| 9581 |
DUFF MEMORIAL NURSING HOME |
285217 |
1104 THIRD AVENUE |
NEBRASKA CITY |
NE |
68410 |
2015-12-09 |
323 |
J |
1 |
0 |
548111 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference: 175 NAC 12-006.09D7 Based on observations, interviews, and record reviews; the facility failed to evaluate resident risk for elopement, provide supervision to prevent elopement, and failed to intervene when the resident did not return to the facility following a leave of absence for one resident (Resident 1). The facility had a total census of 36 residents. Findings are: A. Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Facility investigation dated 12/3/15 stated Resident 1's truck had been parked outside the facility and on 11/30/15 Resident 1's son had brought the keys to the truck. Resident 1 had requested the keys in order to be able to start the truck and sit in it while Resident 1 smoked. Resident 1 also wanted to drive to the store or Walmart to get cigarettes and gas. According to the investigation, Resident 1 was informed that Resident 1 needed to tell facility staff if Resident 1 was leaving the facility. On 12/1/15, Resident 1 could not open the door to the truck due to the truck battery being dead. The Activity Director assisted Resident 1 in getting a locksmith to come out and unlock the truck. On 12/2/15, maintenance staff jump started the truck for Resident 1 and Resident 1 left for Walmart at 11 AM to get a new battery. The Administrator was informed at 6:30 PM on 12/2/15 that Resident 1 had not returned to the facility. The Administrator texted staff stating that the Administrator was not worried and that if the resident was not back in the morning we might start worrying. At 7:24 AM on 12/3/15, the Administrator received a text stating Resident 1's son had been informed Resident 1 had tried to enter Canada via the North Dakota border and was at Pembina County Memorial Hospital in Cavalier, North Dakota. According to the report, Resident 1 reported leaving Omaha and when turning onto I 29, Resident 1 was uncertain if Resident 1 should go left or right. A review of a note written by the Social Service Director dated 12/3/15 revealed Resident 1's son was contacted at 3:45 PM on 12/2/15 when Resident 1 did not return from a trip to Walmart. Resident 1's son reported Resident 1 would leave for long periods of time and might stay out until midnight or even until the next morning. A Progress Note dated 12/3/15 at 1 AM stated Resident 1's son had called the facility to inform the facility that Resident 1 had been found at the border of North Dakota and Canada. According to the Progress Note, Resident 1 had stated Resident 1 was looking for Resident 1's son's house who lived in Nebraska City. Emergency Department Notes from Pembina County Memorial Hospital in Cavalier, North Dakota revealed Resident 1 had driven to the U.S. Port at Pembina, North Dakota. Resident 1 had been confused and had an outdated license. The Progress Note stated Resident 1 believed Resident 1 was in Canada and had told the custom's agent/deputy that Resident 1 was heading for Mexico. A Progress Note dated 12/3/15 at 3:10 AM stated a call had been received from Pembina County Hospital in Cavalier, North Dakota to inform the facility that Resident 1 was in the emergency room . A review of Mapquest Driving Directions revealed it was a total of 618.2 miles between Nebraska City, Nebraska and Cavalier, North Dakota. A review of Resident 1's MDS (Minimum Data Set; a comprehensive assessment used for care planning) dated 11/4/15 revealed Resident 1 scored 3 on the BIMS (Brief Interview for Mental Status; a screening tool used to detect cognitive impairment). A score between 0-7 is identified as the resident having severe impairment of cognition. Resident 1 was identified as independent with walking in room and requiring limited assistance of one for walking in corridor, and locomotion on and off unit. A review of Resident 1's SLUMS (St. Louis University Mental Status Exam) examination dated 10/30/15 revealed Resident 1 received a total score of 4. A score between 1 and 19 with less than a high school education indicated dementia. SLUMS Examination is used as a screening tool for orientation, memory, attention and executive functions. A review of Resident 1's Care Plan revealed a problem dated 10/28/15 of elopement risk on admission, questionable exit seeking, and wanting to go out and smoke. Interventions listed included the following: -Evaluate mobility, cognition, behavior and medications on admission, every quarter and as needed to identify any elopement risk factors. -If noting any exit seeking behavior reassess Wanderguard need (Wanderguard is a departure alert system that cause an alarm to sound when a resident wearing a bracelet attempts to exit a door equipped with a monitor.) -10/28/15; Wanderguard was placed as a precaution but removed 11/3/15 as resident had not made attempts to elope and requested Wanderguard to be off. -Monitor behavior for threatening to leave, seeking exits, pacing. 