7 Based on observation, record review and interview; the facility failed to complete Elopement Risk Assessments (ERA) for residents identified with wandering or increased anxious behaviors and elopements (Residents 8 and 9), failed to monitor security devices per the plan of care (Resident 11) and failed to implement interventions to prevent falls (Resident 15) for 4 of 16 sampled plus 10 non-sampled residents. The facility census was 80. Findings are: A. Record review of a facility document dated March 2010 entitled Elopement defined the term elopement as follows: escape, flees, runs off, disappears or leaves a care-giving environment unsupervised or unnoticed by staff or prior knowledge. Observation on 6/7/10 at 3:45 PM revealed Resident 8 laying on a bed in Resident 8's room. Observation revealed a wanderguard security device (an electronic device that will set off an alarm to inform staff that the resident has come to close to the security devices at the exit doors to the facility) located on the right and left ankles of Resident 8. Record review of Resident 8's Admission Face Sheet dated 5/17/10 revealed an admission date of [DATE]. Resident 8's admission [DIAGNOSES REDACTED]. Record review of a Hospital Discharge Summary dated 3/6/10 prior to admission to the nursing facility identified Resident 8 with moderate to severe Dementia. Record review of Resident 8's Admission Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated 4/9/10 and 30 day assessment dated [DATE] identified Resident 8 with moderate cognitive impairment, periods of restlessness, wandering behavior, independent with ambulation in room and corridor and supervision with locomotion off of the unit. Record review of Resident 8's ERA dated 4/2/10, on the day of Resident 8's admission, revealed incomplete documentation of summary, conclusions, recommendations or interventions implemented related to Resident 8's elopement risk. Record review of Daily Skilled Nurses Notes (DSNN) dated 4/3/10 at 1:40 PM revealed that Resident 8 exhibited general confusion and wanted to go home. Record review of a DSNN dated 4/4/10 at 12:30 PM revealed that Resident 8 exhibited general confusion and ambulated independently on the 500/600 hall, the secured unit, of the facility. At 4:15 PM on 4/4/10, the DSNN indicated that Resident 8 exhibited restlessness, pacing and wanted to get out. The nurses note indicated that the Physician was notified at that time. Record review of a fax communication with Resident 8's physician dated 4/5/10 indicated that Resident 8 had gotten more restless and wanted to get out and go home. A request was made on 4/5/10 to the physician and an order received for anti-anxiety medication for Resident 8. The fax indicated that the family was concerned that Resident 8 would try to get out of the facility. Record review of a Daily Skilled Nurses Note (DSNN) dated 4/5/10 indicated that a wanderguard system bracelet was placed on Resident 8's left leg per family request, 3 days after admission to the facility. Record review of Resident 8's CCP (Comprehensive Care Plan) dated 4/9/10 revealed that Resident 8 was identified as at risk for wandering from the facility unattended due to [DIAGNOSES REDACTED]. A goal for that concern was that the resident would not wander from the facility unattended. The approaches to that concern included that a wanderguard had been placed on Resident 8's left ankle and that it's functioning would be monitored per facility policy. Record review of a Daily Skilled Nurses Note dated 4/27/10 revealed that on 4/27/10, Resident 8 walked out of the exit doors on the 500/600 hall when another visitor came in. The wanderguard did not sound as Resident 8 walked fast. Resident 8 left the facility unsupervised and unnoticed by facility staff. Facility staff were alerted of Resident 8's exit by another facility resident and staff returned Resident 8 to the facility with no injury. Record review of an investigation dated 4/30/10 into Resident 8's elopement from the facility revealed that after the incident, the facility staff placed a second wanderguard system on Resident 8's other ankle as a secondary protective measure to prevent elopements. Interview on 6/9/10 at 11:20 AM with the Director of Nursing (DON) confirmed that Resident 8 was an elopement risk at the time of admission on 4/2/10 when the ERA was initiated and that a wanderguard system bracelet should have been placed on Resident 8 at the time of admission on 4/2/10. The DON confirmed that the assessment was incomplete and did not specifically identify whether or not Resident 8 was at risk for elopement. The DON explained that any answers marked "yes" on the ERA meant that the resident was at risk for elopement and should have interventions initiated to prevent elopement. The DON stated that Resident 8 did not have a new ERA completed after the elopement on 4/27/10. B. Observation on 6/7/10 at 4:00 PM revealed Resident 9 sitting in Residents 9's room on the bed. Observation revealed a wanderguard security device present on Resident 9's left ankle. Record review of Resident 9's Admission Face Sheet dated 3/24/10 revealed an admission date of [DATE]. Resident 9's admission [DIAGNOSES REDACTED]. Record review of Resident 9's quarterly MDS dated [DATE] identified Resident 9 with moderate cognitive impairment, periods of restlessness, mental function varied over the course of the day and as independent with ambulation in room, corridor and locomotion off of the unit. Record review of Resident 9's ERA (no date) revealed incomplete documentation of summary, conclusions, recommendations