Based on review of facility policy, review of clinical records, review of facility documentation, and staff interviews, it was determined that the facility failed to provide supervision to Resident R1 and to ensure the proper function of the resident's wander guard devices which resulted in actual harm to Resident R1 who eloped form the facility, sustained a fall and a sinus fracture. The facility failed to ensure that Resident R3 was free of accidents during transportation via wheelchair which resulted in Resident R3 falling from the wheelchair requiring transfer to the hospital via Emergency Medical Services and diagnosis of a cervical fractured two of five residents reviewed. (Resident R1 and Resident R3)Findings include:Review of facility policy, "Elopement Management", revised July 2017 revealed that upon admission and readmission, residents will be assessed for elopement risk. Residents assessed on admission with risk for elopement will have interventions implemented to promote safety and preventative measures implemented to mitigate elopement risk. If a signaling device is determined to be an appropriate safety device, the facility is to check placement and function of the signaling device routinely. The Maintenance Director or designee will complete preventive maintenance. Review of Resident R1's clinical record revealed that the resident was admitted to the facility on December 13, 2018. An elopement risk assessment completed December 14, 2018, revealed a score of 12, indicating that the resident was at risk for elopement. Review of physician's orders dated December 14, 2019, included orders to check wander guard (signaling device worn by the resident worn to alert staff when resident is near exits) for function daily and check for placement every shift. Review of Resident R1's admission MDS assessment (periodic assessment of resident needs) dated December 20, 2018, included diagnoses of non-Alzheimer's dementia (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability), muscle weakness, and age-related cognitive decline. The assessment also indicated that the resident had a BIMS (Brief Interview for Mental Status) score of 9, indicating moderate cognitive impairment and exhibited wandering behaviors on one to three days of the seven day look-back period. Review of physical therapy evaluation and plan of treatment completed January 9, 2019, indicated that the resident was able to ambulate 510 feet during a six minute walk test and that the "resident presents with good activity tolerance, with minimal balance deficits, she is at her baseline from her last discharge. As her functional test scores indicates minimal risk of falls she doesn't require skilled physical therapy services at this time."Review of Resident R1's quarterly MDS assessment dated March 22, 2019, revealed a BIMS score of 12, indicating moderate cognitive impairment, and no wandering. The assessment indicated that the resident required supervision for walking in the resident's room, corridor, and on the unit. Balance during walking was not steady, but able to stabilize without human assistance. Review of Resident R1's nursing progress note of April 2, 2019, revealed "resident left the unit around 1820 (6:20 p.m). Was informed by staff she had left the unit via an unidentified elevator. Began search of the entire building with all available staff. Was then informed by our Director of Nursing (DON) that she had been located out side and was being transported by ambulance to a local hospital". Additional progress note of April 2, 2019, indicated that the DON was notified at 6:45 p.m. that the resident may be out of the building. The DON then received a phone call that the resident was on the ground outside the building. The resident had sustained a hematoma to her forehead from the fall. The resident had a wander guard on the right upper extremity which was removed and tested by the DON upon returning to the building. The wander guard was functioning and the alarm sounded. Review of hospital emergency department (ED) note of April 2, 2019, revealed resident was brought in by Emergency Medical Services (EMS) for head injury and fall. "Patient wandered away from the dining hall today at the nursing home, tripped, hit her head on concrete as well as sustained some abrasions to her right palm". The Hospital Emergency Department discharge note of April 2, 2019, revealed "minor nondisplaced sinus fracture, will treat with Augmentin C (antibiotic) and follow up with ear nose and throat discharged home with antibiotics". Review of physician's consult of April 5, 2019, revealed minor left frontal sinus fracture and recommended observation, Augmentin orally (antibiotic) and to avoid trauma/pressure to forehead for two weeks.Review of Resident R1's April 2019 Treatment Administration Record (TAR) revealed no documentation that the wander guard had been checked for function from April 1-4, 2019.Review of facility documentation revealed that another resident had observed Resident R1 getting on the elevator on 2 Main. The other resident called the receptionist to alert her that Resident R1 was on the elevator. An elopement drill was initiated. The DON was notified that Resident R1 was found outside the building on the ground. The resident had sustained a hematoma to the forehead and 911 (Emergency Medical Services) had been called.Interview with Resident R2 on April 9, 2019, at 10:55 a.m. indicated that she was playing cards in the aviary by the elevator on 2 Main nursing unit. Resident R2 heard Resident R1 state she was "going home" and saw Resident