11/30/15, resident had not threatened to leave and had been able to follow smoking requirements. Resident 1's Care Plan was updated on 12/4/15 to state Resident 1 had no truck or keys at the facility and Resident 1 had a BIMS score of 8. A BIMS score between 8 and 12 was identified as moderately impaired cognition. Observations on 12/7/15 at 1:45 PM, Resident 1 reported going to get food at Walmart and ended up in Canada. Resident 1 was able to state the city that the facility was located in but was unable to state the name of the facility. Resident 1 reported that Resident 1 could go outside to smoke. Observations at 12/7/15 at 1:57 PM revealed Resident 1 seated outside of the facility on a bench in the smoking area. Resident 1 was smoking a cigarette. There was no staff members with resident and no staff members in the office where the windows looked out over the smoking area. Observations at 12/7/15 at 2:45 PM revealed Resident 1 seated outside of the facility on a bench in the smoking area. There were no staff members with the resident. In an interview on 12/7/15 at 1:54 PM, Registered Nurse A reported Resident 1's care plan had been updated. Resident 1 no longer had a vehicle or keys at the facility. Registered Nurse A reported Resident 1 still had privileges to go out and smoke alone. In an interview on 12/7/15 at 2:23 PM, Nurse Aide B reported Resident 1 was an elopement risk but didn't have keys to the truck anymore. Nurse Aide B reported Resident 1 could go out and smoke without supervision. In an interview on 12/7/15 at 2:43 PM, Nurse Aide C was not aware of any residents on the second floor at risk for elopement. In an interview on 12/7/15 at 3:09 PM, Licensed Practical Nurse D stated that starting with this shift, staff would be logging Resident 1 in and out to smoke but Resident 1 could be outside without supervision. In an interview on 12/7/15 at 3:17 PM, Nurse Aide E reported Resident 1 got cigarettes from the nurse but came and went as desired. In an interview on 12/7/15 at 2:28 PM, the Director of Nursing reported the Department of Motor Vehicles had been notified and Resident 1 would be receiving a letter regarding retaking the test for a driver's license. According to the Director of Nursing, facility policy was that the police would be contacted if a missing resident was not found after 15 minutes. The Director of Nursing reported Resident 1 was still allowed to go outside and smoke without supervision. In an interview on 12/7/15 at 2:50 PM, the Administrator reported meeting with Resident 1 and Resident 1's son regarding Resident 1 having the keys to the truck. The Administrator had gone over the requirements for checking out when leaving the facility and in the Administrator's judgment Resident 1 was okay with having the truck and keys. The Administrator confirmed that the Administrator had not reviewed Resident 1's cognitive assessment before the truck keys had been given to Resident 1. The Administrator confirmed being notified that Resident 1 had not returned to the facility at 6 PM on 12/2/15 and the Administrator made the decision to wait until morning before doing anything further. The Administrator reported going with Resident 1's son to transport Resident 1 from Cavalier, North Dakota back to the facility. On 12/7/15, Resident 1 was informed that Resident 1 would not be permitted to have the truck and keys while living at the facility. According to the Administrator, Resident 1 had stated Resident 1 did not want to stay at the facility if Resident was not permitted to have truck and keys. A review of the facility Leave of Absence Policy revised 5/17/2011 revealed the facility had a sign out book located at the first floor nursing station to record the date, time out, responsible party, destination, approximate time of return, and a reachable phone number. The Elopement Policy dated 5/17/2011 stated an elopement was defined as leaving the facility premises without following the facility's policy for leave of absence. Residents were to be assessed on admission, quarterly, and on changes of condition for elopement risk based on mobility, cognitive status, behavior and medications. A review of the facility Missing Resident policy revised on 5/17/11 stated facility staff were to contact the police when a resident couldn't be located within 15 minutes of noting that the resident was missing. B. The following interventions were initiated for Resident 1 on 12/7-8/15 to decrease Resident 1's risk for elopement and abate the immediacy of the situation -Wanderguard bracelet was applied on 12/7/15. -Elopement book was updated with Resident 1's face sheet and photo. -Resident 1 was to be given 2 cigarettes by the charge nurse for each outing and staff member was assigned to monitor Resident 1 while out of the building. -Flags were added to Resident 1's Medication Administration Record to instruct the charge nurse to assign a staff member to monitor resident while Resident 1 was outside. -Resident 1 was identified as high risk for elopement on report sheet. -Resident 1's care plan was updated with the new interventions. C. The following actions were initiated by the facility on 12/7/15-12/8/15 to abate the immediate jeopardy situation for all residents: -A Risk Assessment Elopement Decision Tree screening tool was implemented to evaluate each resident for risk for elopement. -All residents of the facility were screened using the Risk Assessment Elopement Decision Tree screening tool to determine risk for elopement on 12/7/15. -Report sheet was updated to identify residents at high, moderate, and minimal risk for elopement. -The Missing Resident policy was updated on 12/7/15 to state that if a resident did not return within 15 minutes of the time anticipated to return, the Missing Resident policy would be implemented. -The Elopement Policy was updated to include use of the elopement decision tree and to identify residents at risk for elopement on the report sheet. -Staff education on elopement and missing residents was started with the evening shift on 12/7/15 with all staff being educated prior to working their next shift. |
2016-07-01 |