Springfield Assisted Living

Based on medical record review and staff interviews, the facility failed to prevent a resident elopement. This affected one (Resident #1) of three residents reviewed for elopement. The facility's census was 105.

Findings included:

Review of the medical record for Resident #1 revealed an admission date of 05/12/22. Diagnoses included Alzheimer's disease, delusional disorder, chronic obstructive pulmonary disease, depressive disorder.

Further review of the medical record revealed Resident #1 was cognitively impaired was independent with ambulation and used a walker.

Review of the progress note dated 05/13/23 at 8:55 P.M. revealed Resident #1 was found by police at the local gas station. Resident #1 had no injuries. The resident's son was contacted and returned the resident to the facility. A door alarm was placed on the resident's door. Resident #1's case manager was notified and would be looking for alternative placement for the resident, as the facility could no longer meet the resident's needs.

Review of the elopement risk assessment dated 05/20/23 revealed the resident was at moderate risk for elopement.

Review of the progress note dated 05/24/23 revealed Resident #1 received a 30-day discharge notice due to her increasing care needs. A copy was sent via certified mail to the resident's son and case manager.

Further review of the medical record revealed Resident #1 was never discharged as planned and second elopement took place.

Review of the elopement investigation dated 10/04/23 at 3:00 P.M. revealed Resident #1 walked out of the building with several other residents, got on the bus and rode to the local store. The resident then walked into the store and shopped for an unknown amount of time prior to walking out of the store. Resident #1 then got on a city bus and the driver realized she was memory impaired. The driver notified local police. The resident's son was made aware and went downtown to pick his mother up to return her to the facility. Once they returned, the Executive Director (ED) and Assistance Director of Nursing (ADON) spoke with the resident and son, in regard to, emergency guardianship and placement. Resident #1's son needed to get guardianship. Staff were educated not to allow Resident #1 to leave for outings. Resident #1 had no injuries from her elopement.

Interview on 10/12/23 at 9:20 A.M. the Executive Director (ED) revealed the facility did not have a locked unit nor did they utilize Wanderguards for cognitively impaired residents.

Interview on 10/12/23 at 11:10 A.M. with Bus Driver #200 revealed he had only been employed by the facility for three weeks during the time of the incident with Resident #1. Bus Driver #200 reported Resident #1 was sitting outside with the other resident shoppers when he arrived to pick them up. Resident #1 proceeded to get onto the bus and sat down. Bus Driver #200 verified the resident's name was not on the list, but he did not think anything about it due to the fact this was an assisted living facility. Bus Driver #200 revealed he dropped the residents off at the local store and proceeded to take a resident to the smoke shop across the street. Bus Driver #200 revealed he was gone for about 10 to 15 minutes. When the residents got back onto the bus to leave, he noticed Resident #1 was not there and asked if anyone had seen her. Bus Driver #200 went inside the store and tried to find her but when he couldn't, he went to the courtesy desk and asked for help. The store clerk proceeded to give him a paper stating Resident #1 got on the city bus and was being taken to the local police station. Bus Driver #200 revealed he now has pictures of residents he needs to watch out for and should not be going on outings.

Interview on 10/12/23 at 12:00 P.M. with Assistant Director of Nursing (ADON) #300 revealed she was in charge the day of Resident #1's elopement. ADON #300 revealed she found out Resident #1 was not in the facility by hearing a resident talking to the Activity Director and saying Resident #1 did not get back on the bus from their outing. At that time, the bus driver came up and reported what happened. ADON #300 revealed Resident #1 went outside and to sit after lunch, as she often does on good weather days. The facility residents were going on an outing and waiting on the bus at the same time. When the bus arrived, Resident #1 got on the bus along with the other residents. ADON #300 revealed Resident #1's son brought her back to the facility around 5:00 P.M.

Interview on 10/12/23 at 12:30 P.M. with the ED verified the facility was not equipped to handle residents with cognitive impairment and could no longer meet Resident #1's needs and issued a discharge notice but they never discharged the resident.

Based on staff interview and medical record review, the facility failed to administer medications as ordered. This affected one (#14) out of the four residents sampled for medication administration. The facility census was 98.

Findings include:

Review of the medical record for the Resident #14 revealed an admission date of 04/22/22 with medical diagnoses of diabetes mellitus, hypertension, chronic obstructive pulmonary disease, and atrial fibrillation.

Review of the medical record for Resident #14 revealed a Medicaid Quarterly assessment dated 06/27/22 which documented Resident #14 was oriented and required assistance with bathing and medications and was independent with transfers and ambulation.

Review of the medical record for Resident #14 revealed a form titled, After Visit Summary from Hospital #1 dated 06/03/22 which documented Resident #14 went to the Emergency Room (ER) on 06/03/22 due to complaints of cough and anxiety. The hospital physician ordered Famotidine (antacid) 40 milligram tablet two times per day, hydroxyzine pamoate (an antihistamine that is used for anxiety at times) 50 milligram capsule four times per day as needed and ondansetron (nausea medication) four milligram tablet every eight hours as needed and ordered a follow up appointment with Physician #2 to be scheduled.

