Case Study # 2 Plan of Correction

Review the case study information.

Assuming your team is working in this facility and using the information provided

Your team task are to:

1. Develop the Corrective Action Plan base on the guidelines for POC
2. Do a power point presentation to be presented in the class
3. Submit a Summary paper with references

 

 

Case Study # 2 Plan of Correction

 

On 7/12/18, at 1:37 p.m., an unannounced visit was made to the facility to investigate a self-reported incident about Resident 1. According to the report, Resident 1 was found missing from the facility on 7/7/18, at 4 p.m., and was later found to have been struck by a train. Case Study # 2 Plan of Correction

 

Based on observation, interview, and record review, the facility failed to provide adequate supervision and assistance devices to Resident 1, who was at risk of elopement, by failing to:

 

1. Ensure that a departure alert device bracelet, a WanderGuard, was applied to Resident 1, who had history of wandering out of the facility.
2. Implement the physician’s order for the use of a WanderGuard (a departure alert system).
3. Implement Resident 1’s plan of care to monitor the resident’s departure from the facility.

As a result, Resident 1 was struck by a train and sustained multiple traumatic injuries, which caused his death.

 

On 7/12/18, a review of Resident 1’s clinical record revealed the resident was an 80 year-old male admitted to the facility on 6/25/18, with diagnoses that included psychosis (severe mental illness in which a person loses touch with reality, experiences unusual perceptions, and holds false beliefs called delusions), alcohol abuse, emphysema (chronic lung disease) and abnormality of gait.

 

The Minimum Data Set (MDS – standardized assessment and care planning tool) dated 7/3/18, indicated the resident had short and long-term memory problems and was moderately impaired in cognitive skills for daily decision-making. Resident 1 was assessed to have behavioral symptoms of wandering, which occurred daily and the behavior was not easily altered. The resident was also assessed as manifesting physically abusive, socially inappropriate and resisting care behavioral symptoms. The MDS also indicated the resident required limited assistance with walking and was independent with locomotion on and off the unit.

 

The physician’s orders dated 6/25/18, indicated to give the antipsychotic medications Zyprexa 5 milligrams (mg) twice a day for psychosis manifested by agitation and Haldol 5 mg orally or intramuscular injection every six hours as needed for combativeness or resisting to care. The orders also included the anticonvulsant medication, Depakote (used to treat manic episodes) 500 mg at bedtime for psychosis manifested agitation.

The attending physician also ordered on 6/25/18, a WanderGuard to prevent the resident from leaving the facility without permission. According to the manufacture’s information, WanderGuard is a selective departure alert system used to alert caregivers when a wanderer wearing a bracelet device exits through a monitored door or hallway.

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According to the form titled Elopement Risk Review dated 6/27/18, the resident was ambulatory, had elopement attempts in the past 30 days, manifested wanting to go home, and was always looking for exit doors. The facility staff considered the resident a risk for elopement.

 

A plan of care dated 6/28/18, developed for the resident’s tendency to wander out of the facility, had a goal that the resident would not wander out of the facility every shift for three months. The approaches included to: 1) Assist the resident in reorientation to the room and surroundings, 2) Monitor the resident’s whereabouts with visual checks at least every two hours and 3) WanderGuard bracelet on the resident’s wrist to alert staff.

 

According to the Nurse’s Notes, on 6/27/18, timed at 8 p.m., the resident attempted to walk out of the facility earlier during the shift and on 6/30/18, timed at 11 a.m., the resident tried to get out of the facility. Case Study # 2 Plan of Correction

 

According to an entry in the Nurse’s Notes dated 7/1/18, timed at 11 p.m., Licensed Vocational Nurse 1 (LVN 1) documented the resident tried to leave the facility. The resident walked to the back patio, stood on a Geri chair (geriatric reclining chair) and attempted to climb the patio wall. The resident lost his grip and landed on the Geri chair. LVN 1 documented the resident was agitated and resistive to care and was administered an intramuscular injection of Haldol 5 mg.

 

A Nurse’s Notes documentation dated 7/2/18, timed at 12:47 p.m., indicated the resident went out the back door and was walking outside. The resident was directed to go back to the facility. The documentation made no reference to the WanderGuard and if the alarm went off.

