Citation Number: 220003716
Citation Date: 3/13/2007
Violation Date: 10/30/2006
Class: AA
Penalty: $ 100000.00

T22 DIV 5 CH3 ART3-72311(a)(1)(C)(2) Nursing Services - General (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (C) Reviewing, evaluating and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan.

These regulations were not met as evidenced by:

The facility failed to review, evaluate and update, and implement the care plan for Resident A who had a history of multiple elopements. On 10/30/06 at around 8:00 p.m. Resident A eloped from her room located on the third floor. She was later found lying on the ground unresponsive at 8:25 p.m. in a small garden area in front of the Adult Day Health Center (ADHC). She was pronounced dead at 8:50 p.m. by the physician.

Resident A, an 82 year old female, was admitted to the facility on 6/23/05 with diagnoses of organic brain syndrome, depression and cervical spine fracture following a fall from home on 6/7/05.

The Minimum Data Set (MDS) dated 9/21/06, indicated Resident A was alert with short and long-term memory problems. She had moderately impaired cognitive skills for daily decision-making. Her behavior pattern indicated socially inappropriate/disruptive behavior on a daily basis and wandering behavior one to three times during the week. She spoke a non-English language, was hard of hearing but responded to simple, direct communication. She needed supervision when ambulating with a front-wheeled walker in and out of the room and had a history of falls. She needed physical assistance from staff with activities of daily living such as bathing, dressing and toilet use.

Review of the following Integrated Progress Notes revealed several incidents of elopement by Resident A:

On 1/19/06 at 9:30 a.m."Found resident in the basement outside waiting for the bus and wanted to go Chinatown."

On 5/12/06 at 12:50 p.m. "Resident is in the basement by ADHC (Adult Day Health Center). Staff went down and found resident walking pushing her wheelchair towards the construction area."

On 5/25/06 at 5:30 p.m. "Resident found by Sheriff down by Northside road per wheelchair was brought back to the unit by Hospital Sheriff and West 100 CNA."

On 6/15/06 at 4:00 p.m. "AT (Activity Therapist) called the ward and said she saw the Resident left the wheelchair in the first floor dining room and walk to the dock area going down the stairs."

On 6/18/06 at 7:15 p.m. "CNA after feeding one of the residents in the room, heard the west stairway door close. CNA checked and saw Resident A's wheelchair empty facing to the doorway and Resident A walking in the stairway holding the handrail on the 2nd step going down."

On 7/7/06 at 12:00 p.m. "Resident A was found by van driver wheeling self to construction area."

There were no documented assessments after each incident of elopement to determine the cause of the wandering behavior.

On 10/30/06 at 6:00 p.m. Resident went to the first floor and tried to argue with another resident. The Resident was escorted back to her unit. Restless, agitated, wanted to go to the elevator. Tried to kick and fight with CNAs 1 and 2 who prevented her from going to the elevator.

On 10/30/06 at 6:45 p.m. "Dr. ABC was notified of resident's severe agitation. Ordered 0.5 mg. (milligrams) Ativan IM (intramuscular), given."

On 10/30/06 at 7:30 p.m. LN (Licensed Nurse) spoke to Resident's daughter and explained to her about Resident A's several attempts to leave.

The following Focused Progress Notes dated 10/30/06 documented the events that occurred on the evening of 10/30/06 leading up to the time of Resident A's death.

At 7:45 p.m. "Resident A got out of bed and walked to the elevator. CNAs 1 and 2 and LN caught her in time and escorted her back to her bed."

At 8:00 p.m. "Resident checked, was in bed with her eyes closed."

At 8:05 p.m. "Because of Resident's multiple attempt to elope, Nursing Supervisor was notified sent a 1:1 coach CNA 3 to watch Resident."

At 8:10 p.m. "Resident not in bed when checked at this time. Resident eloped while CNA 3 was enroute to the unit. Resident went very quick, left her wheelchair and walker, disconnected her bed alarm."

At 8:15 p.m. CNAs 1 and 3 searched for the Resident. IP (Internal Police) was notified to help search the premises.

At 8:25 p.m. "CNAs 1 and 2 found Resident A on the ground close to the ADHC area on her back. Noted blood coming out of her right ear. Non-responsive, not breathing, Code Blue and 911 was called. When chart was checked, and there was a DNR (Do Not Resuscitate) order, the code was stopped right away.

At 8:50 p.m. "Pronounced dead by Dr. XYZ."

Review of Resident A's care plan revealed she was assessed for problem of risk for elopement related to dementia since 6/23/05. The goal of the care plan was Resident A will have no episodes of elopement and will be kept safe within the facility. The target date for the care plan was 7/6/06. There were no documented assessments after each incident of elopement. The following interventions were identified to address the problem of elopement:

1. Activity therapist - to explore with residents activities of choice to keep him/her busy and occupied.

2. Nursing staff - to supervise whereabouts of resident and provide redirection if resident is getting confused or noted wandering on and off the facility.

The above care plan was re-written on 5/23/06. There were no changes in the interventions despite the fact Resident A proved to be a high risk for elopement and injury. There were no evaluations made whether the interventions were effective for the Resident. She had 6 documented incidents of elopement from January to July 2006 that were all potentially dangerous situations because of the Resident's cognitive impairment and poor safety awareness until she finally eloped in the evening of 10/30/06 and was found dead outside the building of the facility.

The facility environment and resident areas were inspected on 11/22/06 at 4:00 p.m. The Resident's room was next to the Nurses' Station and the west elevator was around the corner from the Resident's room.

