CLASS AA CITATION 0- ACCIDENTS & SUPERVISION
The following reflects the findings of the California Department of Public Health during the investigation of complaint.
Regarding : Accidents
The investigation was limited to the specific complaint/self reported event investigated and does not represent the findings of a full inspection of the facility.
Representing the Department of Public Health Dennis Burlingame HFEN
The facility must ensure that -
(1) The resident environment remains as free from accident hazards as is possible: and
(2) Each resident receives adequate supervision and assistance devices to prevent accidents.
The facility failed to supervise a wheel chair bound resident who had displayed wandering and exit seeking behaviors approximately 40 minutes prior to the accident.
Despite the facility having a Care Plan which directed staff to keep the Resident in an observed area and despite the facility policies which directed staff actions in the event of door alarm activation, Resident A was still able to exit the alarmed emergency door. On 11/7/09 at approximately 3:30 P.M., Resident A exited an alarmed emergency door onto a stairwell landing. The resident then pushed open a second metal door and, while secured in his wheel chair, the resident tumbled down a concrete stairwell, landing at the base of the stairs. The resident was transported to a nearby hospital , where he died 11/9/09 from injuries sustained during the fall.
On 11/19/09 at 2:50 P.M. , Immediate Jeopardy [IJ] was called as the facility did not have an adequate system in place to ensure that other residents who exhibited wandering behavior on the 2nd floor where Resident A resided , did not exit the emergency doors. Seven (7) other residents besides Resident A were identified as exhibiting wandering behavior.
On 11/19/09 at 5:34 P.M ., the IJ was abated after a credible plan of correction was received from the facility . The plan of correction included the following :
1. A 24-hour monitoring system was developed that included designated employees who would monitor the emergency exits. 2. Residents with wandering and elopement behavior will be identified and assessed. 3 In-service education on monitoring will be completed by 11/30/09. 4. Education of employees will include how to respond to alarms, and how to turn alarms on and off. 5. Delayed door release system will be installed on all emergency exits.
Resident A was admitted to the facility on 514/09 with diagnoses that included dementia (progressive decline in mental function) and psychosis (loss of contact with reality ). according to the AdmissionlDischarge Summary. According to the resident's Minimum Data Set assessment (MDS) Resident A's cognitive skills for daily decision making indicated that the resident had modified independence and difficulty in new situations only. Review of the resident's medical record revealed a Care Plan, documenting that Resident A was at risk for falling and injury related to his dementia, congenital anomalies on hands (no fingers ), and his history of falls . The Care Plan also documented , "Approach Plan" 10/2/09, "keep resident in observed area while in WC [wheelchair) and soft belt while in WC for safety."
The facility's report of the incident, on 1117/09 at 2:30 p, M., noted that Resident A was seen by the staff sitting in a wheelchair (WC) in front of the nurse's station. At 3:15 P.M .. the resident was seen in the hallway. At 3:25 P.M., the door alarm on the East exit door of the facility went off. There was a cement landing outside the East exit door. A metal grate door with a push handle was to the right of the alarmed exit door. When the metal grate door was pushed opened, there was one flight of cement stairs which lead down to the ground level. Resident A exited through the alarmed East door, and then opened the metal grate door. The resident was discovered on the ground at the bottom of the cement stairs lying on his right side while still in his WC. Two people were outside the building and saw the resident on the ground. One person went for assistance. and the other person called for emergency personnel.
On 11/18/09 an observation was made of the East stairwell on the second floor at the facility. The Door Alarm log was then reviewed . The Door Alarms had been checked and found to be working between 1109 and 11/09. The door alarms were checked monthly according to the maintenance Supervisor.
According to the Nurses' Notes for 11/7/09 at 2:30 P.M., Resident A was in front of the Nurses' station. Per the Notes, "The resident was alert and responsive to both verbal and physical stimuli."
During an interview with CNA 6 on 11/19/09 at 2:15 PM , the CNA said that on the date of the incident [11 /7/09]. "The alarm went off and Licensed Nurse 1 [LN 1] and the Restorative Nursing Assistant (RNA) responded. The resident was at the exit door. they turned him back to the nurse's station. This happened around 2:40 PM
On 11 /19/09 at 9:30 A.M, the Supervisor was interviewed . She said that she was. "In the reception area in the front lobby" when she was told there was a resident lying on the ground and she was directed towards the East stairwell. The Supervisor went on to state that she ran outside and saw the Resident lying on the ground. The Resident was still in his wheelchair. The Supervisor said, "I then ran up the stairs and knocked on the exit door. Licensed Nurse 1 [LN 1] opened the door and I told her that Resident A was on the ground . Per the Supervisor. "The Resident was bleeding from the head and ear. pressure was applied to the head wound" and the emergency personnel had arrived and took over care of the Resident.