 

The Nurse’s Notes documentation dated 7/5/18, timed at 2 p.m., indicated the resident’s roommate reported seeing Resident 1 exiting from the sliding door in his room. Staff went to locate the resident but did not find him. The administrator, the director of nursing, and the police were notified. The note further stated that a certified nursing assistant (CNA) found the resident on a street (busy street located approximately 0.25 miles from the facility) and gave Resident 1 a ride back to the facility. The time the resident was found and returned to the facility was not stated in the nurse’s note. The documentation made no reference to the WanderGuard and if the alarm went off.

 

According to the form titled Activities Risk Meeting Notes, dated 7/6/18, the prior night (7/5/07), the resident stepped on a Geri-chair and climbed the fence. The resident was later found on a nearby street and was brought back to the facility. The documentation made no reference to the WanderGuard and if the alarm went off.

 

The documentation further indicated the plan of action was for the resident to wear the WanderGuard and to monitor the resident’s whereabouts frequently.

 

Further review of the Nurse’s Notes revealed that on 7/7/18, at 3 p.m., LVN 1 documented Resident 1 was observed sitting in the front lobby. At 4 p.m., LVN 1 documented the resident was not found in the facility and the police department was notified.

 

According to the Social Services Notes dated 7/10/18, timed at 2:15 p.m., Social Service Designee (SSD) received a telephone call from Police Detective informing the facility Resident 1 was hit by a train and died on Saturday evening (7/7/18, the same day the resident eloped from the facility).

 

The police detective informed the facility the time of death was 6:33 p.m.

 

On 7/12/18, at 1:58 p.m., during an interview, LVN 1 stated that on 7/7/18, the resident was agitated and he informed LVN 2 (medication nurse) of the resident’s behavior. At 2 p.m., LVN 2 administered the resident an injection of Haldol 5 mg. LVN 1 further stated that at around 3:36 p.m., he did not see Resident 1 at the nurse’s station and told CNA 2 and other staff members to look for the resident while LVN 1 went to check the park. LVN 1 stated that around 4 p.m., he noticed a Geri-chair close to the patio wall outside the resident’s room. LVN 1 was not sure how the resident got out of the facility.

 

On 7/12/18, at 5:16 p.m., during a telephone interview, followed by a written declaration on 7/17/18, CNA 2 stated she was assigned to take care of Resident 1 on 7/7/18, but was not informed the resident had wandering behavior until after the resident was missing. CNA 2 stated she did not remember seeing Resident 1 wearing a WanderGuard bracelet.

 

On 7/17/18, at 8:45 a.m., maintenance staff was observed changing the gate lock on the patio. At 9 a.m., during an interview, LVN 2 stated the side gate to the patio was observed unlocked and broken on the day the resident went missing. LVN 2 was not aware how long the lock had been broken.

 

Further record review revealed there was no documented evidence Resident 1 was wearing the WanderGuard bracelet as ordered by the physician during the three occasions the resident attempted to elope from the facility (6/27/18, 6/30/18 and 7/1/18), and when the resident eloped from the facility on four occasions (7/2/18, twice on 7/5/18, and on 7/7/18).

 

According to the Coroner’s Report dated 7/8/18, on 7/7/18, at 6:33 p.m., a train struck Resident 1 as the train crossed over a rail bridge. The train engineer and the conductor saw a man squatting down in the middle of the train tracks, but were unable to stop the train in time.

 

An Examination Protocol from the Department of Coroner dated 7/10/18, indicated Resident 1’s cause of death was multiple traumatic injuries sustained as a pedestrian struck by a train.

 

The facility failed to provide adequate supervision and assistance devices to Resident 1, who was at risk of elopement, by failing to:

 

1. Ensure that a departure alert device bracelet, a WanderGuard, was applied to Resident 1, who had history of wandering out of the facility.
2. Implement the physician’s order for the use of a WanderGuard (a departure alert system).
3. Implement Resident 1’s plan of care to monitor the resident’s departure from the facility. Case Study # 2 Plan of Correction

 

As a result, Resident 1 was struck by a train and sustained multiple traumatic injuries, which caused his death.

 

The above violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result and was a direct proximate cause of Resident 1’s death.