or interventions implemented related to Resident 9's elopement risk. Interview on 6/9/10 at 2:45 PM with the DON confirmed that the assessment was incomplete and did not specifically identify whether or not Resident 9 was at risk for elopement or not. Interview on 6/9/10 at 11:20 AM with the DON revealed that the DON explained that any answers marked "yes" on the ERA meant that the resident was at risk for elopement and should have interventions initiated to prevent elopement. Record review of Nurses Notes (NN) dated 4/7/10 at 10:00 AM and 4/8/10 at 10:30 AM revealed that Resident 9 exhibited an increase in confusion, restlessness and agitation. On 4/8/10, NN indicated that orders were received from Resident 9's physician to start an antidepressant medication. A Clinical Health Record of a physician visit dated 4/8/10 revealed that Resident 9 exhibited "increased episodes of "Dementia", "Up at night roaming times 2 in the last week." NN on 4/10/10 at 1:25 AM revealed that Resident 9 was up two times between 11:00 PM and 1:00 AM and ambulated to the nurses station. NN's dated 4/10/10 at 3:30 PM revealed that Resident 9 had gone out to the patio at 2:00 PM and had crossed the street and was walking by the church. Resident 9 left the facility unsupervised and unnoticed by facility staff. Resident 9 was returned to the facility by staff with no injury and a wanderguard security device was placed on Resident 9's left ankle. Interview on 6/9/10 at 2:45 PM with the DON revealed that Resident 9 did not have a new ERA completed after the elopement on 4/10/10. C. Resident 11 was admitted to the facility on [DATE] according to 6/10 treatment sheet. According to Resident [DIAGNOSES REDACTED]. Resident 11's MDS dated [DATE] identified Resident 11 as having short and long term memory problems and modified independence with cognitive skills for daily decision-making. A review of Resident 11's Care Plan revealed a problem dated 4/22/10 of "resident is at risk for wandering from facility unattended due to long and short term memory loss." Interventions included: - "Wander prevention device q (every) shift", - "Make sure wander guard is in good working order q shift", - "Allow to wander freely within facility", - "Take on walks or allow to wander ad lib in enclosed courtyard when weather allows", - "Divert attention when resident becomes insistent on leaving facility", - "Verify location of (Resident 11) frequently", - "Check promptly when alarm system goes off to insure resident's safety/whereabouts. Redirect resident's attention as needed." In an interview on 6/10/10 at 11:15 AM, Van Driver G reported Van Driver G checked wander guard bracelet once per month for functioning. Van Driver G provided documentation that Resident 11's wander guard bracelet was checked on 5/25/10. Observations revealed Resident 11's wander guard bracelet was functioning when checked by Van Driver on 6/10/10. In an interview on 6/10/10 at 11:05 AM, LPN (Licensed Practical Nurse) Charge Nurse, reported daily checks of Resident 11's wander guard bracelet should be recorded on treatment record. A review of Resident 11's 6/10 treatment record revealed no documentation of wander guard bracelet being checked. In an interview on 6/10/10 at 11:25 AM, DON (Director of Nursing) reported nursing staff were not checking wander guard bracelets for functioning each shift just for placement. The DON reported that, if checking the wander guard bracelet it was not on Resident 11's treatment sheet, it was not being checked. D. Record review of an Admission and discharge Summary sheet dated 3/22/10 revealed Resident 15 was admitted to the facility on [DATE] and re-admitted on [DATE]. Record review of a Fall Risk assessment dated [DATE] revealed that Resident 15 had a score of "0". According to the scoring information on the Fall Risk assessment sheet, a score of 10 or above represented high risk. Record review of a fax sheet sent to Resident 15 physician dated 4/21/2010 revealed Resident 15 had a fall to the floor. Record review of an Unusual Occurrence report dated 4/21/2010 revealed the preventive measure was to instruct the resident to use the call light. Record review of a fax sheet sent to Resident 15's physician dated 4/23/2010 revealed that Resident 15 was found in front of a recliner and the personal alarm was sounding. Record review of an Unusual Occurrence Report dated 4/23/2010 revealed the preventive measure was a personal alarm. Record review a fax sheet sent to Resident 15 physician dated 4/25/2010 revealed Resident 15 was on the floor. According to the information on the fax sheet dated 4/25/2010, Resident 15 slid off the bed with the personal alarm attached. Record review of an Unusual Occurrence Report dated 4/25/2010 revealed the preventive measure was "none this shift". Record review of a Fax sheet sent to Resident 15's physician dated 4/29/2010 revealed Resident 15 slid off the bed and landed on the knee's. Record review of an Unusual Occurrence report dated 4/29/2010 revealed the preventive intervention was a "blue bumper to define edge of bed". Record review of Resident 15's CCP dated 3/28/2010 revealed Resident 15 was at risk for fall. Resident 15's CCP did not contain any evidence that the interventions identified on the Unusual Occurrence Report dated 4/21/2010/, 4/23/2010, 4/25/2010 and 4/29/2010 had been identified on Resident 15's CCP. An interview with the DON was conducted on 6/10/2010 at 11:35 AM. The DON confirmed during the interview, that the interventions were not implemented to prevent further falls for Resident 15. |
2014-07-01 |