Lakeside Health And Rehab

Penalty

Inspection fine: $22,925

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when a resident with severe cognitive impairment and a documented history of exit-seeking and wandering behaviors was able to elope from the facility without staff knowledge. The resident, who had diagnoses including Alzheimer's disease and unspecified dementia, had repeatedly demonstrated behaviors such as pulling on exit doors, expressing a desire to leave, and making statements about going home. Nursing progress notes documented multiple incidents of the resident attempting to exit the facility, verbalizing intent to break a window, and expressing significant distress and anxiety in the days leading up to the event. On the day of the incident, the resident manipulated a window in a different room on the secure unit, removed the screen, and exited through the window. The facility's monitoring and supervision were insufficient to prevent the resident from leaving undetected. The resident was later found outside the facility by a passerby and brought to city hall, where facility staff retrieved the resident. Upon return, a body audit revealed a small skin tear on the resident's left wrist. The facility's failure to implement an effective monitoring plan and to secure all potential exit points, such as windows, contributed to the resident's ability to elope. Staff interviews and record reviews indicated that while the resident was known to be at high risk for elopement, interventions in place were not adequate to prevent the incident. The deficiency was determined to have caused, or was likely to cause, serious injury, harm, impairment, or death to residents, resulting in a finding of Immediate Jeopardy.

Removal Plan

• Head count of all residents was performed and all other residents were accounted for.
• Resident was returned to the memory care unit and Incident and Accident was completed. Small skin tear on wrist was noted and treated by D.O.N.
• Facility initiated and completed skin audits, elopement risk assessments, and BIMS score on the resident.
• Resident transferred to St. [NAME] Behavioral Health for evaluation and treatment.
• Initiated staff in-service on abuse, neglect and misappropriation, elopement policy and the facility elopement book.
• All residents assessed for elopement risk via elopement/wandering assessment. All residents who are at risk for elopement were noted to be residing in Memory Care Unit of facility. Care plans were updated accordingly.
• All residents' evaluation assessments (BIMS) were updated.
• Elopement book reviewed to ensure all residents at risk for elopement were in the facility’s elopement book with resident picture and demographics.
• All window seals on sliding windows throughout the facility were modified so the windows could not be manipulated to move over the stopper and/or come off track.
• Facility trained all staff on recognizing key factors such as cognitive impairments (e.g., dementia), history of wandering or elopement, through the individualized care plan. Also educated staff on established protocols for preventing elopement, including recognizing early warning signs, managing exit seeking behaviors, and responding to potential incidents.

Penalty

Inspection fine: $12,340

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide adequate supervision for a resident, leading to an elopement incident. The resident, who had a history of cerebral infarction and moderate cognitive impairment, was admitted to the facility with a care plan that required the use of a rolling walker for ambulation due to limited physical mobility and impaired balance. On the day of the incident, the resident was in the lobby and asked a laundry aide if they could go outside. The laundry aide, unsure of the resident's care plan, asked a CNA who incorrectly confirmed that the resident could go outside unsupervised. The resident exited the facility through the front door, which was opened by the laundry aide for another resident. The staff was unaware that the resident was outside and unsupervised. The resident wandered off the facility grounds and was later found at an event center approximately 900 feet away. The staff only realized the resident was missing after noticing their absence from their room and initiated a search. The resident was located after being missing for over three hours. Interviews with the staff revealed a lack of familiarity with the resident's care plan and inadequate supervision protocols. The CNA admitted to not knowing the resident's specific needs and failing to verify the care plan before allowing the resident to go outside. The laundry aide also confirmed that no staff members were present outside when the resident left the facility. The incident highlighted a significant lapse in supervision and communication among the staff, leading to the resident's elopement.