| 1599 |
PARKERSBURG CENTER |
515102 |
1716 GIHON ROAD |
PARKERSBURG |
WV |
26101 |
2018-07-12 |
689 |
K |
0 |
1 |
5JPY11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, review of the reported allegations of elopement to the nursing home program, and review of facility policy, the facility failed to provide an environment free from accident hazards over which the facility had control. Secure care equipment failed to function properly which had the potential to allow a resident, utilizing the secure care equipment, to leave the facility without staff knowledge. Once the door was opened by a visitor, a resident, or anyone not wearing a secure care alarm, any resident with a secure care alarm could exit the building without activating the alarm. Resident #34 was observed attempting to leave the facility when another resident exited the building. No alarm sounded although the resident had secure care devices on her ankle and wheelchair. Testing of the system found it failed to activate an alarm when a resident wearing a secure care device went through the door when opened by a visitor or other person not wearing a device. Further investigation found an incident when a former resident, Resident #58, had exited the facility while the door was held open by another resident. The report regarding that incident noted, Equipment will be tested , . The transmitter was tested and was working properly according to the immediate action taken. However, the investigation did not indicate if the testing was done when the door was opened or closed. After consultation with the State office a determination of immediate jeopardy was made based on the facility's failure to ensure the secure alarm system was working properly to prevent residents with secure care systems from exiting the facility without staff knowledge. The facility was previously aware of the elopement of Resident #58 on 05/24/18. This incident should have alerted the facility the secure care system was not operating properly. The facility NHA was notified of the immediate jeopardy on 07/11/18 at 12:05 PM The facility provided an acceptable plan of correction. After verifying implementation of the plan, the immediate jeopardy was abated on 07/11/18 at 12:15 PM This practice had the potential to affect five (5) of five (5) residents with a secure care system. Resident identifiers: #2, #38, #34, #37, and #45. After removal of the immediate jeopardy, deficient practices remained at a scope and severity of E. A random opportunity for discovery found the facility failed to ensure the environment over which it had control was free from accident hazards for Resident #4, who fell outside the facility while smoking. A cabinet was unlocked in the shower room creating a potential for more than an isolated number of residents to be exposed to a hazardous chemical. Facility census: 61. Findings included: a) Resident #34 On the morning of 07/10/18, at approximately 10:30 AM, observations found Resident #34 attempting to leave the facility when another resident, without an alarm system, was exiting the building. No alarm sounded at that time. At the time of the incident, the surveyor was unaware Resident #34 was wearing a secure alarm system. The surveyor was alerted to the incident when the male resident was cursing Resident #34, telling her to get back into the building. Licensed Practical Nurse, #52 intervened and assisted Resident #34 back inside the building. Review of the resident's medical record at 8:30 on 07/11/18, found a ninety-eight (98) year old female resident admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the resident's current care plan found a focus/problem of, Resident is at risk for elopement related to Cognitive Loss/ Dementia, dated 09/08/16. The goal associated with the focus/problem: Resident will not attempt to leave the facility without an escort. Interventions included: Secure care device to maintain safety, dated 10/26/17. On 04/29/18, this intervention was revised to include, Utilize and monitor security bracelet left ankle and left side of wheelchair per protocol. At 9:30 AM, on 7/11/18, LPN #52 was asked about the observation on Resident #34 occurring on 07/10/18. LPN #52 said the resident would try to exit the facility because she thought she needed to get her kids or get her mother and father. When asked why the secure care alarm did not activate yesterday, LPN #52 said the other resident had already opened the door. The other resident did not have a secure care alarm bracelet because he was allowed to go outside, unattended. Since the door was open, she could get out. LPN #52 said the door did not alarm if someone else already had it opened. The resident is smart enough to know she could make a beeline to the front door because the door was opened. At 10:00 AM on 07/11/18, investigation found Resident #34 had two (2) secure care alarm devices - one device was on her ankle and one device attached to her wheelchair. The alarm system of the front door was tested on [DATE] at 10:05 AM, by the NHA and the Maintenance Supervisor (MS). When a secure care bracelet was held by the MS, within approximately two to three feet of the front door, the door locked. However, once the MS stepped back from