cms_NE: 2438

In collaboration with The Seattle Times, Big Local News is providing full-text nursing home deficiencies from Centers for Medicare & Medicaid Services (CMS). These files contain the full narrative details of each nursing home deficiency cited regulators. The files include deficiencies from Standard Surveys (routine inspections) and from Complaint Surveys. Complete data begins January 2011 (although some earlier inspections do show up). Individual states are provides as CSV files. A very large (4.5GB) national file is also provided as a zipped archive. New data will be updated on a monthly basis. For additional documentation, please see the README.

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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
2438 WAKEFIELD HEALTH CARE CENTER 285209 306 ASH STREET WAKEFIELD NE 68784 2019-01-16 689 J 1 0 QW7C11 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER ,[DATE].09D7 Based on observations, record reviews and interviews, the facility failed to: 1) ensure interventions were in place for the prevention of elopement (when a resident leaves the premises or a safe area without authorization and/or supervision) for Residents 1, 3, 8 and 9; and 2) develop interventions for the prevention of elopement for Resident 2. The sample size was 9 and the facility census was 22. Findings are: [NAME] Review of the facility policy titled Wander Guard monitoring system dated ,[DATE] revealed the facility utilized an elopement prevention system known as Wander Guard (a bracelet/signaling device is worn by the resident and sounds an alarm if the resident comes within a certain distance of the door). The policy included the following: -Nursing staff were to determine at the time of admission, which residents were at risk for wandering. A wandering risk assessment was to be performed on the day of admission; -Residents determined to be at high risk to wander (scoring 8 or above on the wandering assessment) would have a signaling device applied to their dominant wrist. Due to certain conditions alternate placement of the signaling device might be necessary; -The 90 day signaling device would be checked daily to ensure it was functioning; and -Problems with the Wander Guard signaling devices would be immediately reported to the Director of Nursing (DON and the Administrator and the Care Plan would be updated to reflect additional safeguards. B. Interview with Licensed Practical Nurse (LPN)-A on [DATE] at 4:40 PM revealed 6 residents currently residing in the facility wore Wander Guards. LPN-A indicated the following: -Resident 1's Wander Guard was not functioning; -Resident 1's Wander Guard could not be replaced as there were no additional Wander Guard bracelets available in the facility. C. Review of Resident 1's Wandering Risk assessment dated [DATE] revealed the following regarding Resident 1: -forgetful/short attention span; -experiencing feelings of anger/fear of abandonment; -known wanderer/history of wandering; and -the wandering risk score was 9 which indicated the resident was at moderate risk for wandering. Review of Resident 1's current Care Plan dated [DATE] revealed the resident was at risk to wander and a goal was developed that the resident would not wander away from the facility unattended. Interventions included the following: -anticipate and meet basic daily needs in an effort to deter exit seeking; -if exit seeking/wandering occurs try using distraction to get resident to return/remain in facility; -monitor Wander Guard signaling device placement and battery function daily; and -Wander Guard signaling device on at all times and replaced every 90 days and as needed. Review of Resident 1's Medication Administration Record (MAR) dated ,[DATE] revealed an order to change the Wander Guard signaling device every 90 days. Documentation indicated the Wander Guard signaling device was changed on [DATE]. Review of Resident 1's MAR dated ,[DATE] revealed the Wander Guard signaling device was due to be changed on [DATE]. Documentation on [DATE] indicated the Wander Guard was not replaced and a 9 (refer to progress notes) was documented on the MAR. Review of Resident 1's Progress Notes dated [DATE] revealed no progress notes regarding the Wander Guard Signaling device. Interview with LPN-A on [DATE] at 4:40 PM revealed LPN-A was not aware if additional interventions had been developed for the prevention of elopement by Resident 1 other than watching the resident more closely. Interview with the DON on [DATE] at 6:45 PM confirmed Resident 1's Wander Guard signaling device had not been changed as required on [DATE] due to unavailability of additional devices. The DON confirmed additional interventions for the prevention of elopement had not been developed for Resident 1. At 7:00 PM on [DATE] LPN-A was observed to test the functioning of Resident 1's Wander Guard