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Plan of Correction (POC) Check List

Facility:
Requirements of Deficiency Correction:		Present	Not Present	Not Applicable
I.        The POC describes what corrective action(s) will be accomplished for those individuals found to have been affected by the deficient practice.
A.	The POC specified the specific action taken for the affected residents.
B.	The POC identified the title of the person/s responsible for the specific corrections.
C.	The POC indicated the date the specific actions were completed.
Comments:
Requirements of Deficiency Correction:		Present	Not Present	Not Applicable
II.      The POC describes how the facility will identify other individuals having the potential to be affected by the same deficient practice and what corrective action(s) will be taken.
A.	A method/ system to identify other residents was described.
B.	If other resident/s affected by the deficient practice identified, indicated
C.	The POC indicated the title of person/s responsible for identifying other residents and making corrections.
D.	If other affected residents are identified, the POC indicated the date action was completed for correction for each one.
Comments:
Requirements of Deficiency Correction:		Present	Not Present	Not Applicable
III.    The POC describes what measures will be put in place or what systemic change will be made to ensure that the deficient practice does not recur.
A.	The POC specified training/re-training of specified categories of staff.
B.	The POC identified the title of the training presenter/s.
C.	The POC indicated the date/s training was presented.
D.	The POC specified the provisions developed in new or revised facility policies and procedures, if required.
E	The POC included staffing responsibility changes, if required.
Comments:
Requirements of Deficiency Correction:		Present	Not Present	Not Applicable
IV.       The POC describes how the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place. The POC must be implemented, evaluated for effectiveness, and integrated into the QA program. Case Study # 2 Plan of Correction
A.	The POC described a system of monitoring at defined intervals as appropriate.
B.	Performance is tracked and reported to the QA Committee quarterly for evaluation and further action.
C.	The POC specified the title of the person/s responsible for the monitoring.
Comments:
Requirements of Deficiency Correction:		Present	Not Present	Not Applicable
V.          The POC includes dates when corrective action(s) will be completed.
Comments:

RUBRIC FOR CRITICAL THINKING CASE PRESENTATION

Rating Criteria	Emerging	Developing	Mastering
	1	1.5	2
Summarized problem, question, or issue     Points:     /2	Issue/ problem is not stated or fails to identify and summarize accurately.	Issue/ problem is stated, described, and clarified so that understanding is not seriously impeded by omissions.	Issue/ problem is stated clearly and described comprehensively, delivering all relevant information necessary for full understanding.
Analyzes supporting data and evidence     Points:     /2	Information is taken from source(s) without any interpretation/ evaluation. Viewpoints of experts are taken as fact, without question.	Information is taken from source(s) with enough interpretation/ evaluation to develop a coherent analysis or synthesis. Viewpoints of experts are subject to questioning.	Information is taken from source(s) with enough interpretation/ evaluation to develop a comprehensive analysis or synthesis. Viewpoints of experts are questioned thoroughly.
Influence of context and assumptions         Points:     /2	Approach to the issue is in egocentric and socio- centric terms. Does not relate to other contexts. Analysis is grounded in absolutes, with little acknowledgement of own biases. Does not recognize context and underlying ethical implications.	Presents and explores relevant contexts and assumptions, although in a limited way. Analysis includes some outside verification, but primarily relies on authorities.  Provides some consideration of assumptions and their implications.	Analyzes the issue with a clear sense of scope and context, including an assessment of audience. Identifies influence of context. Questions assumptions, addressing ethical dimensions underlying the issue.
Student’s position (perspective, thesis/hypothesis)       Points:     /2	Position is clearly adopted with little consideration. Addresses a single view of the argument, failing to clarify the position relative to one’s own. Fails to justify own opinion or hypothesis is unclear or simplistic.	Presents own position, which includes some original thinking, though inconsistently. Justifies own position without addressing other views or does so superficially.  Position is generally clear, although gaps may exist.	Position demonstrates ownership. Appropriately identifies own position, drawing support from experience and information not from assigned sources. Justifies own view while integrating contrary interpretations. Hypothesis demonstrates sophisticated thought.
Conclusions and related outcomes (implications and consequences)       Points:     /2	Conclusion is inconsistently tied to some of the information discussed; related outcomes (consequences and implications) are oversimplified.	Conclusions consider evidence of consequences extending beyond a single issue. Presents implications that may impact other people or issues. Presents conclusions as only loosely related to consequences. Implications may include vague reference to conclusions.	Conclusions and related outcomes (consequences and implications) are logical and reflect student’s informed evaluation and ability to place evidence and perspectives discussed in priority order.
Presentation/Communicates effectively       Points:     /5	Not enough preparation was done for the presentation of the information, it therefore lacks many elements of what is expected.     (1-2)	The student presents the information fairly clearly and displays a reasonable understanding of their information.Case Study # 2 Plan of Correction   (3-4)	The student presents the information clearly and displays a complete understanding of their information. It is evident that the student was well prepared. (5)
Total:        /15

 

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