the door, the door could be opened. When the door was held open by the surveyor, the MS was able to pass through the front doors, while holding the secure care bracelet, without the alarm sounding. The MS said the alarm system should always activate when any resident with a secure care system passed through open doors. This had the potential to affect Residents #2, #38, #34, #37, and #45. At 11:05 AM on 07/12/18, the NHA said, As for the wander guard system we just had random checks in place that were not documented. It was just verbal saying the doors were checked. I have changed that now. b) Review of the facility reports of elopement to the nursing home program Further investigation of the facility's reportable allegations of elopement to the nursing home program found another resident, Resident #58, (now discharged ) had exited the facility on 05/24/18. The facility's investigation found, (Name of resident) and another male resident were found taking a walk outside of the facility back by the employee smoking area. (Name of Resident) does not have capacity and currently has a secure care transmitter in place. (Name of Resident) exited the facility while the door was held open by another resident who is alert/oriented and does not have a secure care transmitter. No injury occurred to (Name of Resident) or the other Resident. (Name of resident) re-entered the building without difficulty or issue. Equipment will be tested . alert/oriented resident will be educated. The transmitter was tested and was working properly, according to the immediate action taken. At 10:32 AM on 07/11/18, the NHA said she did not know how staff tested the doors after the elopement on 05/24/18. She could not verify the door was tested after being opened. Observation with the NHA found a secure care system on the front door, the patio door, leading to the staff smoking area and the service entrance doorway. At 10:50 AM on 7/11/18, the NHA said she called the Secure Care Company. She said, It is a fluke and Secure Care is on the way. The NHA verified the Secure Care Alarm System was supposed to alarm even if the door was already opened when any resident wearing a secure care alarm passed through the open door. c) Review of the facility's policy for, Patient Security Bracelet. The facility's policy, effective 05/01/16 included, Patient security bracelets (e.g., wander guard) will be inspected per manufacturer's recommendations but at a minimum of: Every shift for placement, and Daily for function d) Notification of immediate jeopardy At 12:05 PM on 07/11/18, the NHA was notified in writing the immediate jeopardy was being called due to the failure of the Secure Care Alarm System to function properly. The NHA was also informed the facility should have known about the malfunctioning system on 05/24/18 when an actual elopement occurred during which time the resident was wearing a secure care bracelet. e) Plan of correction Doors 1. All doors were manned by facility staff at 10:55AM to ensure no resident exited the building who were wearing secure care equipment. The Administrator (NHA) contacted the secure care health systems at 10:47AM to request tech support for secure care equipment failure. Call received from secure care tech at 11am to review step by step process of resetting the master code for the secure care system with the Maintenance Director. At 11:20am the secure care function was reset by the Maintenance Director and all doors were functioning appropriately with the door opened or closed when a resident with a secure care transmitter in place was trying to exit. Residents #2, #34, #38, #37, #45 have not experienced any negative outcomes. Resident #58 no longer resides in the facility. 2. All residents of the facility who have secure care transmitter in place have the potential to be affected. The Maintenance Director/designee checked all residents who have secure care transmitter bracelet to ensure proper functioning with or without the code entered and door was opened or closed on 7/11/18 at 2:16pm with no additional corrective action required. 3. The NHA/designee will reeducate all staff beginning 7/11/18 regarding ensuring the safety of residents with the secure guard wander system including the functioning of the secure care system with the door opened or closed and notifying Maintenance and NHA immediately if the system does not function appropriately with a posttest to validate understanding. Staff not available will be provided reeducation and complete posttest upon return to work by the NHA/designee. New staff will receive education and complete posttest during orientation by the NHA/designee. The maintenance director/designee will check the secure care system functioning daily across all shifts X 2 weeks including weekends then three times a week for two weeks then randomly thereafter to ensure the secure care alarm are function properly when the doors are opened and closed. 