Parkview Northwest Healthcare Center

Penalty

No penalty information released

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 complete a Preadmission Screening and Resident Review (PASARR) Level II for a resident after a significant change in their mental health status. The resident, who was admitted with diagnoses including obstructive and reflux uropathy, benign prostatic hypertrophy, gastro-esophageal reflux disease, and insomnia, was later diagnosed with schizoaffective disorder, bipolar type. This new diagnosis was added on July 3, 2024, but the facility did not initiate a Level II PASARR as required by their policy. The facility's policy mandates a new PASARR whenever there is a change in a resident's condition that affects their mental health status. Despite this, the resident's PASARR, dated March 22, 2021, had ruled out serious mental illness diagnoses, including schizoaffective disorder, while the resident was in the hospital prior to admission. The oversight was confirmed during an interview with the social worker, who acknowledged that the facility should have completed the necessary review following the new diagnosis.

Penalty

Inspection fine: $36,185

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 and timely interventions for a cognitively impaired resident with a history of exit-seeking behaviors, resulting in the resident's elopement. The resident, who resided in a secured unit, broke a window in his room using a fire extinguisher and later exited the building by jumping out of the second-story window. The resident was missing for approximately 12 hours before being found by police and EMS six miles from the facility. This incident affected one of three residents reviewed for elopement risk and highlighted the facility's failure to ensure the safety of residents at risk for elopement. On the morning of the incident, a State-tested Nursing Assistant (STNA) discovered the broken window and reported it to a Licensed Practical Nurse (LPN). The staff moved the resident to a common area but later allowed him to return to his room with the broken window. The LPN assigned to monitor the resident left him unsupervised to attend to another resident, during which time the resident eloped through the broken window. The facility's failure to provide continuous supervision and secure the environment contributed to the resident's ability to elope. The resident's medical record revealed a history of schizoaffective disorder, schizophrenia, dementia, and other mental health conditions, making him a high risk for elopement. Despite being identified as an elopement risk and residing in a secured unit, the facility did not implement adequate measures to prevent his escape. The incident underscores the facility's shortcomings in monitoring and safeguarding residents with known exit-seeking behaviors, leading to a serious lapse in resident safety.

