El Rancho Vista Health Care Center
8925 Mines Avenue, Pico Rivera, CA 90660
Citation Number: 940004104
Citation Date: 08/12/2011
Violation Date: 7/7/2007
Class: AA
Penalty: $ 80,000

CLASS AA CITATION -- PATIENT CARE

F-323
CFR 483.25 (h) Accidents
The facility must ensure that-
(1) The resident environment remains as free from hazards as is possible; and
(2) Each resident receives adequate supervision and assistance devices to prevent accidents.

On 7/12/07, at 1 :37 p.m., an unannounced visit was made to the facility to investigate a self-reported incident about Resident 1. According to the report, Resident 1 was found missing from the facility on 7/7/07, at 4 p.m., and was later found to have been struck by a train.

Based on observation, interview, and record review, the facility failed to provide adequate supervision and assistance devices to Resident 1, who was at risk of elopement, by failing to:

1. Ensure that a departure alert device bracelet, a WanderGuard, was applied to Resident 1, who had history of wandering out of the facility.
2. Implement the physician's order for the use of a WanderGuard (a departure alert system).
3. Implement Resident 1's plan of care to monitor the resident's departure from the facility.

As a result, Resident 1 was struck by a train and sustained multiple traumatic injuries, which caused his death.

On 7/12/07, a review of Resident 1 's clinical record revealed the resident was an 80 year-old male admitted to the facility on 6/25/07, with diagnoses that included psychosis (severe mental illness in which a person loses touch with reality, experiences unusual perceptions, and holds false beliefs called delusions), alcohol abuse, emphysema (chronic lung disease) and abnormality of gait.

The Minimum Data Set ( MDS - standardized assessment and care planning tool) dated 7/3/07, indicated the resident had short and long-term memory problems and was moderately impaired in cognitive skills for daily decision-making. Resident 1 was assessed to have behavioral symptoms of wandering, which occurred daily and the behavior was not easily altered. The resident's behavior was also assessed as manifesting physically abusive, socially inappropriate and resisting care behavioral symptoms. The MDS also indicated the resident required limited assistance with walking and was independent with locomotion on and off the unit.

The physician's orders dated 6/25/07, indicated to give Resident 1 the antipsychotic medications, Zyprexa 5 milligrams (mg) twice a day for psychosis manifested by agitation and Haldol 5 mg orally or intramuscular injection every six hours as needed for combativeness or resistance to care. The orders also included the anticonvulsant medication, Depakote (used to treat manic episodes) 500 mg at bedtime for psychosis manifested agitation.

The attending physician also ordered on 6/25/07, a WanderGuard to prevent the resident from leaving the facility without permission. According to the manufacturer's information, WanderGuard is a selective departure alert system used to alert caregivers when a wanderer wearing a bracelet device exits through a monitored door or hallway. According to the form titled Elopement Risk Review dated 6/27/07, the resident was ambulatory, had elopement attempts in the past 30 days, manifested wanting to go home, and was always looking for exit doors. The facility staff considered the resident a risk for elopement.

A plan of care dated 6/28/07, developed for the resident's tendency to wander out of the facility, had a goal that the resident would not wander out of the facility every shift for three months. The approaches included: 1) Assist the resident in reorientation to the room and surroundings, 2) Monitor the resident's whereabouts with visual checks at least every two hours, and 3) WanderGuard bracelet on the resident's wrist to alert staff.

According to the Nurse's Notes, on 6/27/07, timed at 8 p.m., the resident attempted to walk out of the facility earlier during the shift and on 6/30/07, timed at 11 a.m., the resident tried to get out of the facility.

According to an entry in the Nurse's Notes dated 7/1/07, timed at 11 p.m., Licensed Vocational Nurse 1 (LVN 1) documented the resident tried to leave the facility. The resident walked to the back patio, stood on a Geri chair (geriatric reclining chair) and attempted to climb the patio wall. The resident lost his grip and landed on the Geri chair. LVN 1 documented the resident was agitated and resistive to care and was administered an intramuscular injection of Haldol 5 mg.

