Monroe Community Hospital

Based on an observation, resident and staff interviews, and record review conducted during an Abbreviated Survey (complaint #NY00103737), it was determined that for one of two residents reviewed for accidents, the facility did not provide adequate assistance devices to prevent accidents. Specifically, Resident #1, who uses a power wheelchair outside the facility after dark, was not assessed for safety devices. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy, and is evidenced by the following:

Resident #1 was admitted to the facility on 2/6/09 and has diagnoses including cervical spinal cord injury and quadraparesis (paralysis in arms and legs). The Comprehensive Care Plan (CCP), dated 12/14/10, included that the resident may be off the unit until midnight, and if going out on pass, he would be expected to sign out appropriately. The Certified Nursing Assistant (CNA) care sheet, dated 8/1/11, shows that the resident sits in a manual wheelchair during the day and can switch to the power wheelchair on the evening shift.

The 8/2/11 Minimum Data Set Assessment includes the resident has no cognitive impairment, is independent with setup help for locomotion off the unit, and uses a (manual or electric) wheelchair for mobility.

Review of a progress note written by the Nursing Supervisor on 7/14/11 revealed that upon her arrival to work at 12:10 a.m., she had observed the resident, who was wearing dark clothing, riding on the black electric wheelchair in the road. The resident was hard to see. There were no reflective markers of any kind on the chair. This same information was documented in an Incident Investigation report, dated 7/18/11, and on an undated memo written by the Director of Nursing.

When interviewed on 8/2/11 at 8:55 a.m., the resident said on 7/14/11 he was drinking at a bar and missed his bus. He came back to the facility in his power wheelchair, riding on the sidewalks, except for at one intersection, where there is a bump in the sidewalk. If he rides in the street, it makes it shorter to turn into the facility parking lot.

An observation made on 8/2/11 at 10:10 a.m. revealed that the manual and the power wheelchairs used by the resident are black. Neither wheelchair was fitted with safety devices that could warn drivers of a potential hazard.

When interviewed on 8/2/11 at 12:24 p.m., the Physical Therapist stated that she was aware that the resident was using the power wheelchair outside of the building, on the grounds, and to attend outside programs and did know that this resident is known to come home late at night. She reported that residents are not routinely assessed for safety devices, like reflectors or a flag, unless the resident makes a request or a referral to do so. At 1:30 p.m. that day, the Social Worker said that the Nurse Manager had asked her to look into reflectors for the resident's wheelchair, but she had not done anything yet.

[10 NYCRR 415.12(h)(2)]

Based on resident and staff interviews and record review conducted during an Abbreviated Survey (complaint #NY00103737), it was determined that for one of two residents reviewed for mental abuse and involuntary seclusion, the facility did not ensure that a resident was free from involuntary seclusion. Specifically, Resident #1 was left in bed after violating curfew the previous day and had a care plan in place that included the potential for involuntary seclusion. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy, and is evidenced by the following:

Resident #1 has diagnoses including cervical spinal cord injury and quadraparesis (paralysis of arms and legs).

Review of the psychiatric consultation note, dated 3/26/10, revealed a recommendation to include consequences for inappropriate behaviors in the resident's care plan. The example given was to remove the resident's wheelchair if the resident persists in making upsetting comments to another resident living on the unit.

The 12/14/10 Comprehensive Care Plan includes the resident may be up and off the unit until midnight. Failure to return to the unit at the designated time will result in removal of the wheelchair the next day if he does not have a program outside of the building.

A Social Worker's (SW) note, dated 7/14/11, includes that she met with the resident to determine if they would be meeting at 1:00 p.m. The resident stated he was told that he was late coming in so he was still in bed due to a change in his care plan. The SW was informed the resident was out past midnight the previous evening and returned to the to facility in an unsafe manner.

Review of the Behavior Care Plan, dated 7/18/11, revealed that the resident's failure to return to the unit at the designated time would result in the loss of his power wheelchair, may use manual wheelchair. If the resident looses use of the manual wheelchair, he will be placed in a stationary chair in his room as resident allows for 24 hours. The Nurse Manager's (NM) initials are at the bottom.

During an interview on 8/2/11 at 8:55 a.m., the resident stated that on 7/13/11 he was out drinking at a bar, missed the bus back to the facility, and rode in his wheelchair back to the facility arriving on 7/14/11 at approximately 12:15 a.m. The next day his Certified Nursing Assistant (CNA) told him that he had to stay in bed due to missing his curfew. He replied, "What? You're kidding me!" and called the NM and left her a message on her phone. When the NM came to see him, she told him he needed to stay in bed due to his behavior. He replied that he did not want to stay in bed all day, but did until the next day.

Interviews completed on 8/2/11 are as follows:

a) At 9:56 a.m., CNA #2 said she worked on 7/14/11, and the NM told her that the resident had to stay in bed that day, and he did.

b) At 1:30 p.m., the SW reported that she believes she saw the resident around 1:00 p.m. on 7/14/11 and he was still in bed. He told her to "ask them" when she inquired about this. The SW did not recall that his care plan required that he stay in bed for missing curfew. The SW also said that she did not participate in a decision to require that the resident stay in bed or in a stationary chair as a behavioral intervention. She did know of the plan to remove the power wheelchair. When asked at this time what she would expect if this situation arose, she stated that it is reasonable for the resident to call if he is late, and if inebriated to place him in a manual wheelchair.

c) At 2:15 p.m., the NM said that it was a team decision that the resident remain in bed that day, and she did tell the staff he was to stay in bed. She also said that on the 7/18/11 care plan "as resident allows" means that the resident could stay in bed that day if he did not want to stay in a stationary chair in his room, and administration told her to add that part to the care plan.

d) At 3:10 p.m., the Assistant Director of Nursing said he had participated in the 7/18/11 care plan regarding using a stationary chair, but this has not been used.

[10 NYCRR 415.4(b)(1)(i)]