Review of the medical record for Resident #14 revealed no nurse or physician notes to support the resident went to the ER on 06/03/22. A nurse progress note dated 06/07/22 at 12:22 A.M. documented Resident #14 had two new prescriptions for famotidine and hydroxyzine pamoate, and the orders were faxed to the pharmacy.

Review of the June 2022 medication administration record (MAR) for Resident #14 revealed famotidine was not given until 06/07/22. The review of the June MAR did not have documentation to support the ondansetron was ordered.

Interview on 09/02/22 at 2:30 P.M. with Director of Nursing (DON) #60 confirmed Resident #14 returned to the facility on 06/03/22 from the hospital. DON #60 confirmed Resident #14 did not receive famotidine and hydroxyzine pamoate medications ordered on 06/03/22 in the ER. DON #60 confirmed the medications were not ordered or given until 06/07/22.

This violation substantiates Complaint Number OH00135247.

Based on medical record review, staff interview and policy review, the facility failed to notify the physician and family representative of a resident's change of condition. This affected one (#115) out of the three residents sampled for change of condition. The facility census was 98.

Findings include:

Review of the medical record for Resident #115 revealed an admission date of 08/27/18 with medical diagnoses of kidney disease, failure to thrive, hypothyroidism, and Depression.

Review of the medical record for Resident #115 revealed a Medicaid Quarterly assessment dated 01/20/22, which stated the resident had limited memory but was alert and required assistance with medication administration. The assessment revealed the resident was able to transfer herself and utilized a wheelchair.

Review of the medical record for Resident #115 revealed a nurse's note dated 02/26/22 at 7:57 P.M. which documented Resident #115 was confused and the resident stated she felt something was wrong. The nurse's note documented the nurse would attempt to get a urine sample to check for possible urinary tract infection (UTI). Review of the medial record did not have documentation to support the nurse contacted the Director of Nursing (DON), resident's physician, or Resident #115's family/representative regarding the resident's change in condition. Review of the medical record for Resident #115 did not have documentation to support the nurse obtained a urine sample to check for UTI.

Review of the medical record for Resident #115 revealed a nurse's note dated 02/27/22 at 1:46 P.M. which documented the resident had fallen in her room and was sent out to the hospital due to mental status change. The nurse's note stated the family and doctor were notified.

Interview on 09/02/22 at 3:30 P.M. with DON #60 confirmed Resident #115's family and physician were not notified of Resident #115's change of condition on 02/26/22. DON #60 confirmed Resident #115's medical record did not have any documentation to support the nurse completed the urine test. DON #60 confirmed the nurse did not follow the Change of Condition Policy.

Review of the policy titled, Change in Condition revealed the nurse is to notify a residents primary care physician, family, Area Agency, Case Manager, and DON when the resident is experiencing a change in condition. The policy continued to state that if the change in condition warrants an Emergency Room visit then the resident is to be sent to the local Emergency Room for evaluation.

This violation substantiates Complaint Number OH00132724.

Based on medical record review, staff interview, and review of the Resident Bill of Rights, the facility failed to provide a residents representative with access to their full medical record as requested. This affected one (#115) out of the three residents sampled for medical record access. The facility census is 98.

Findings Include:

Review of medical record for Resident #115 revealed an admission date of 08/27/18 with medical diagnoses of kidney disease, failure to thrive, hypothyroidism, and Depression. The medical record revealed Resident #115 was discharged from the facility on 04/02/22.

Review of the medical record revealed a Medicaid Quarterly assessment dated 01/20/22 which documented the resident had limited memory but was alert and required assistance with medication administration. The assessment revealed the resident was able to transfer herself and utilized a wheelchair.

Further review of Resident #115's medical record revealed there was no documented information regarding the resident or representative requesting access to the residents medical record or requesting copies of the medical record.

Interview on 09/02/22 at 1:10 P.M. with Director of Nursing (DON) #60 confirmed she received a request from Resident #115's representative for the residents medical record. DON #60 stated the medical record request came after the resident was discharged on 04/02/22 but she doesn't have the exact date. DON #60 confirmed the facility did not have a Medical Records Request policy so she contacted a representative at Agency #3 for guidance in what information to include for a medical record request from a resident or family. DON #60 stated she received a checklist of medical record items that should be sent with a medical record request from Agency #3. DON #60 stated she utilized the checklist to complete Resident #115 family's request for medical records. DON #60 stated she did not have a copy of what medical records were provided to Resident #115's representative but confirmed she did not send Resident #115's entire medical record as requested. DON #60 confirmed she did not provide/send the nurses notes, physician progress notes or the medication administration records for Resident #115. DON #60 stated she was not able to locate the checklist utilized for Resident #115's medical records request.

Review of the form titled, Springfield Assisted Living Resident Bill of Rights, every resident shall have the right to have knowledge through his or her physician of all medical treatments, tests, and medications.

This violation substantiates Complaint Number OH00132724.