4. Trends identified will be reviewed by the Maintenance Director/designee monthly at the Quality Improvement Committee (QIC) for any additional follow up and/or inservicing until the issue is resolved and randomly thereafter as determined by the QIC committee. At 12:05 PM on 07/11/18, the immediate jeopardy was abated after verifying staff were posted at each exit door. The secure care system was repaired with technical support of the alarm company and the doors were repaired at 11:20 AM on 07/11/18. After removal of the immediate jeopardy, deficient practices remained at a level of E. f) Resident #4 At 11:25 AM on 07/09/18, Resident #4 said she fell the first night she came to the facility. She said she went outside to smoke, alone. She said she was not used to riding in a wheelchair, it was dark, and she was not familiar with the place and somehow, her wheelchair got stuck on the sidewalk and fell . She said an ambulance driver came along and found her. They didn't know I had fallen. She said she went to the hospital. I had a nasty black eye, broke some bones in my face and had a big knot on my head. They thought I broke my nose. After that I wasn't allowed to smoke alone again. Medical record review found the resident was admitted to the facility on [DATE]. Review of the nursing notes found the following entries: - 03/29/2018 at 10:26 AM, Admission Note: Resident admitted /readmitted to 220-[NAME] Arrived by private car and wheelchair. Information upon admission obtained from patient family and/or significant other chart. Reason for admission is Long Term Care. A Braden score of 20.0 and Fall Risk score of 6.0 were obtained as part of this assessment. Call bell placed within reach. Physician notified/orders verified: Yes. See nursing admission assessment (UDA) for detailed clinical findings. 03/29/18 at 8:54 PM, Resident fell while outside smoking, staff notified by EMS (Emergency Medical Services) staff bringing in new resident, EMS had already gotten resident up and placed in wheelchair and brought in building. Resident had notable swelling to left eye and forehead. Abrasions to left forehead, left eye and left nose. Neuro's (neurological check) intact. Patient requested to go to Hospital. (Name of physician) and Niece notified. 03/29/18 at 11:30 PM, Report called in from (name of local hospital) stating Resident was being released that CT (computerized tomography) was negative resident dx (diagnosis) was facial fracture and hematoma to left forehead Review of the hospital discharge summary, dated 03/29/18, found the resident had a traumatic hematoma of her forehead and a closed [MEDICAL CONDITION] bones. The smoking assessment completed on 03/29/18 at 10:26 AM, noted the resident did not use oxygen, did not have dementia, and independent smoking was allowed. According to the assessment, the resident was able to demonstrate the location of smoking area, able to hold, light and discard appropriately. Review of the risk management system found the resident fell on [DATE] at 8:30 PM Resident was outside smoking when EMS came to drop off a new admit and found resident on side walk. EMS picked resident up off of sidewalk and brought her inside in her wheelchair before alerting staff. Nurse assessed patient after being alerted of fall. Abrasions noted to left side of nose, left eye, left forehead and left cheek. Wounds cleansed with normal saline and [MEDICATION NAME] placed to avoid infection, resident alert and oriented stated she was trying to turn around to come back in and her wheelchair went off side walk and got stuck, she attempted to get herself unstuck and fell on left side of face. No other injuries noted. Resident requested to be sent to ER A second smoking assessment, completed on 03/30/18 at 4:22 PM (the day after the first assessment), noted the resident lacked capacity and lacked safety awareness with history of falls and was not allowed to smoke. This assessment noted the resident had dementia, poor memory and was unable to demonstrate the location of the designated smoking area. At 2:32 PM on 07/10/18, the Director of Nursing (DoN) was unable to provide any further information related to the resident's fall while smoking. She was unable to provide documentation the facility assessed the resident for the ability to physically transport herself to and from the smoking area. At 10:02 AM on 07/12/18, the DoN was again asked if she had any information to validate the resident was thoroughly assessed for safe smoking upon admission. No further information was provided. c) An observation of the 100 Hall shower room, on 07/10/18 at 7:35 AM, revealed the wall cabinet containing a bottle of Virex, a hazardous item, was unlocked. This was an area accessible to residents. According to the Material Safety Data Sheet (MSDS), Virex is a corrosive agent capable of causing permanent damage to the eyes and skin and is an irritant to the respiratory tract. It also noted Virex is capable of causing permanent damage to the gastrointestinal tract if swallowed. An interview with Nurse Aide (NA) #43, on 07/10/18 at 07:40 AM, verified the cabinet was unlocked and the side containing the Virex could not be locked with the key present. Additionally, there were keys hanging that did lock the left side of the cabinet, making locking and unlocking the left side accessible to anyone. An interview with the NHA, on 07/10/18 at 8:50 AM revealed that cabinets containing hazardous items should be locked and keys not readily accessible to anyone in the shower room. |
2020-09-01 |