Evergreen Valley Nursing Home
Deficiency Details, Complaint Survey, February 10, 2010
Regional Office: Capital District Regional Office
F323 483.25(h): FACILITY IS FREE OF ACCIDENT HAZARDS
Severity: Potential for more than Minimal Harm
Corrected Date: March 19, 2010
The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents.
Citation date: February 10, 2010
Based on observation, record review and staff interview during a complaint investigation (Case #NY00080251), the facility did not conduct a thorough investigation to determine the possible systemic factors that contributed to a resident's undetected exit from the facility. Specifically, the facility lacked the device to test the functionality of the Wanderguard bracelet and Resident #1 was observed outside the facility, without a coat along the perimeter fence of the facility. The resident's location was reported by the motorist to an employee in the parking lot who assisted the resident back into the facility. There was no actual harm with the potential for more than minimal harm that was not immediate jeopardy. This was evidenced by the following:
The resident was admitted to the facility on 12/24/09 with diagnoses of Alzheimer's dementia, hypertension and depression. The "Nursing Admission/Readmission Form" dated 12/24/09, assessed the resident as oriented to person only and her verbal responses were not understandable.
The "Elopement Risk" form dated 12/24/09 at 2:10 pm, documented the resident was at risk for elopement and a "wanderguard (a transponder bracelet for detection) was applied."
The "Resident Personal Profile" dated 12/24/09, documented the resident was able to ambulate and transfer independently, able to verbalize and make her needs known and did not identify the resident's fall or elopement risk status.
The facility's Incident Report dated 12/26/09 at 9:45 am documented, "resident found wandering outside of facility at 9:45 am. Brought in by Certified Nurse Aide (CNA) at that time." The "follow-up activity" section of the Incident Report dated 12/26/09, documented a "yes" response to equipment failure, with the explanation "elopement wanderguard did not go off when resident stepped out past (passed) door." The corrective action documented was, the replacement of the Wanderguard and initiation of 15 minute checks. The Incident Report did not document the time the resident was last observed before being found outside the facility.
The facility's Investigation Note (summary) dated 12/28/09, documented the staff interviews determined the resident was last observed in the facility on 12/26/09 at 9:20 am, 25 minutes before she was found outdoors. This report documented the resident had no prior attempts to exit the facility. The Wanderguard was reportedly checked for function, prior to this undetected exit. The "Wanderguard Tester" (tests function of the wanderguard transponder) could not be located." Additional interviews during the facility's investigation revealed the Wanderguard Tester, had not been available for several days and that only placement of the Wanderguard bracelet was being checked by the staff.
The facility's written policy titled "Ankle Transmitter" dated 1/19/09 , documented the proper "fit" and location for the application and replacement of an ankle transmitter without any process for verification of function, prior to application of the transmitter (transponder). The "daily transmitter testing" read "the nurse in charge will test the transmitter daily to ensure it is working properly and document."
The "Daily Transmitter Testing Log" for December 2009 documented, "placement" on the night shift for 12/26/09, 12/27/09 and 12/28/09, but there was no documentation that the designated night shift staff checked the Wanderguard bracelet function. Check marks were present every shift between the evening of 12/24/09 and the evening shift of 12/25/09 to document the presence, but not the functionality of the Wanderguard.
CNA #1 who had been approached by the unidentified motorist, was interviewed on 1/7/10 at 2:35 pm. She stated she was told, "a lady is walking on the fence line near the opposite side of the facility's property, in only a sweater." She stated the resident was near the fence behind the laundry. The CNA continued, that she saw the resident was wearing a Wanderguard transponder and walked the resident around the building, to the employee entrance near the rear parking lot. Upon entering the facility the resident's Wanderguard transponder did not sound the detection alarm, she then reported that to the nurses.
The unit Licensed Practical Nurse (LPN #1) stated during an interview on 1/7/10 at 1:40 pm, CNA #1 reported returning the resident from outdoors. LPN #1 stated she checked the resident's vital signs (blood pressure, pulse and respirations) and stated she did not hear the Wanderguard alarm when the resident returned to the facility from outdoors. LPN #1 stated after this resident's alarm did not sound the alarm upon her return to the facility the other resident's Wanderguard transponder were checked for function by taking the residents to the door because the tester was not available, and "we found a couple with issues," but she could not provide additional details of those "issues."
CNA #2 stated during an interview on 1/7/10 at 1:30 pm this resident "followed people." On 12/26/09, she had observed the resident following LPN #1 on the unit earlier in the day and did not recall seeing the resident in the dining room at breakfast.
During an interview on 1/7/10 at 2:00 pm the Registered Nurse (RN #1) stated CNA #1 reported finding the resident outdoors, after informed by an unidentified motorist and requested she (RN #1) assess the resident. RN #1 stated, CNA #1 told her the Wanderguard did not work when the resident re-entered the facility, so it was replaced. RN #1 stated all Wanderguard bracelets were checked at the door as the tester unit was "missing" and "we had a few that did not work and we replaced those too." RN #1 was asked to describe the resident's whereabouts prior to her undetected exit and stated, "when I got here (7:00 am) she (Resident #1) was at the B-wing desk. She did follow them (toward the employee exit) when they were leaving and they redirected her back." When asked about the missing tester unit, she stated "A-wing knew it was missing and some of the B-wing (staff) knew it was missing. The (missing tester) message had been passed verbally shift to shift. It had been missing about 4 days."
During an interview on 1/7/10 at 3:45 pm LPN #2 stated, the Wanderguard Tester unit had been missing after her last use on 12/23/09 and was not available on 12/24/09 and she then checked placement only of the transponder while verbally reporting at shift change to oncoming nurses that the Wanderguard Tester unit was missing. She stated on 12/26 /09 when leaving the facility, after her shift between 7:30 am and 8:00 am, this resident had followed the 2 nurses (LPN #2 and RN #2) toward the employee entrance, they escorted the resident back to the dining room, and then these 2 nurses left the facility.
During an interview on 1/7/10 at 3:55 pm, RN #2 stated this resident had been "wandering around during the night, but did not attempt to leave the building until she followed us (LPN #2 and RN #2) to the time clock (at the employee entrance). We took her back to the dining room." She continued, "we (night shift) were to check the Wanderguard, but the checker (tester unit) had been missing since 12/23/09, so we were just checking for placement."
The evening shift supervisor (RN #3) stated during an interview on 1/7/10 at 4:30 pm, that the Wanderguard tester had been, "reported by word of mouth missing and only placement was being checked." She was unable to state a specific date when the Wanderguard Tester was first reported missing, but knew it had been a "few days."
During an interview on 1/8/10 at 11:40 am LPN #3 stated, "it was reported to me the tester was missing while I was off for 3 days, could have been around the 23rd."
During an interview on 1/7/10 at 11:50 am RN #4, who coordinated the facility investigation, stated that LPN #2 did not do Wanderguard function tests, but LPN #3 did do them and she was not aware of the missing tester until after the resident's undetected exit. When asked if all staff working on 12/26/09 were interviewed related to the undetected resident exit, she stated RN #1, "got statements from people who saw the resident. I think everyone was in the dining room." She stated she had not conducted interviews. She stated no interviews were done with the staff on who worked on the night shift, except to ask about the Wanderguard function testing completed.