According to the Nurses Notes dated 11/7/09, the paramedics (emergency personnel) arrived at the facility at 3:35 P.M. The Resident was transferred to the hospital at 3:50 P.M.
The facility's Director of Nursing [DON] interviewed Licensed Nurse 1 [LN 1] on 11/11/09. On 11/19/09 documentation of the interview was reviewed. LN 1 was unavailable for interview by the Department. Per this interview record , LN 1, "Thought she heard an alarm pause a little bit and then she quickly walked to the emergency exit door ... She [LN 1] then turned off the sound, she looked outside from inside (door) she heard the Supervisor knocking, she opened the door and the Supervisor told her to go downstairs to check and stay with the Resident." The emergency personnel arrived about 8-10 minutes later and took over care of the Resident. LN 1 was asked by the DON if someone had called her attention to the incident and LN 1 stated, "No." The facility's Director of Nursing [DON] interviewed Licensed Nurse 2 [LN 2] on 11 /9/09 at 2:00 P.M. On 11/19/09 documentation of the interview was reviewed . LN 2 was unavailable for interview by the Department. Per this interview record , Resident A had been placed in the dining area in front of the Nurses' station. Per the interview record , "The resident propels self around; he is fast, in a matter of minutes he would be gone from where he was." "We (nursing staff) have been taking turns to watch him in Nurses station/dining room." Per the interview record , LN 2 was located in another hallway at the time when the door alarm went off and taking vital signs and giving medication Per the interview, LN 2 could have heard the alarm, but she had a stethoscope (used to transmit sounds in the body to the nurse's ears) and was giving medications to another resident. "The next thing she knew the Supervisor is telling her the resident had an accident.."
The Interdisciplinary Team (lOT) notes dated 11 /9/09 supported CNA 6's statement that Resident A previously attempted to exit through the alarmed door on 11 /7/09. Per the lOT notes, "The resident is up in wc daily for safety monitoring every 2 hours . needs to be in observed area when in wc. 10/31 /09 . with wandering behavior propels himself in and out of room , on way to hallways or in front of nurses' station . Staff started to watch and keeping him in dining room for meals, activities, in Nurses' station or front of nurses station for monitoring his behavior."
On 11 /19/09 the facility's policy, "Actions to take in event of door alarm activation or general power outage in the facility" were re viewed. Per the facility policy, "It is the policy of the facility, upon activation of any door alarm ...... to ensure the continued safety of all residents is maintained. The facility has established procedures for accurately identifying and quickly locating any resident, who is determined or believed to be missing from the facility ." Procedure: 1. In the event of Alarm: a. Determine which door was activated. b. Visually inspect each door to see if open or if any resident's are near or outside door. 2. Immediately conduct resident count to ensure all residents on unit can be accounted for.
On 11/18/09 an observation was made of the East stairwell on the second floor at the facility. The exit door had an alarm that emitted a high pitched sound when opened. There was a cement landing outside the exit door. The stairway was to the right and was entered by going through a metal grate door with a push handle. The Door Alarm log was then reviewed. The Door Alarms had been checked and found to be working between 1109 and 11/09. The door alarms were checked monthly according to the maintenance Supervisor.
Resident A exited the building through the alarmed emergency door and fell down 20 steps onto a concrete landing at the base of the stairs while still secured in his wheelchair by a soft belt restraint. The resident suffered multiple lacerations on face, scalp with bright red blood coming out of left ear per the emergency department flow Resident A was admitted to the hospital with diagnoses of, "Acute fall with clinical basilar skull fracture, left maxillary sinus fracture , scalp hematoma and hemo tympanum [blood in the middle ear] per the Emergency Physician documentation. Resident A died on 11/9/09. According to the autopsy report, the cause of death of Resident A was. "Complications following blunt force trauma of the head and torso ."
The facility failed to supervise a wheel chair bound resident who had displayed wandering and exit seeking behaviors. Despite the facility having a Care Plan which directed staff to keep the Resident in an observed area , and despite the facility policies which directed staff actions in the event of door alarm activation, Resident A was still able to exit the alarmed emergency door unobserved. The facility's failure to supervise Resident A presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result and was a direct proximate cause of the death of the patient.