Rick Patrick
rick@greenepublishing.com
This is the fourth in a series of articles on the findings of deficiencies at Lake Park of Madison. These deficiencies were noted in inspection reports obtained by Greene Publishing, Inc. The reports were provided by the Agency for Health Care Administration (AHCA).
The latest findings on Lake Park of Madison Nursing and Rehabilitation Center, completed Wednesday, March 31 and recently made available online, shines light on more problems at the local facility. This more recent scrutinization from the AHCA was in response to a complaint received after a resident escaped out of a window and was missing for an hour before being returned to the facility. In the report's initial comments, it states that, “at the time of the survey, the facility was not in compliance with 42 CFR (Code of Federal Regulations) Part 483, Requirements for Long Term Care Facilities.” As a result of their findings, “Immediate Jeopardy was identified for failing to provide supervision to prevent resident elopement and failing to ensure windows and entry/exit doors were secured at all times.”
“Immediate Jeopardy” is a situation wherein the facility's noncompliance with one or more requirements has caused, or is likely to cause serious injury, harm or even worse to a resident receiving care at the facility. According to the website harmony-healthcare.com, there are four levels of severity when it comes to nursing care facilities and the deficiencies they might receive. The first level of severity is accompanied by the letters “A,” “B” or “C,” which shows the scope, from isolated to widespread. These represent a situation that is not particularly serious and no actual harm or even potential for harm is found. The next severity level, Level Two, carries the tags, “D,” “E” and “F.” This suggests there is noncompliance that may not have caused actual harm, but carries the potential for harm to a resident or patient. These are among the more common citations in nursing home inspections or surveys. The next severity level, Level Three, carries with it the letters “G,” “H” and “I.” This represents actual harm has been inflicted on a resident. This could be a bruise, a skin tear or even upsetting a patient. The next and most severe level, Level Four, represents the highest level tags a facility can receive during a survey. This level carries with it the “Immediate Jeopardy” (IJ) label and is signified by the letters: “J,” “K” and “L” on the scope and severity grid. This “Immediate Jeopardy” is the situation Lake Park found itself in recently. It is not uncommon for monetary fines to accompany IJ findings. The administrator was notified of the IJ findings. At the time, there were 92 patients in the facility, two of whom were determined to be at risk of elopement. An Extended Survey was conducted and the IJ was removed for the time being. The scope and severity was reduced to a “Level Two – D.”
The AHCA report states that facilities must ensure that resident environments remain as free of accidental hazards as possible. Residents are to receive adequate supervision and assistance devices to prevent accidents. The report further states the these requirements were not met as evidenced by observation, staff interviews and record reviews, the facility failed to ensure that residents at risk of elopement were not able to exit the building unsupervised via a window. The report also states that the facility failed to ensure the windows and all entry/exit doors were secured to prevent subsequent elopements for other residents at risk for elopement.
In their report, the ACHA went on to say, “the facility's failure to prevent an elopement and eliminate potential hazards placed two residents at a likelihood of serious injury. Residents are at risk for being injured or killed by passing cars on the highly traveled Highway 90 that runs in front of the facility, drowning in lakes/holding ponds that surround the facility; or trapped, injured or killed in the barbed wire fencing that surrounds the dairy farm located directly behind the facility. Also, residents could be harmed by entering an unlocked, unmanned maintenance shed located behind the facility that houses tools, other maintenance equipment and chemicals.”
All this came as a result of an incident that took place at Lake Park when a resident [frequently referred to as “Resident #1” in the AHCA report] known to be a flight risk was able to escape unnoticed out of a window. The event was described in the ACHA report. “On [redacted] at approximately 2:45 p.m. the resident eloped out the window in her bedroom and was found 0.5 miles from the facility, across a major highway at a COVID-19 [redacted] event being held by the local college. The resident was unattended for one hour and 32 minutes, based on witness statements, nursing documentation and [a] review of the Madison County Sheriff's Office (MCSO) incident report. On [redacted], 27 days after she was admitted, the resident was transferred to another nursing home with a secured unit.”