A Nurse's Notes documentation dated 7/2/07, timed at 12:47 p.m., indicated the resident went out the back door and was walking outside. The resident was directed to go back to the facility. The documentation made no reference to the WanderGuard and if the alarm went off.

The Nurse's Notes documentation dated 7/5/07, timed at 2 p.m., indicated the resident's roommate reported seeing Resident 1 exiting from the sliding door in his room. Staff went to locate the resident but did not find him. The administrator, the director of nursing, and the police were notified. The note further stated that a certified nursing assistant (CNA) found the resident on a street (busy street located approximately 0.25 miles from the facility) and gave Resident 1 a ride back to the facility. The time the resident was found and returned to the facility was not stated in the nurse's note. The documentation made no reference to the WanderGuard and if the alarm went off.

According to the form titled Activities Risk Meeting Notes, dated 7/6/07, the prior night (7/5/07), the resident stepped on a Geri-chair and climbed over the fence. The resident was later found on a nearby street and was brought back to the facility. The documentation made no reference to the WanderGuard and if the alarm went off. The documentation further indicated the plan of action was for the resident to wear the WanderGuard and to monitor the resident's whereabouts frequently.

Further review of the Nurse's Notes revealed that on 7/7/07, at 3 p.m., LVN 1 documented Resident 1 was observed sitting in the front lobby. At 4 p.m., LVN 1 documented the resident was not found in the facility and the police department was notified.

According to the Social Services Notes dated 7/10/07, timed at 2:15 p.m., Social Service Designee (SSD) received a telephone call from Police Detective informing the facility Resident 1 was hit by a train and died on Saturday evening (7/7/07, the same day the resident eloped from the facility).

The police detective informed the facility the time of death was 6:33 p.m.

On 7/12/07, at 1 :58 p.m., during an interview, LVN 1 stated that on 7/7/07, the resident was agitated and he informed LVN 2 (medication nurse) of the resident's behavior. At 2 p.m., LVN 2 administered the resident an injection of Haldol 5 mg. LVN 1 further stated that at around 3:36 p.m., he did not see Resident 1 at the nurse's station and told CNA 2 and other staff members to look for the resident while LVN 1 went to check the park. LVN 1 stated that around 4 p.m., he noticed a Geri-chair close to the patio wall outside the resident's room. LVN 1 was not sure how the resident got out of the facility.

On 7/12/07, at 5:16 p.m., during a telephone interview, followed by a written declaration on 7/17/07, CNA 2 stated she was assigned to take care of Resident 1 on 7/7/07, but was not informed the resident had wandering behavior until after the resident was missing. CNA 2 stated she did not remember seeing Resident 1 wearing a WanderGuard bracelet.

On 7/17/07, at 8:45 a.m., maintenance staff was observed changing the gate lock on the patio. At 9 a.m., during an interview, LVN 2 stated the side gate to the patio was observed unlocked and broken on the day the resident went missing. LVN 2 was not aware how long the lock had been broken.

Further record review revealed there was no documented evidence Resident 1 was wearing the WanderGuard bracelet as ordered by the physician during the three occasions the resident attempted to elope from the facility (6/27/07, 6/30/07 and 7/1/07), and when the resident eloped from the facility on four occasions (7/2/07, twice on 7/5/07, and on 7/7/07).

According to the Coroner's Report dated 7/8/07, on 7/7/07, at 6:33 p.m., a train struck Resident 1 as the train crossed over a rail bridge. The train engineer and the conductor saw a man squatting down in the middle of the train tracks, but were unable to stop the train in time.

An Examination Protocol from the Department of Coroner dated 7/10/07, indicated Resident 1's cause of death was multiple traumatic injuries sustained as a pedestrian struck by a train.

The facility failed to provide adequate supervision and assistance devices to Resident 1, who was at risk of elopement, by failing to:
1. Ensure that a departure alert device bracelet, a WanderGuard, was applied to Resident 1, who had history of wandering out of the facility.
2. Implement the physician's order for the use of a WanderGuard (a departure alert system).
3. Implement Resident 1's plan of care to monitor the resident's departure from the facility.
As a result, Resident 1 was struck by a train and sustained multiple traumatic injuries, which caused his death.

The above violation 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 Resident 1's death.