R1 get on the elevator. Resident R2 stated that no alarm sounded at that time. Resident R2 called the receptionist on the ground floor to alert her that Resident R1 was on the elevator. The receptionist indicated that Resident R1 was not there. Resident R2 stated that the phone call was made at 6:41 p.m. Interview with the Nursing Home Administrator (NHA) on April 9, 2019, at 11:05 a.m. revealed that the elevator by the receptionist desk does not have a wander guard alarm, however, there is an alarm on the door to the outside. The alarm did not sound on the door when Resident R1 exited. The NHA revealed that the resident exited the front door, went down the driveway, and up the sidewalk towards the business office building where she was found.Interview with facility business staff, Employee E3 on April 9, 2019, at 11:35 a.m. revealed that he was leaving the business office building around 6:45 p.m. when he saw a resident on the ground. Employee E3 indicated that bystanders had stopped to assist the resident and he checked her name band. Employee E3 called the receptionist to alert her and the DON arrived on scene.Interview with maintence staff, Employee E4 on April 9, 2019, at 11:55 a.m. revealed that residents from 2 Main can access the elevators even if wearing a wanderguard. Employee E4 indicated that all exits to outside have wanderguard alarms, including the lobby entrance. The sensitivity on all alarms was increased to better detect residents wearing wander guards.Interview with the DON on April 9, 2019, at 12:10 p.m. revealed that the elopement drill worked in this situation, but the equipment was deficient. All staff were re-inserviced on elopements after the incident.Interview with Physical Therapy Director, Employee E8 on April 10, 2019, at 10:35 a.m. revealed that Resident R1 had been reassessed on January 9, 2019, and it was determined that resident could ambulate independently and was able to ambulate 500 feet without difficulty. Therapy Director estimated that Resident R1 had ambulated approximately 400 from the front door to the location of the fall.The facility failed to supervised Resident R1 and failed to ensure proper function of the resident's wander guard device which resulted in actual harm to Resident R1 who eloped form the facility, sustained a fall, required transfer to the hospital via Emergency Medical Services and diagnosis of a sinus fracture. Review of Resident R3's annual MDS assessment dated February 12, 2019, revealed a BIMS score of 15, indicating that the resident was cognitively intact. The assessment also indicated that the resident required extensive assistance of one person for locomotion on the unit and used a wheelchair for mobility.Review of progress note of March 2, 2019, revealed that at approximately 5:45 p.m. Resident R3 had fallen from the wheelchair in the dining room. Resident was able to state that she was being wheeled into the dining room for dinner when she fell forward out of the wheelchair. Resident R3 was assessed with a large hematoma over the left eye and a small laceration on the bridge of the nose. Emergency Medical Services (911) was called. Review of progress note of March 3, 2019, revealed that the resident was admitted to the hospital with a C-spine fracture ( fracture of cervical vertebrae in the neck). Review of hospital after visit summary dated March 8, 2019, revealed diagnosis of closed type III fracture of odontoid process (projection that grows off the front portion of the second cervical vertebrae) requiring a laminectomy cervical posterior fusion (surgery to stabilize the spine).Review of written statement of licensed staff Employee E6 obtained on March 2, 2019, revealed that Resident R3 stated "she was being wheeled into the dining room by Employee E7 (nursing assistant) and she was pushing her too fast." Review of facility submitted information indicated that Resident R3 asked Employee E7 to "slow down," but Employee E7 continued to push Resident R3 to the dining room table, at which time Employee E7 stopped abruptly and the resident fell forward out of her chair.Interview with the Physical Therapy Director on April 10, 2019, at 10:40 a.m. revealed that Resident R3 required a bariatric wheelchair and was in the appropriate wheelchair at the time of the incident.Interview with the DON on April 10, 2019, at 9:15 a.m. revealed that the resident was not interviewed because she was sent directly to the hospital. Additional interview at 1:45 p.m. revealed that the facility determined that non licensed staff, Employee E7 was responsible for the accident and terminated Employee E7.The facility failed to ensure that Resident R3 was free of accidents during transportation via wheelchair which resulted in Resident R2 falling from the wheelchair and requiring transfer to the hospital via Emergency Medical Services. Resident R3 sustained a cervical fractured as a result of the fall requiring surgery.483.25(d)(2) Free of Accident Hazards/supervision/devicesPreviously cited 10/5/1828 Pa. Code: 201.14(a) Responsibility of licenseePreviously cited 10/5/1828 Pa. Code: 201.18(b)(1)(3) Management28 Pa. Code: 211.10(d) Resident care policiesPreviously cited 10/5/1828 Pa. Code: 211.12(d)(1)(5) Nursing servicesPreviously cited 10/5/18
| ||Plan of Correction - To be completed: 05/15/2019|
Preparation and/or execution of this Plan of Correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The Plan of Corrections is executed solely because the provisions of federal and state law require it. The Plan of Correction serves as the facility's allegation of compliance.
