| 9487 |
PREMIER ESTATES OF PIERCE, LLC |
285139 |
P O BOX 189, 515 EAST MAIN STREET |
PIERCE |
NE |
68767 |
2013-08-06 |
323 |
J |
0 |
1 |
C9MJ11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7, 12-006.09D7a Based on observations, record review and staff interview; the facility failed to assure a safe environment was provided for residents identified at risk for falls and wandering. The outside exit door of the Activity Room was propped open and staff failed to respond to the door alarm for 3 minutes. Resident 38, who was at risk for wandering and falls, was seated in a wheelchair outside of the building on an unsecured patio and was unattended during this time. In addition, the facility failed to transport Resident 47 to the whirlpool room in a safe manner on 2 occasions. Facility census was 51. Findings are: A. Review of admission orders [REDACTED]. Review of facility policy entitled Resident Elopement with a revision date of 8/20/12 identified when an employee heard a door alarm, the employee should immediately go to the site of the alarm. Review of Resident 38's Minimum Data Set (MDS- a federally mandated comprehensive assessment tool used for care planning) dated 5/28/13 revealed [DIAGNOSES REDACTED]. The assessment indicated the resident had short and long term memory loss with severely impaired decision making skills, required limited assist of one with locomotion, used a wheelchair for mobility in the corridor and had behaviors of wandering, rejection of cares and physical behaviors directed at others 1-3 days during the 7 day assessment period. Review of Fall Risk Evaluation for Resident 38 dated 5/28/13 identified a total score of 20. A total score of 10 or above represents a high risk for falls. Review of an Elopement Risk Review for Resident 38 completed 5/28/13 indicated the resident was at risk for elopement. Review of Resident 38's Care Plan (revised 6/6/2013) indicated the resident was at risk for elopement due to mobility status, [DIAGNOSES REDACTED]. Interventions included: -Provide safe location for wandering behaviors as needed. -Check placement and function of wander-guard bracelet every shift. -Increase observation of resident during and after visitors. Care Plan also indicated Resident 38 was at risk for wandering related to [DIAGNOSES REDACTED]. Interventions included: -Evaluate resident for placement of safety/monitoring device (wander-guard bracelet) quarterly. -Observe for increased safety risks, wandering into others rooms, constant wandering without rest, and exit seeking behaviors. In addition, Resident 38 was identified as a potential for injury related to falls due to impaired cognition, Alzheimer's disease, recent falls, history of falls, ambulatory/incontinent, balance problems and poor safety awareness with frequent attempts to self-transfer. The Care Plan identified Resident 38 had 11 falls during the last quarter. Interventions included: -Check on resident frequently. -Pressure alarm (device which consists of a control unit/box and a pressure sensitive pad. An alarm sounds when a resident moves from a certain position) to bed and chair at all times. -TABs alarm (personal alarm with a pull string that attaches magnetically to the alarm with a garment clip to the resident. When the resident attempts to rise out of the chair or bed the pull string magnet is pulled away from the alarm which causes the alarm to sound, alerting the care giver) to chair and bed at all times. -Fall mat to right side of bed closest to the window. -High/low bed to be kept in lowest position whenever resident in bed. -Self releasing safety belt with alarm to wheelchair. -Redirect resident if noted to be wandering down hallway to unoccupied area. -Encourage staff to answer alarms when going off and to toilet resident routinely and as needed. Review of Resident 38's Nurse's Notes revealed the following: -4/26/13 at 6:30 AM .alarm sounding, staff responds to alarm and finds resident on back beside bed. -4/30/13 at 6:30 PM .found on left side in activity room on floor. Resident had been up in wheelchair and wandered into an unsupervised area. Resident unaware of safety needs. -5/1/13 at 6 PM, Resident wanders through facility . -5/4/13 at 5 PM, Resident wandering through the hallway . -5/7/13 at 8:25 PM, Resident noted wandering about facility . -5/8/13 at 12:15 AM, Resident found lying on floor beside bed . -5/8/13 at 5:30 PM, Resident has been up in the wheelchair and self-propels around the facility. -5/9/13 at 5 PM, Resident wanders in wheelchair through facility . -5/12/13 at 11 AM, Resident has been trying to stand up multiple times this morning . -5/13/13 at 9:20 PM, Resident noted to be wandering