cms_RI: 5
Data source: Big Local News · About: big-local-datasette
| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 5 | ROYAL OF WESTERLY NURSING CENTER | 415004 | 79 BEACH STREET | WESTERLY | RI | 2891 | 2018-02-08 | 689 | J | 1 | 0 | QYSV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on surveyor observation, interview and record review, the facility failed to identify hazards and risks to ensure an environment that is free from accident hazards, and provides supervision to each resident to prevent avoidable accidents for 1 of 20 residents who reside on the secured Westerly Unit relative to supervision and exit door alarms. Findings are as follows: On 2/6/2018 resident ID# 1 exited the glass exit door to an outdoor patio which is adjacent to the common area of the secured Westerly Unit. The resident was noted to fall outside of the door onto the ground which went un-noticed by staff. Resident ID# 1 was on the ground outdoors for an unknown period which resulted in a hospital admission for hypothermia and a laceration above her eye. During surveyor observation of the secured Westerly Unit on 2/8/18 at approximately 9:20 AM, it was identified that there were two exit doors which open to the outside. Both doors have an alarm located adjacent to the top of door which when in the on position will sound an alarm if the door is open. This alerts staff that someone has opened the door. The alarms can be shut off to each exit door by manually pressing the on and off switch. The common room exit door has a glass front full view and a push bar which easily opened with very little resistance and was noted to close itself upon exit. During an interview with the Director of Nursing on 2/8/2018 at approximately 9:40 AM she stated elopement assessments are not the practice of Royal Healthcare and therefore one was never completed for resident ID# 1. Additionally, she stated this resident had no elopement history and has never attempted to leave the facility. She states the door alarms should be on always and could not explain why the alarm had been shut off or who may have shut the alarm off. She states, according to nursing staff it appeared the resident may have stood up from her chair, ambulated to door, pushed on the door handle and fell out the door. It appears the door closed behind her with the resident on the ground outside of the building, and out of view of the glass door. During an interview on 2/8/18 at approximately 10:00 AM, with the activity staff member for the secure unit she states she works full time on this unit. She states she started activity approximately 10:10 AM and identified that resident ID# 1 was not there and thought she may be with the hairdresser or in her room. The activity staff states several minutes later she went to the patient's room to check on her and she was not there. She states, I then asked the nurse on the unit where the resident was. The nurse called the hairdresser and physical therapy to see if the resident was in either place. She states when it was found the resident was not with anyone else they began an immediate search and found the resident on the ground outside. During an interview with the unit nurse on 2/8/18 at approximately 10:10 AM, she stated that although she was not the nurse on 2/6/18 the unit was fully staffed with one nurse, three nursing assistants and one activity staff. During an interview on 2/8/18 at approximately 11:00 AM, with two full-time Westerly Unit nursing assistant, staff A and B, revealed that resident ID# 1 was left unattended in the common room on the Westerly Unit, which is described as a secure unit. The resident was last seen by staff at approximately 9:30 AM, and then found outside on the concrete patio which is adjacent in the common room. Per the incident report the resident was found outside at 10:45 AM. S/he had fallen outside to the side of the glass door. Staff A and B told the surveyor that the resident was not visible from the inside of the facility. Additionally, both stated the door alarm did not sound and was noticed to be off when the resident was found. Review of the resident record for resident ID# 1 revealed s/he was admitted on [DATE] to the secured unit with a [DIAGNOSES REDACTED]. S/he was unable to complete a brief mental status test due to severe cognitive impairment. Review of the quarterly comprehensive assessment completed 1/2018 revealed the resident was a total assistance with all aspects of care and required the assistance of 1-2 staff to transfer and ambulate, however per the plan of care the resident sometimes forgets her limitations and gets up without assistance and is at risk for falls. Interventions/Approaches to this problem include: observe frequently and encourage activity in a supervised area when out of bed. Staff to stay with me when I am not in a common area because I am impulsive. Review of the incident report and progress notes for 2/6/2018 reveals that at approximately 10:45 AM resident ID# 1 was found outside of the common room exit door on the ground. Her temperature was noted to be between 81 and 82 degrees when she was found. She had a laceration above her eye. The resident was verbally responsive and cold to touch. Nursing staff wrapped the resident in blankets and 911 was called. Staff noted the door alarm was in the off position and did not sound to alert staff that the door had been opened. During an interview with the Director of Nursing on 2/8/2017 at approximately 1:10 PM, she was unable to provide a policy for maintenance or monitoring of the alarms on this secure unit, but did provide a hand-written log for the past 3 weeks of weekly alarm testing by maintenance which had just been implemented 3 weeks ago. Additionally, she stated that prior to this incident there was no one responsible to make sure the alarms are on and functioning daily and was unable to provide evidence of staff education regarding the alarm system prior to this incident. You are hereby formally notified that where the above listed deficiencies also constitute non-compliance with the applicable provisions of the Rules and Regulations for Licensing of Nursing Facilities, they are deficiencies under State regulations and grounds for licensure sanctions. | 2020-09-01 |