| 68 |
SANDIA RIDGE CENTER |
325032 |
2216 LESTER DRIVE NE |
ALBUQUERQUE |
NM |
87112 |
2017-03-20 |
323 |
G |
0 |
1 |
30NH11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that each resident received adequate supervision and assistive devices to avoid falls and elopement (unsupervised exit from the facility) for 2 (R #s 4 and 128) of 6 (R #s 4, 73, 79, 128, 156 and 160) residents reviewed for accident hazards. R #4 was not fitted with a Wanderguard device (an electronic monitoring bracelet), allowing her to exit the facility without detection. After R #128 sustained a fall which resulted in a fractured hip, the facility failed to provide adequate supervision, which resulted in the resident falling 2 mores times resulting in skin tears and another fractured hip. These deficient practices likely caused R #128's injuries, and could jeopardize residents at risk for elopement through exposure to street traffic, temperature extremes, or other environmental hazards. The findings are: Findings related to R #4: [NAME] Record review of a Risk Management System document dated 3/19/17 found that it pertained to an elopement event of R #4 on 03/17/17. The document indicated The resident exited the center with another resident at 7:12 pm. The staff was informed of the resident outside at 7:21 pm. The resident was brought back into the center and was assessed for injury and none was noted. B. Record review of R #4's care plan dated 08/02/16 found a focus area stating Resident/Patient is at risk for elopement related to: Cognitive Loss (thinking impairment) / Dementia. Among the listed interventions was Utilize and monitor security bracelet per protocol. All later versions of R #4's care plan were found to have continued this focus area and intervention. C. Record review of R #4's Minimum Data Set Assessment (a tool for reporting on resident characteristics) found a section stating Wandering - Presence & Frequency. To the question Has the resident wandered?, a response of Behavior of this type occurred daily was documented and signed by the Social Services Director on 01/27/17. D. Record review of R #4's progress notes found: 1. A nurse's note dated 07/25/16 stating Res (resident) up through much of shift wandering Tries doors and attempts to enter residents' rooms. Redirected multiple times. 2. A Social Services Dept. (SSD) note dated 07/26/16 stating She is exit seeking and has tried to get out the doors on hall 500. She is wearing a wanderguard bracelet as she does wander around the facility. 3. A Social Services Dept. note dated 08/03/16 stating SSD also spoke to (resident's family member/power-of-attorney) about how (R #4) is wandering around the facility and that she has been exit seeking. Again they refused to have her in the secured unit. The family believes she will adjust and that it will just take her time. SSD explained that we are worried for her safety as she tries to go out the side doors that do not have the wanderguard alarm system. Family wants to keep her in the general area. 4. An Administrator's note dated 08/10/16 stating . She continues to wander and is exit seeking. Family denies her needing a locked unit. Will continue to educate family that she would be safer in a locked unit. Resident has a wander guard . 5. A Social Services Dept. note dated 11/01/16 stating She does have a wanderguard. 6. A nurse's note dated 03/18/17, related to the elopement incident on 03/17/17, stating Resident left facility with another resident this evening at shift change. Residents both found at sign attempting to return. Resident no longer has a wanderguard. Requesting orders for renewal of wanderguard order. Spoke with family, and family wants resumption of wanderguard order. E. On 03/20/17 at 12:35 pm, during interview with the Administrator, she stated that R #4 was on a trial of not having a Wanderguard. She stated that she would look for documents supporting her assertion that a planned, intentional trial was taking place. She did not provide any such documentation by survey's end. F. On 03/20/17 at 12:52 pm, during interview with Unit Manager #3, she stated that R #4 was discharged to a hospital on [DATE], and returned on 03/14/17. She stated that EMTs (Emergency Medical Technicians) routinely cut off Wanderguards when transporting patients, and confirmed that R #4's Wanderguard was not replaced upon her return to the facility. She confirmed that the resident was not wearing a Wanderguard when she eloped through the facility's front door on 03/17/17. [NAME] On 03/20/17 at 12:55 pm, during interview with R #4's family member/power-of-attorney, she stated that R #4 is supposed to have a Wanderguard. She stated that R #4 had had a Wanderguard prior to being discharged to the hospital on [DATE], but that when she returned from the hospital on [DATE], she no longer had it on. She indicated that facility staff had advised her that a new physician's orders [REDACTED].