TUCSON, AZ- SANDSTONE OF TUCSON REHAB CENTRE

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 40581

Based on clinical review, facility documentation, staff interviews, and the facility policy and procedures, the facility failed to ensure one resident (#10) did not elope from the facility. The deficient practice could result in residents being physically and/or emotionally harmed.

Resident #10 was admitted to the facility on [DATE] and was readmitted on [DATE] with the diagnoses that included personal history of traumatic brain injury (TBI), Type II Diabetes, anxiety disorder, major depressive disorder, and acquired absence of left leg below the knee.

Review of the care plan dated May 4, 2023 revealed that the resident is an elopement risk related to disoriented to place, diagnosis of TBI and prior history of leaving facility prior to recommended physician discharge. May 2, 2023 noted to be a moderate risk for elopement. The goal stated the resident will not leave the facility unattended through the review date. Interventions included to monitor for high risk elopement activity such as hanging out by exit doors, packing belongings, stating he has to meet someone or pick-up children, and to provide safe environment for resident to enjoy interactions with others which may also include areas both indoors and outdoors with supervision.

Review of the Elopement Risk Assessment revealed that the resident had a score of 4.

Review of an interview conducted on May 21, 2023 by the facility with a licensed practical nurse (LPN/staff #80) revealed that staff arrived to work at approximately 6:06 p.m., attended report and then went to take the resident’s vitals, but he was not in his room. The staff called downstairs to the reception desk and was told that the resident was outside in the smoking area. The staff went to the resident’s room a second time at approximately 10:44 p.m. to administer medications, but the resident was not in his room. One of staff #80’s coworkers went downstairs to see if the resident was in the smoking area and the coworker did not see the resident. After staff #80 attempted to contact the LTC Unit Manager and after the LTC Unit Manager (LPN/staff #120) called back, staff #80 contacted the police.

A progress note dated May 22, 2023 revealed that (LPN/staff #80) called the front desk at about 9:30 p.m. to check if the resident was outside and the lady confirmed that the resident was outside in the smoking area. Then at about 10:44 p.m., the staff went to the resident’s room to give the resident’s medications and he was not there, and his food tray was on the table. A coworker went outside to check for the resident, but the resident was not outside. Staff called the unit manager, DON, night supervisor, regional management, 911 and family. The writer and coworkers searched the building and outside.

An interview was conducted on June 14, 2023 at 3:34 p.m. with a certified nursing assistant (CNA/staff #22), who stated that there are residents on the second floor who are allowed to smoke independently and staff do not go with these residents downstairs to the smoking area, but if she knows that a resident smokes and the resident doesn’t come back after 30 minutes, she goes downstairs and checks on the resident. She stated that the smoking area is located on a patio area where a resident could just walk off from the facility. She also stated that she has heard of residents walking away from the facility, and in the last year, staff had to look for a couple of residents, who were found at the bus stop.

An interview was conducted on June 15, 2023 at approximately 2:00 p.m. with the Administrator (staff #1)…She stated that the resident was outside smoking when he left the facility,
and has not been located, but he was alcohol seeking and is probably out drinking. She stated that the resident left his phone and a few other belongings behind.