signaling device. The device was functioning at this time. Interview with LPN-A at 7:00 PM on [DATE] confirmed Resident 1's Wander Guard signaling device was expired and the device needed to be replaced every 90 days to assure reliability. D. Review of Resident 3's MAR dated ,[DATE] revealed an order to change the Wander Guard signaling device every 90 days. Documentation indicated the Wander Guard signaling device was changed on [DATE]. Review of Resident 3's Wandering Risk Assessment completed [DATE] included the following regarding Resident 3: -forgetful/short attention span; -disturbed by environmental noise levels, recent medication change; -known wanderer/history of wandering; and -the wandering risk score was 8 which indicated the resident was at moderate risk for wandering. Review of Resident 3's current Care Plan dated [DATE] revealed the resident was at risk for wandering. Interventions included the following: -anticipate and meet basic daily needs in an effort to deter exit seeking; -if exit seeking/wandering occurs try using distraction to get resident to return/remain in facility; -monitor Wander Guard signaling device placement and battery function daily. It is kept on wheelchair so the resident cannot remove it; and -Wander Guard signaling device on at all times (on the wheelchair) and replaced every 90 days and as needed. Review of Resident 3's MAR dated ,[DATE] revealed the Wander Guard signaling device was due to be changed on [DATE]. Documentation on [DATE] indicated the Wander Guard was not replaced and a 5 (which meant hold) was documented on the MAR. Further review of the MAR from [DATE] through [DATE] revealed no evidence the Wander Guard was replaced. Review of Resident 3's MAR dated ,[DATE] and ,[DATE] revealed the Wander guard signaling device was checked every evening to ensure it was functioning. A 9 was documented on the MAR on [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE] (which meant to refer to progress notes). Review of Resident 3's Progress Notes from [DATE] through [DATE] revealed no documentation regarding the functioning of the Wander Guard signaling device. Review of Resident 3's MAR dated [DATE] through [DATE] revealed no evidence the Wander Guard signaling device was replaced (the last replacement was [DATE] which was over 90 days). Interview with the DON on [DATE] at 6:45 PM confirmed Resident 3's Wander Guard signaling device was not changed on [DATE]. The DON confirmed additional interventions were not developed for the prevention of elopement. At 7:09 PM on [DATE], Licensed Practical Nurse (LPN)-A tested the battery of Resident 3's Wander Guard signaling device and noted the device was not functioning. Interview with LPN-A at 7:09 PM on [DATE] confirmed Resident 3's Wander Guard signaling device would not be replaced as there were no devices available. E. Interview with the Administrator on [DATE] at 6:05 PM and 7:30 PM revealed additional Wander Guard signaling devices were ordered by facility staff on [DATE]. The Administrator indicated there had been a discrepancy with the billing from the supplier of the Wander Guard signaling devices and after this was resolved the supplier was paid on [DATE]. The Administrator reported the Wander Guard signaling devices were supposed to arrive on [DATE] but as of [DATE] the devices had not arrived. The Administrator reported being unaware that any of the Wander Guard signaling devices currently in use were not functioning. F. The immediate jeopardy identified on [DATE] was abated to a D level on [DATE] at 8:00 PM when: -15 minutes checks were implemented and documented beginning at 6:00 PM for Resident 1 and at 6:30 PM for Resident 3 on [DATE]; -motion sensors were placed by the doorways to Resident 1 and Resident 3's rooms to alert staff when the resident's exited their rooms; -daily checks of all Wander Guard signaling devices would continue; and -15 minutes checks and room door motion sensors would be implemented if the daily Wander Guard checks determined additional signaling devices were not functioning. [NAME] Review of a Wandering Risk assessment dated [DATE] revealed Resident 2 was admitted to the facility that day. Documentation further indicated the following regarding Resident 2: -forgetful/short attention span; -recent experiences included admission with the last month, transfer from one unit to another and surgery; -ambulates with 1 assist; -[MEDICAL CONDITION]; -Taking antidepressants; and -the wandering risk score was 7 which indicated the resident was at moderate risk for wandering. Review of Resident 2's Interim Admission Care Plan dated [DATE] indicated a goal that the resident will not wander from facility unattended. Further review of the Interim Admission Care plan revealed there were no interventions related to this goal. Review of the current Care Plan dated [DATE] revealed no evidence the resident's