#4 eloped. Findings Related to R #128: H. Record review of R #128's Nurse's Note dated 07/01/16 stated, This day an Agency nurse worked on hall 500. Reported that resident was found on the floor at 7am during breakfast, lying down and a pillow on the back of his head. Nurse stated assessed resident and was in pain. (Name of Nurse Practitioner) was informed and assessed Resident and gave new orders to transport resident to the ER (emergency room ) for evaluation. Efforts to reach the nurse for pertinent details fruitless. I. Record review of R #128's Nurse's Note dated 07/06/16 stated, Resident was re-admitted [DATE] from the hospital due to a hip fx (fracture). [NAME] Record review of the facility's investigative report regarding R #128's incident on 07/01/16 concluded by saying, His care plan has been updated with new fall interventions. K. Record review of the Fall Risk Assessment portion of R #128's Nursing assessment dated [DATE] indicated he scored 19.0 which was considered High Risk for falls. L. Record review of R #128's Nurse's Note dated 10/26/16 stated, Resident self-reported to me @ (at) around 1500 (3:00 pm), that he had tripped in his room; time unknown. He sustained 2 skin tears; one to his left outer elbow and one to his left knee. M. Record review of the facility's RMS (Risk Management System) Event Summary Report regarding R #128's fall on 10/21/16 stated Preventative measures in place prior to fall: n/a. The report also stated Interventions added immediately after fall and care plan updated: VS (vital signs) taken; woundcare. N. Record review of R #128's Nurse's Note dated 02/15/17 stated, Received call back from on call (Name of on call physician) for Radiology Report on (Name of R #128). Results are right intertrochanteric fracture (hip fracture) with minimal displacement. Keep patient comfortable and let (Name of R #128's physician) know in the morning. Message was left for family member during day shift. No call back. O. Record review of the facility Follow-up Summary of R #128's incident on 02/15/17 revealed The resident did have a surgical repair of his hip and has returned back to the center. Although the center could not conclude the causation of the fracture, it is possible the resident fell in his room and got himself back up. Per the hospital records, the ortho (orthopedic, the branch of medicine dealing with the correction of deformities of bones or muscles) notes stated his fracture was acute and was probably due to a fall as they found a laceration (a deep cut or tear in skin or flesh) to his scalp. P. Record review of R #128's History and Physical completed by his physician on 03/02/17 indicated his past medical history of [REDACTED]. It also indicated his subsequent surgeries related to those fractures: Left Hip ORIF (An Open Reduction Internal Fixation surgery which involves realigning the bone or joint and then using steel rods, screws and/or plates to keep the fracture stable) (MONTH) (YEAR), Right Hip ORIF (MONTH) 16, (YEAR). Q. Record review of R #128's care plan revealed he did not have a focus related to fall prevention or any fall related interventions prior to 02/16/17. R. On 03/15/17 at 2:53 pm, during an interview with LPN #4, she stated R #128 did not have a fall when he was on the 100 unit in (MONTH) (YEAR). She stated he complained of pain and was eventually sent out for an x-ray which confirmed a hip fracture however since nobody saw him fall she stated she did not consider that he fell . LPN #4 stated R #128 was unsteady on his feet, but did not consider him to be a fall risk. She also stated she was not sure whether R #128 had any interventions in place related to fall prevention. S. On 03/15/17 at 3:33 pm, during an interview with the DON, he stated that a resident is considered a fall risk after they have their first fall. The DON verified that R #128's first fall at the facility occurred on 07/01/16 which resulted in his left hip being fractured. The DON stated that after a fall, the resident's care plan should be updated with new interventions added to prevent future falls. The DON failed to provide an updated care plan for R #128 after his fall on 07/01/16 and after his fall on 10/21/16 which resulted in 2 skin tears. T. On 03/16/17 at 8:47 am, during an interview with the Administrator, she verified that R #128 did not have his care plan updated after his fall on 07/01/16 or after his fall on 10/21/16. She verified that his care plan was not updated until 02/16/17 after his fall on 02/15/17. The Administrator was unable to provide an answer as to what interventions were in place to prevent R #128's second and third falls. |
2020-09-01 |