Resident R1 was immediately evaluated by the Director of Nursing and was transferred to Bryn Mawr Hospital for follow up treatment on 4/2/19.
Resident R1 currently resides at Broomall Rehabilitation and Nursing Center which provides a secure environment for residents.
Prior to the incident, Resident R1's wander guard bracelet was checked daily by the nursing staff for function and on each shift for placement. This is confirmed in both Point Click Care TAR documentation and on paper forms used as audit tools. On April 2, 2019, Resident R1's wander guard bracelet was also checked for functionality after the event and was functioning properly.
A 100% audit of facility security systems was completed on 4/2/19. The audit was completed by the Maintenance Director/Designee and included wander guard alarms and bracelets as well as door alarms. Sensitivity was increased on the Wander Guard door alarms.
Resident R3 was immediately assessed by nursing staff and was transferred to Lankenau Hospital for further evaluation and treatment for a cervical fracture on 3/2/19.
The Resident Care Specialist/Certified Nursing Assistant who was transporting the resident by wheelchair was suspended immediately pending investigation on 3/2/19. Upon completion of the investigation, the RCS was terminated from employment on 3/7/19
Identification of Others at Risk
Residents who are assessed as a risk for elopement and/or residents who require wander guard bracelets have the potential to be affected by this alleged deficient practice.
Residents who require assistance with wheelchair transport also have the potential to be affected by this alleged deficient practice.
Upon discharge from the hospital and return to the facility on 4/2/19, Resident R1 was provided with the following services:
Physician orders for care including treatments and medication – 4/3/19
Temporary 1:1 observation – 4/3/19
Pain Assessment – 4/5/19
Skin Assessment – 4/5/19
Elopement Risk Evaluation – 4/2/19
Fall Risk Assessment – 4/2/19
ENT appointment for follow up – 4/3/19
ST evaluation – 4/4/19
PT evaluation – 4/6/19
FAST Assessment – 4/3/19
BIMS Assessment Reviewed – 4/12/19
Cognitive Testing – 4/3/19
Psych follow up - Ongoing
Social Services follow up for support - Ongoing
Family meeting to discuss best options for continued care including possible room move – 4/4/19
Second transfer to Bryn Mawr Hospital for further evaluation of ataxic gait on 4/3/19.
The receptionist on duty at the time of the elopement received a one on one inservice on elopement procedures and response. This training was provided by the reception supervisor on 4/23/19.
Facility staff received Elopement Training that included: Elopement Policy and Procedure, The definition of elopement per the State and Federal regulatory guidelines, Elopement Binders/books with identifying information including pictures on residents at risk for elopement, The Wander Guard System, Resident Identification, Testing the Wander Guard, The Facility Security Management Plan and Response to a Missing Resident.
The training was provided by the Staff Development Director, Interim Administrator and the Director, Regulatory Compliance. The training was completed on 4/2/19, 4/3/19, 4/4/19 and 4/18/19.
An external evaluation of the facility Wander Guard door alarms was requested thru the Company IT Department 4/3/19.
Wheelchair training was completed for staff who transport residents via wheelchair. The training was provided by the Rehab Program Manager and the Staff Development Director/Designee and was completed on 4/23/19 and 4/24/19. This training will be added to orientation and will also be completed annually.
Abuse and Neglect training will be completed for facility staff. The education will be completed by the Staff Development Director/Designee prior to the compliance date.
A QAPI Four Point Plan was completed regarding Elopement. The plan was completed on 4/2/19 with updates on 4/3/19, 4/4/19 and on 4/24/19.
The Plan will continue to be followed times three (3) months.
Any issues found will be corrected immediately and the Four Point Plan updated accordingly.
Any trends will be submitted to QAPI for further recommendations.
Ongoing Elopement Drills will be completed to determine further educational needs and the QAPI Four Point Plan updated accordingly.
These drills will be performed by the DON/Designee and will be completed monthly times three (3) months and quarterly thereafter.
Any issues found will be corrected immediately.
Any trends will be submitted to the QAPI Committee for further recommendations.
Monthly evaluation of Wander Guard alarms for functionality, sensitivity and/or any other issues are part of the TELS Preventative Maintenance Plan for Broomall Rehabilitation and Nursing. These will continue per protocol.
Wander Guard bracelets are checked every shift for placement and daily for functionality. As of May 1, 2019, functionality will also be checked every shift.
Any issues found will be corrected immediately.
Any trends will be submitted to the QAPI Committee for further recommendations.