moderate risk of wandering was addressed and there were no interventions developed for the prevention of wandering and/or elopement. Observation at 6:35 PM on [DATE] revealed a handwritten note taped to the desk at the Nurses Station which indicated Resident 2 needed a Wander Guard when the supplies arrived. Interview with the DON on [DATE] at 7:30 PM revealed Resident 2 was currently not considered an elopement risk as the resident required assistance with transfers and mobility. The DON confirmed there was no documentation related to this assessment. Review of Resident 2's Progress Notes dated [DATE] at 1:39 PM revealed the resident scored at a moderate risk to wander. Documentation further indicated the resident was unable to ambulate without assistance, had an unsteady gait and therefore a Wander Guard was not to be placed at this time. There was no evidence additional interventions for the prevention of elopement were developed. Review of Resident 2's Progress Notes dated [DATE] at 5:59 PM included the following: -the resident was last seen in the room at 4:30 PM; -at 5:05 PM staff reported the resident was not in the room and the resident could not be located in the facility; -at 5:25 PM staff located the resident outside within the immediate block and at a house on the southwest corner. The resident was assisted back into the facility; and -the buttock area of the resident's pants was noted to be wet and muddy. The resident sustained [REDACTED]. H. Interview with the Administrator on [DATE] at 9:00 AM revealed the Wander Guard policy was revised and residents who were determined to be at moderate risk and high risk for wandering/elopement would have a Wander Guard. The Administrator reported additional Wander Guard signaling devices were delivered to the facility on [DATE] and were placed on Residents 1, 2 and 3. The Administrator reported there were 3 additional Wander Guards available for resident use and the plan was to keep some Wander Guards in stock. I. Review of the revised policy Wander Guard monitoring system dated [DATE] revealed .Residents determined to be at a moderate or high risk to wander will have a signaling device applied to their dominant wrist. [NAME] Interview with the DON and Registered Nurse (RN)-E on [DATE] at 9:47 AM revealed the following regarding the Wandering Risk Assessments: -Residents with a score of ,[DATE] were low risk for wandering/elopement; -Residents with a score of 5 or above were at moderate risk for wandering/elopement; and -Residents with a score of 11 were at high risk for wandering/elopement. K. Review of Resident 8's Wandering Risk assessment dated [DATE] revealed the resident's wandering risk score was 5 which indicated the resident was at moderate risk for wandering. Review of Resident 8's current Care Plan dated [DATE] revealed no interventions to address the resident's moderate risk for wandering/elopement. Observations of Resident 8 on [DATE] at 8:25 AM revealed the resident was not wearing a Wander Guard although the resident was identified at moderate risk for wandering/elopement. L. Review of Resident 9's Wandering Risk assessment dated [DATE] revealed the resident's wandering risk score was 7 which indicated the resident was at moderate risk for wandering. Review of Resident 9's current Care Plan (undated) revealed no interventions to address the resident's moderate risk for wandering/elopement. Observations of Resident 9 on [DATE] at 9:30 AM revealed the resident was not wearing a Wander Guard although the resident was identified at moderate risk for wandering/elopement. M. Interview with the DON and RN-E on [DATE] at 9:47 AM confirmed Resident 8 and 9 were not wearing Wander Guards and alternate interventions for the prevention of elopement had not been developed. The DON and RN-E further indicated the current Wandering Risk Assessments were most likely not accurate regarding the resident's risk for wandering/elopement. N. The immediate jeopardy identified on [DATE] was abated to a D level on [DATE] at 3:15 PM when: -The Wandering Risk Assessment form was revised to more accurately assess each resident's risk of wandering/elopement; -All residents of the facility were reassessed using the revised Wandering Risk Assessment form; -Care Plans for all residents identified at risk for wandering/elopement were revised and interventions for the prevention of elopement were developed and implemented; -All Wander Guards in use were functioning properly and additional Wander Guard signaling devices were available for use; -A plan was developed to routinely audit Care Plans and ensure interventions for the prevention of wandering/elopement were implemented; and -Provision of staff education regarding wandering assessments, implementing Care Plan interventions and monitoring to ensure interventions were in place for prevention of wandering/elopement. 2020-09-01