Removal Plan

• LPN #220 was informed the window in Resident #39's room was broken.
• LPN #220 was stationed outside the resident's room to supervise and ensure the safety of Resident #39 and to prevent re-entrance and access to the resident's room.
• LPN #220 stationed outside of the resident's room responded to another resident screaming and went to check on the resident.
• STNA #265 checked the resident's room for the resident and noted him missing.
• Resident #39 was believed to have exited through the broken second floor window and landed 13 feet below on the exterior ground which consisted of grass and concrete and was unsecured. On the ground there was a pillow, unused gloves, wipes, a flat bed sheet and a bed spread. A head count was conducted immediately and there was a total of 45 residents present in-house out of a census of 47 (there was one resident on a Leave of Absence (LOA) with family and Resident #39 was unaccounted for).
• Upon discovering the Resident #39 could not be located, STNAs #218, #217, #312, #265 and LPN #251 began searching the facility.
• All other windows were checked by STNAs #216 and #312 and validated as being secured, and all exits/entrances were validated as being secured by STNA #218.
• STNAs #218 and #312 searched the perimeter of the facility.
• LPN #293 notified the local Police Department Resident #39 was missing. Resident #39's Guardian, Psychiatric (Psych) Physician #316 and Medical Director (MD) #317 were notified by LPN #251.
• Maintenance Technician (MT) #318 arrived at the facility.
• The DON and Administrator were notified that Resident #39 could not be located.
• LPN #293 was placed on door watch outside of Resident #39's room to ensure the resident's room was not entered due to the broken window where she remained until the window was fixed by MT #318.
• The DON, Business Office Manager (BOM) #207, Therapy Manager #258, Activities Director (AD) #305, MT #318, Administrator, RDO #315, Minimum Data Set (MDS) Coordinator #256 and Social Services Designee (SSD) #271 arrived at the facility and conducted an additional neighboring community search to locate the missing resident.
• Calls were made to all local hospitals by SSD #271 and Resident #39 was not located.
• The Administrator conducted a second audit of all door alarms and the elevator keypads to check for proper function and locking mechanism. No concerns were identified.
• MT #318 conducted a second window audit to ensure all windows were secured and in proper function. There were no concerns identified.
• The DON and RDO #315 reviewed/completed wandering observation tools for each resident. No new residents were identified as an elopement risk.
• MDS Coordinator #256 reviewed/updated all care plans to identify residents who were at risk for wandering and elopement. No new residents identified.
• The DON reviewed the elopement binder, the elopement policy, pictures, and face sheets of all at risk residents and no corrections were needed.
• The search for Resident #39 was concluded by the facility staff.
• The DON and Administrator initiated education on elopement management with all facility staff. There were 108 educated out of 108 total staff and completed and the facility utilized no agency staff. All 108 staff were educated electronically and any staff member not present was instructed to sign off on the education prior to the next scheduled shift.
• Education was provided to the Administrator by RDO #315 on elopement management and elopement prevention.
• Education was provided to the Administrator and DON by RDO #315 on management of potential risks and hazards to prevent accidents that include but not limited to safeguarding identified risks/hazards to avoid exposure to residents.
• Education was provided to the Administrator and DON by RDO #315 on supervision of residents when known risks or hazards are identified that include but not limited to one-on-one (1:1) supervision.
• Resident #39 was located in a neighboring community six miles away by STNA #265 who was heading home and familiar with the area. STNA #265 observed the resident with the police and EMS. STNA #265 notified the DON Resident #39 had been located.
• RDO #315 was notified by the Administrator that Resident #39 had been located by STNA #265.
• An unknown Dispatcher at the local Police Department (PD) called the Administrator to provide an update on the status of Resident #39. The PD Dispatcher was instructed to have EMS transport Resident #39 to the local hospital for a psychological evaluation.
• Resident's #39's Guardian was notified by the DON and Administrator Resident #39 had been located and was being transported to the local hospital for a medical and psychological evaluation.
• Psych Physician #316 was updated by the Administrator and DON on the status of the resident being transitioned to the hospital's Psychiatric Unit. Psych Physician #316 reported the hospital would evaluate the resident and determine if he was appropriate for a 72-hour hold (psychiatric admission).
• An unknown ER Nurse at the local hospital called and spoke with the Administrator and DON and informed them Resident #39 would be assessed psychologically and medically.
• Medical Director #317 was updated on Resident #39's status by the Administrator.
• The DON and Administrator reported to the Quality Assurance Performance Improvement (QAPI) committee the findings related to compliance. The QAPI committee consists of the Administrator, DON, SSD #271, RD #252, BOM #207, MDS Coordinator #256, RDO #315, Therapy Manager #258, and MD #317 (via telephone).
• The DON called the local hospital for an update on Resident #39. The hospital noted Resident #39 was assessed, and no new discoveries or diagnoses were determined, thus the resident was set for discharge back to the facility.
• An elopement drill was conducted by the DON and Administrator. No issues were identified.
• Resident #39 returned to the facility. The resident's Guardian and MD #317 were notified of the resident's return with no new orders given.
• Resident #39 was immediately placed on 1:1 observation and will remain until determined by the Interdisciplinary Team (IDT) and MD #317 that 1:1 observation was no longer required. All staff were educated on expectations of the resident being on 1:1 observation by the DON and Administrator.
• An admission assessment was completed (including skin, pain, and a Braden Scale) on Resident #39. A care conference with the facility's IDT and Resident #39's Guardian/mother was scheduled.
• To monitor for ongoing compliance, elopement drills will be completed twice weekly for four weeks, then monthly. The drills will be conducted by the DON or Administrator on day shifts and night shifts.
• A 72-hour care conference was held with the facility's IDT which included SSD #271, DON, Administrator, Therapy Manager #258, MD #317, RDO #315, Registered Dietitian (RD) #252, BOM #275 and Resident #39's Guardian/mother. The Guardian was okay with the new interventions of a room move, 1:1 observation, and a psychiatric consultation. A Brief Interview Mental Status (BIMS) assessment was completed on Resident #39 and noted to be a 12 which indicated the resident was cognitively intact. Resident #39's care plan was updated to show the resident eloped and new interventions include 1:1 observation, educate the resident to speak with staff if he would like to take a walk outside, provide diversionary activities, notify the physician of behavior changes, and offer additional snacks and hydration.
• Resident #39's room change was conducted. Resident remains on 1:1 observation close to the nurse's station.