the hallways . -5/17/13 7:00 PM, Resident noted to be walking wheelchair out of the activity room, alarms sounding . -5/17/13 at 7:45 PM, Resident found by staff sitting on the floor next to bed . -5/23/13 at 1:15 AM, Staff entered resident's room and found resident on the floor next to the bed . -5/25/13 at 5:00 PM, Resident wanders through facility halls and other areas . -5/25/13 from 8:30 PM to 11:30 PM, Resident tries repeatedly to get up out of bed . -5/26/13 at 5 PM, Resident wandering through the hallways, occasionally sets off alarms when attempting to stand up. -5/27/13 at 10 PM, Resident wanders about facility in wheelchair. -6/3/13 at 4:15 PM, Resident was found on the floor beside bed . -6/7/13 at 5:30 PM, All alarms sounding, resident found on the floor in Chapel area by the desk . -6/9/13 from 2 AM to 4 AM, Resident up and restless, makes repeated attempts to self-transfer, resident in wheelchair at Nurse's desk . -6/9/1 from 6 PM to 10 PM, Resident aimlessly wandering through facility with several attempts made to self- transfer . -6/18/13 at 6 PM, Observed resident lying on the floor on back in Room 46 with wheelchair behind resident . Intervention initiated to place resident on hourly checks to monitor whereabouts. -6/29/13 at 8:20 PM, Resident found on floor in hallway, tipped over wheelchair and lying on back. Resident to remain on hourly checks . -6/30/13 at 10:20 AM, Resident up in wheelchair wandering about . -7/1/13 at 2 AM, Resident's alarms sounding, resident attempting to get up. Resident up in wheelchair wandering the area . -7/6/13 at 4 PM, Resident continues to wander through the facility . -7/7/13 at 6 PM, Resident continues to wander through the facility . -7/25/13 at 7:30 PM, Resident is up in wheelchair and self-propels in the halls . -7/28/13 at 2:30 AM, Resident awake and restless, trying to get out of bed. Placed up in wheelchair at Nurse's Station . During an observation on 7/24/13 at 3:15 PM, Resident 38 self-propelled in a wheelchair from the Activity Room down the Wing 1 hallway to the Nurse's Station. Resident observed to have a TABs alarm, sensor alarm, and a self-releasing safety-belt in place. A wander-guard bracelet was noted to the resident's left ankle. During an interview on 7/25/13 from 8:40 AM to 8:45 AM, Registered Nurse (RN)-S verified Resident 38 was self-mobile in wheelchair and frequently wandered around in the facility. In addition, RN-S identified Resident 38 had sustained several falls over the last quarter and remained at high risk for injury related to falls and wandering. During observation of the Activity Room on 7/25/13 at 10:48 AM; the door which led to an outside unsecured concrete patio was propped open with a chair and a continuous alarm was heard sounding. No facility staff was observed in the Activity Room at this time. Further observation revealed Resident 38 was outside of the facility on the patio. Two concrete sidewalks extended off the patio. 1 sidewalk led to a road adjacent to a baseball field approximately 50 feet from the patio and the second sidewalk led to the facility parking lot which was approximately 50 feet from the patio. No facility staff was observed outside with the resident. Resident 38 had removed the self-releasing seat belt and had attempted to stand up from the wheelchair. The TABs alarm remained attached to the back of the resident's shirt but was pulled taunt, and the alarm for the self-releasing seat belt and the sensor pad were both sounding. No facility staff responded to the open door alarm or to the Resident's personal alarms which all continued to sound. At 10:51 AM (3 minutes later), the Activity Director (AD) wheeled Resident 47 out of the facility through the alarming open door and positioned the resident on the patio next to Resident 38. The Activity Director cued Resident 38 to sit down and silenced the resident's alarms, then walked back into the facility leaving both residents unsupervised outside on the patio. The AD retrieved a 2-way radio from a desk in the Activity Room and returned outside and used the radio to request staff assistance to the Activity Room. The Activity Room door remained propped open and door alarm continued to sound, but no further facility staff responded to the alarm. During an observation on 7/25/13 at 10:58 the AD removed the chair from the Activity Room door leading to the unsecured patio and closed the door silencing the door alarm. No additional facility staff responded to the door alarm during the 10 minutes the door was open and alarming. During an interview on 7/25/13 at 11:00 AM, the AD verified Resident 38 was at risk for elopement and falls. In addition, the AD indicated