This incident “resulted in a finding of 'Immediate Jeopardy' at a scope and severity of 'J.' The facility Administrator was notified of the Immediate Jeopardy finding on [redacted] at 5:10 p.m., prior to the survey exit on [redacted]. The Immediate Jeopardy was determined to have begun on [redacted], the day Resident #1 exited the building unsupervised via a bedroom window. Immediate Jeopardy was found removed on [redacted] when the facility provided evidence of immediate corrective actions. The deficient practice was reduced to a scope and severity of level 'D.'”
Other findings showed instances where some door alarms were working, while other door alarms were not. There were also screen doors that exited to the patio/smoking area that were unlocked and no staff supervision was observed.
There was another resident of Lake Park who was also determined to be at high risk for elopement. This resident [referred to as Resident #2] did not actually leave the facility, but, according to the ACHA report, the potential was present. In Resident #2's room, a window could be easily opened in either the locked or unlocked position. Resident #2's roommate stated the lock had been that way “forever.” Resident #2's roommate informed surveyors that the window “does not always catch.” The resident revealed staff had been made aware of the window not “catching” and that the window had been in that condition for months. The resident stated, “they probably just need to clean the insects and frogs out of the window track, and it may latch.” The ACHA also obtained photographic evidence of this. Resident #2 was to be checked every 15 minutes, due to her elopement risk. However, when asked where the documentation of this could be found in the resident's medical record, a staff member revealed “if it's not [in] the nursing notes, maybe the CNAs (Certified Nursing Assistants) do it in the kiosk since they are conducting the checks more often. During ACHA's interview with the Assistant Director of Nursing (ADON), it was revealed that Resident #2 was an elopement risk, identified in the elopement book and was currently on “q [every] 15-minute checks.” The ADON did admit that documentation was inconsistent and indicated that staff were at least expected to document at the end of their shift, at a minimum.
Lake Park's response was “the facility will ensure that the resident environment remains as free of accident hazards as is possible. Resident #1 was returned to [one-on-one] care and was relocated within two days of the incident to a facility with a secure unit with the permission of the resident's representative. An alarm was installed on the window of Resident #2 and the staff will continue with 15-minute checks. Facility staff utilizes observation, staff interview, record review and our elopement screening tool to identify other residents with the potential for elopement. Each of these residents were assessed for their ability to exit through a window. Care plans were reviewed for any needed revisions and assessments were updated. Facility staff educated all staff members on facility procedures for elopement, either in person or by telephone. All window locks were inspected and are in working order. All window tracks were cleaned and are clear of debris. The East Porch alarm has been reconnected. It had been disconnected during the installation of the new call system on East.
Lake Park further listed systemic changes, including: A “review and revision of current policies and procedures have been performed and are in place to prevent harm/potential harm, including a new protocol requiring Administrator notification when a resident is placed on one-on-one care and is removed from one-on-one care. The elopement assessment will now include assessing residents to determine their ability to exit through a window. Window lock inspections have been added to daily room round inspection forms. Our Admission Notification Form has been revised to improve communication to staff of potential risk issues for new admissions. Windows and window lock monthly inspections have been added to our preventative maintenance program. Window track cleaning has been added to the housekeeping deep cleaning schedule for resident rooms. Elopement policies and prevention training will be included as an annual in-service on our annual education calendar. Facility has added a mobile text alert or blast text pink alert as part of the procedures for elopement that notifies all staff of a resident elopement and allows them to be aware and to join in the search for the missing resident. The Elopement Manual has been revised to include all residents at risk for elopement and not just the residents that reside on that unit. The facility will conduct elopement drills at a rate of one per shift per month for the next six months and one drill per year thereafter. Elopement training will be the responsibility of the Risk Manager/ADON. Oversight of the drills will be provided by the Executive Director. Any elopement attempts or other deviations from the Elopement Policy will be brought to the Risk Manager immediately and the Risk Manager will immediately call a QAPI Risk meeting for prompt intervention.”
Lake Park also included the following statement, which has been included in each of the inspection reports submitted by the AHCA. “Submission of this plan of correction constitutes our written allegation of compliance for the deficiencies cited. Submission of the plan of correction is not an admission that the deficiency exists or that it is cited accurately. This plan of correction is submitted to meet state and federal requirements.
A full copy of this report as well as information about the AHCA and Florida's nursing facilities can be found at https://ahca.myflorida.com/.