Observations:
Based on clinical record review, staff interview and review of facility policy, it was determined that the facility failed to ensure two of 13 residents reviewed received adequate supervision resulting in an elopement and a fall during a transfer using a lift (Residents 33 and 35).
Findings include:
Review of facility policy "Elopement/Wandering Risk Assessment" reviewed June 13, 2022, revealed that "When responding to an alarm, if it cannot be determined what triggered the alarm, immediately verify that every resident is safe and accounted for by conducting a visual head and name reconciliation"
Review of Resident 33 progress notes dated June 1, 2021, at 11:46 p.m. revealed "Approx. 7 p.m. this Nurse investigated a door alarm coming from Admin (administration) area; alarm computer was checked but did not indicate a code alert (alert notifying staff that a resident wandered outside of their designated area by a wearable tracker); this Nurse followed the sound to the door near Administration offices; no one was observed outside or inside. A surgical mask was found on the floor near the steps by the BR (bathroom) door in the same area."
Review of Resident 33's progress notes dated June 1, 2021, at 11:46 p.m. revealed "Approx. 7:20 p.m., this Nurse arrived @ (at) Res (resident) room to admin (administer) meds (medications) & (and) discovered Res was not in her room nor in her BR (bathroom). Call light was not on. Immediately, Activities Area was checked & all rooms/BR's on unit were checked for Res. When Res not found on unit, Security was notified."
Review of Facility's investigation documentation for Resident 33's elopement dated June 1, 2021, revealed that staff did not conduct a visual head and name reconciliation when a door alarm was triggered by unknown means.
Interview with the facility's Nursing Home Administrator and the Assistant Director of Nursing on June 10, 2022, failed to provide any documentation showing that staff conducted a visual head and name reconciliation as per facility policy "Elopement/Wandering Risk Assessment".
The facility failed to provide Resident 33 with adequate supervision, which resulted in Resident 33 eloping from the facility for 20 minutes before the facility recognized resident was missing.
Review of facility policy "Lifting/Transferring/Repositioning Resident Safely," last revised December 2018 revealed: "Two employees will always be available when using a lift for residents who have no weight bearing ability and cannot provide assistance or balance."
Review of Resident 35's annual Minimum Data Set (MDS - periodic assessment of resident's needs) dated February 18, 2022 revealed the resident required an extensive assistance with two staff persons for transfers and had impairment to both upper and lower extremities.
Review of Resident 35's care plan revealed the resident was at risk for falls due to unsteady gait and poor balance, with an intervention added October 23, 2018 to "Please allow me to have assistance with 2 staff persons using Hoyer lift during transfers, toileting and [activities of daily living.]"
Review of Resident 35's progress notes revealed a nurse's note dated April 7, 2022, which stated, "On 4/6/22 at [7:30 p.m.]. The nurse was called into the residents room by staff. The resident was assisted to the floor by [nurse aide.] The resident was on the VERA LIFT. While on the lift the resident let go of the handles and began to fall. The [nurse aide] then assisted the resident to the floor. The resident was free from injury." The note further indicated the root cause of Resident 35's fall was: "The resident was being transfer using a lift with only one person. All lifts required 2 staff members."
The facility's failure to have two staff persons present while assisting Resident 35 during a transfer in the lift which resulted in a fall was discussed with the Nursing Home Administrator and Director of Nursing on June 10, 2022, at 9:35 a.m.
28 Pa. Code 201.29(c) Resident rights
28 Pa. Code 211.10(d) Resident care policies
| | Plan of Correction - To be completed: 07/15/2022
Part I.
A. To ensure residents safety, after elopement the resident was immediately given a code alert bracelet and shall receive ongoing elopement assessments. The nursing staff in-serviced on elopement policies and procedures.
B. Elopement binders were placed at welcome house, main office, and the nursing station to ensure all staff are aware of residents at risk for elopement. All nursing staff have a code alert pager that are worn at all times during shift that alert staff what resident is alarming. Staff were re-educated on how to respond properly using the pager system. Residents are assessed for elopement risk on admission, after 72 hours, 30 days, and quarterly. The WillowBrooke Skilled Court Center (WBC) staff were educated on what s/s to look for to identify someone that may elope, so proactive intervention can be in place to prevent elopement from occurring.
C. The Security Officers in Welcome House have pagers as well. Once the code alert alarms, the nursing staff respond and deactivate alert once the resident is visualized. Security then calls nursing to verify the resident is visualized. A report is written and completed for every code alert alarms to ensure procedure is followed.
D. Elopement status will be reviewed weekly during the standard of care meeting to ensure appropriateness of current residents and assess if any resident should be added to the list. A weekly elopement drill to be conducted x 4 weeks then monthly x2. The results will be presented to the QAPI committee for review.
Part II.
A. The deficient practice was past occurrence. The nurse was called into the room after the resident was lowered to the floor by the CNA. The resident was assessed with no injury noted. MD and the POA were made aware. No new orders. The CNA was given a performance counseling for following policy/procedure on proper lifting/transferring. Nursing staff were re-educated on proper techniques used to transfer residents with a mechanical lift.
B. The resident's transfer status is documented under special instruction tab in PCC that can be seen by the CNA and nurses. PT/OT/Nursing update information to include what assistance is needed for ADL's and transfer. There is also a Kardex tab in POC that has instructions on how to care for the resident. The information continues to be evaluated and updated as the resident's physical or mental ability change. Currently all residents who need mechanical lift transfer are clearly identified with number of staff assistance in place. Random observations on all three shifts are completed to assure that staff are using the appropriate lift and are providing required assistance.
C. An in-service to nursing assistants was completed on 5/30/2022 regarding safety on resident transfer, support, and reinforcement of the importance to follow the resident's plan of care. The DON/designee will conduct a random audit to ensure staff are following the correct care instructions per policy weekly x4 weeks, then monthly x2. Any non-compliance will be corrected timely.
D. Results of audits will be presented to the QAPI committee for review.
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