the door had been propped open so residents could be taken outside for an activity. When asked if AD would normally leave the door open with residents outside and unsupervised, the AD indicated it depended on whether or not there was an Activity Assistant scheduled to work. During an interview on 7/25/13 at 11:05 AM, the Administrator verified the AD should not have left the Activity Room door propped open and left Resident 38 outside unattended. In addition, the Administrator indicated all staff should immediately respond to a continuously sounding alarm. During an interview on 7/25/13 at 2:30 PM, the Administrator identified Residents 38, 6, 60, 32, 30, 54, 50, 37, 28, 44 and 15 were at risk for wandering, exit seeking and/or using a wander-guard bracelet. During the environmental tour completed 7/31/13 from 10:32 AM to 11:27 AM, the Maintenance Supervisor verified the distance from where Resident 38 was positioned on the patio was 41 feet from the road and 51 feet from the facility parking lot. ABATEMENT STATEMENT Based on the following, the facility has removed the immediacy of the situation: 1.) Assessments regarding wandering, elopement and risk for falls have been completed on all facility residents. 2.) A list of all residents identified at risk for elopement, wearing a wander-guard bracelet and at risk for falls compiled and posted in manner to alert all staff. 3.) All staff educated on assuring the safety of residents; residents not to be left unattended outside, reviewed list of residents identified at risk for falls, elopement and wearing a wander-guard bracelet, no outside doors to be left propped open and staff to respond in timely manner to door alarms and wander-guard alarms and resident personal alarms. Education also provided to temporary staff employed by nursing pool agencies (pool staff) regarding safety of residents and the system implemented to assure pool staff were alerted to residents identified at risk for falls, elopement and wearing wander-guard bracelets. 4.) Schedule completed to assure adequate coverage for activities using Department Managers whenever an Activity Assistant not available. All Department Managers were educated on need to provide assistance as scheduled with activities. 5.) The Interdisciplinary Team updated the care management assignment cards of all residents to ensure interventions were identified for residents at risk for falls and elopement to ensure resident safety. The immediacy has been removed, however, the deficient practice is not totally corrected. Therefore, the scope and severity has been lowered to D. B. Review of the Owner's Operator and Maintenance Manual for the 1900/1900S Bath Lift (A bath lift is a type of wheeled chair which may be used for transport. The same chair is then used to lower and raise a resident into a whirlpool bathtub) dated 7/13 revealed the following .During transfer, raise the seat so the resident's feet are suspended from the floor. DO NOT roll caster base over objects such as carpet, raised carpet bindings, door frames, or any uneven surfaces or obstacles that would create an imbalance of the lift and could cause the lift to tip over. C. Review of Resident 47's MDS dated [DATE] revealed [DIAGNOSES REDACTED]. The 7/8/13 MDS indicated the resident required extensive assistance for transfers. On 7/25/13 at 8:30 AM, NA-O (Nursing Assistant) was observed to wheel Resident 47, who was seated in the bath lift chair, down the corridor of Wing 2, over the raised carpet edge strip, across the carpeted area of the sitting area by the nurses' station, and over the raised carpet edge strip at the entrance of Wing 3. The bath lift chair seat was raised to a height of approximately 3.5 feet which caused the resident's feet and legs to dangle in the air. On 7/29/13 at 7:50 AM, NA-L was observed to wheel Resident 47, who was seated in the bath lift chair, down the corridor of Wing 2, over the raised carpet edge strip, across the carpeted area of the sitting area by the nurses' station, and over the raised carpet edge strip at the entrance of Wing 3. The bath lift chair seat was raised to a height of approximately 3.5 feet which caused the resident's feet and legs to dangle in the air. Interview with NA-T on 7/31/13 at 11:40 AM revealed residents were to be raised to a height where feet were just barely off of the floor when being transported in the bath lift chair. NA-T verified witnessing Resident 47 being transferred in the bath lift chair with the chair elevated to a level that was too high. NA-T was not aware the policy indicated the bath lift chair was not to be rolled over raised objects such as carpet or raised carpet bindings. |
2016-07-01 |