On 11/22/06 at 4:10 p.m. CNA 1 was interviewed. She recalled the incident on 10/30/06 and stated she put the Resident back in bed at 7:50 p.m. and she was quiet then. She went to another room to put another resident in bed. CNA 2 only worked 4 hours so she left at 8:00 p.m. At 8:10 p.m. The Licensed Nurse told CNA 1 that Resident A was gone. "Her bed alarm was disconnected. CNA 1 checked the rooms and bathrooms. I checked the basement, the Day Room, and smoking area but nobody saw her. CNA 3 arrived. CNAs 1 and 3 went down to the first floor and checked the east and west side. CNA 3 found the Resident. She was laying on her back with blood on her right ear. Her pants pulled down to above her knees. Her shirt was up to her waist. She was laying next to the square cement on the ground but there was no blood on the cement."

The Nurse Manager was interviewed on 11/27/06 at 3:15 p.m. She stated Resident A was very demented but a very active lady. The family requested Resident A remain on the floor and to try to use Risperdal to control her behavior. She also said, "I don't know what triggered her behavior the night of 10/30/06. She left her wheelchair and walker in her room. I think the Resident walked to the west elevator to the basement, got out of the west exit near the ADHC. The sheriff who was supposed to be there at the exit was sick and there was no coverage. The Resident was found unresponsive with grass on her hands and her pants were pulled down."

The Licensed Nurse was interviewed on 11/27/06 at 4:50 p.m. She stated the following:

On 10/30/06, it was only the second time that she took care of Resident A. She gave her Albuterol inhaler at around 4:30 or 5:00 p.m. then she took her dinner break. When she came back around 5:30 p.m. she saw the Resident sitting in the wheelchair and the 2 CNAs trying to block her from going to the elevator. The CNAs said "We need help." The CNAs told her she had a history of taking off and she can be very aggressive and difficult to manage.

At 6:00 p.m. she checked the medication book and gave the Resident a tablet of Ativan 0.25 mg. with Ensure to calm her down but she spit out the medication and threw the Ensure at her. She called Dr. ABC who gave an order for Ativan (an anti-anxiety medication) 0.5 mg. IM (intramuscular). They put the Resident in bed, she was fighting but the 2 CNAs held her down and the LN gave the Ativan injection on the Resident's buttock.

At 7:55 p.m. Resident A was quiet but the LN had a feeling she would need help if she woke up restless, so she called the Supervisor who said she would send a sitter.

At 8:10 p.m. she was passing the medications then she looked again in the Resident's room and she was gone.

At 8:25 p.m. CNA 3 found the Resident and the LN came down with him. The LN saw the Resident on her back, pale, not breathing, with blood oozing from the right ear. She had her jacket on with her pants pulled down to her knees. Dr. XYZ notified the family and the Resident's daughter and son came and they were devastated.

On 3/05/07, a copy of the report (Case no: 2006-1131) from the Office of the Chief Medical Examiner Medical Division was faxed to the District Office. The document revealed the following: Cause Of Death: "Blunt Force Injuries". Manner: "Undetermined".

The Coroner's Report also indicated that "based upon the San Francisco Police Department investigation, it is apparent that the decedent went out the third floor window of Clarendon Hall at Laguna Honda Hospital; however it remains unclear if the decedent accidentally fell or jumped to her death. The decedent was exhibiting clinical dementia, continually tried to leave the hospital, and had history of falls prior to this event. Therefore the manner will be undetermined until further substantial information is received".

A copy of the San Francisco Police Report (No. 061160447) was faxed by the facility to the District Office on 3/6/07. The report documented that at 2015 hrs. on Monday, October 30, 2006, San Francisco Sheriff Watch Commander radioed that a resident (Resident A) from Ward 300 was missing, and was last seen in the ward about 2010 hrs. without shoes and wearing green pants. CNA 3 who had been searching for the resident entered the ward and said he found Resident A outside on the ground. The Sheriff Officer followed CNA 3 to the grassy area near the Clarendon Hall Basement Entrance where Resident A was found laying on her back, unconscious, and bleeding from her right ear. Dr. XYZ declared Resident A's death at 0850 hrs. The Sheriff Officer's report documented "When I observed (Resident A) lying on her back on the ground in that position, it appeared as though she apparently leaned down and then fell, hitting her head on a nearby concrete slab where her head was resting". "I have attached a copy of the Visitor's Sign in Log for Post Four (Clarendon Hall Basement Entrance). There was no cadet at that post after 2000 hrs. because that cadet had been assigned elsewhere. From 1800 hrs. to the time I received the call regarding (Resident A) disappearance, I stationed myself in the nearby parking lot. At no time did I hear any loud or unusual noises nor did I see (Resident A) leave the building. I observed very little activity outside the building".

Therefore, the facility failed to review, evaluate and update the care plan for Resident A to manage her wandering behavior. The written care plan was updated once on 5/23/06 with no changes in the interventions despite multiple incidents of elopement.

The facility failed to implement the care plan for Resident A when the staff failed to supervise the Resident's whereabouts and prevent the Resident from six (6) documented incidents of elopement from the facility from January to July 2006. Each incident was a potentially dangerous situation for Resident A because she was cognitively impaired and had poor safety awareness.

The facility failed on 10/30/06 to manage the Resident's agitated state and provide adequate supervision to prevent her from wandering out of the facility alone at night. She was found unresponsive on the grounds of the facility at 8:25 p.m. and pronounced dead at 8:50 p.m.

The above violations presented an imminent danger to the patient and were a direct cause of the death of the patient.