ALDEN-LONG GROVE REHABILITATION AND HEALTH CARE CENTER I.D. NUMBER 0040687 RFD, BOX 2308, HICKS ROAD LONG GROVE, IL 60047 As a result of a complaint survey conducted on September 28, 1998, by representative(s) of the Department, it has been determined the following violations occurred. "A" VIOLATION(S) Adequate and properly supervised nursing care and personal care shall be provided to each resident to meet the total nursing and personal care needs of the resident. All necessary precautions shall be taken to assure the safety of residents at all times, such as but not limited to: nonslip wax on floors, side rails on beds, safe equipment and assistive devices properly maintained, and proper use of safety devices. The DON/HSS shall oversee the nursing services of the facility. This person's duties shall include – Planning an up-to-date resident care plan for each resident based on the resident's individual needs and goals to be accomplished, physician's orders, and personal care and nursing needs. Personnel, representing other services such as nursing, activities, dietary, and such other modalities as are ordered by the physician, shall be involved in the preparation of the resident care plan. The plan shall be in writing and shall be reviewed and modified in keeping with the care needed as indicated by the resident's condition. The plan shall be reviewed at least every three months. All exterior doors shall be equipped with a signal that will alert the staff if a resident leaves the building. Any exterior door that is supervised during certain periods may have a disconnect device for part-time use. If there is constant 24 hour a day supervision of the door, a signal is not required. AN OWNER, LICENSEE, ADMINISTRATOR, EMPLOYEE OR AGENT OF A FACILITY SHALL NOT ABUSE OR NEGLECT A RESIDENT. These requirements are not met as evidenced by the following. Based on observation, record review and interviews with the facility staff, the facility – 1) failed to provide necessary supervision for two cognitively impaired residents (R1, R2) who wandered out of the facility and sustained a fracture of the hip, bruises and hematoma to other parts of their bodies; 2) failed to adequately assess and develop individualized care plans for the cognitively impaired residents that are identified as wanderers; and 3) failed to provide effectively functioning exit door alarms to ensure the safety of cognitively impaired residents. Evidence includes the following: R 1's record review revealed that R 1 is a 81 year old female who was admitted to the facility on 2/2/98. R 1 has multiple diagnoses which include Dementia, Depression with Psychosis, Insulin Dependant Diabetes and Glaucoma. Review of R 1's Minimum Data Set (MDS) dated 4/18/98 revealed that R 1 has short-term and long-term memory impairment and her decision making ability is moderately impaired. The facility also indicated in the MDS that R 1 is a wanderer, vision moderately impaired and has problem making herself understood. The Resident Assessment Protocol (RAP) summary for vision, behavior and cognition is not comprehensive. These RAPs simply re-stated what was stated in the MDS. 4/17/98 care plan interventions for behavior and mood are not specific to address R 1's wandering problem. Review of nursing progress notes revealed the following: 7/23/98 (4:30 am) revealed that R 1 was not to be found in her room. Staff found R 1 in sitting position outside at the facility's driveway at the front doorway. R 1's both buttocks and knees were abraded, a 5 cm diameter abrasion to right elbow and pain to both legs was noted. R 1 was assisted to wheelchair and transported to her bed. 7/23/98 (4:45 pm) R 1 complained of severe pain when touching her right leg. Shortening and external rotation of right leg was noticed. 7/23/98 (5:40 pm) R 1 was sent to the hospital (approximately 13.5 hours after the resident was found out side of the facility) and was admitted with diagnosis of right hip fracture. The only entry prior to 7/23/98 was of 6/26/98 on which it was documented (R 1 restless. . . ambulating in hallway at 2300, [R 1 stated] 'I packed my belongings; call my sister-in-law. . . .') There was no documentation to show as to when R 1 was last seen prior to wandering out of the facility on 7/23/98 04:30 am. There was no documentation to show if the facility had thoroughly investigated the incidence of R1 wandering out of the facility and sustaining hip fracture on 7/23/98. Surveyor observed R 1 on all days of the survey in wheelchair, most of the time dozing, difficult to be aroused. R 1 also was observed to be forgetful, at times alert and confused. Surveyor inquired with R 1 to know about her leaving the facility. R 1 could not remember how she got out of the facility when she got hurt. R 2's record review revealed that R 2 is a 88 year old female, was admitted to the facility on 3/27/96. R 2 has multiple diagnoses which include: Dementia with delusions and confusion, Depression, Dizziness and Hypertension. R 2 has physician order to go on pass with accompaniment. Review of R 2's MDS of 10/2/97 revealed that R 2's short term and long term memory is impaired, her decision making is moderately impaired and needs cues and supervision. In the MDS it was also indicated that R2 is a wanderer and will wander around the building not knowing where to go or what to do. The RAPs for cognition, mood and behavior are comprehensive. The RAPs simply re-stated what was stated in the MDS. 10/6/97 care plan interventions for wandering problem are not specific. Review of R 2's nursing progress notes revealed the following documented instances of R 2 wandering out of the facility: 9/3/98 (7 am - 3 pm) "(R 2) ...at 11:25 am reported to front office by a passerby that (R 2) is walking on Old Hicks Road, Staff went to get resident.....(R 2) complained of dizziness." 9/7/98 (3 pm - 11 pm) "....6:00 pm resident eloped from facility and was found walking along Hicks Road. In the incident report of 9/7/98 it was documented "outsider came to the facility and informed staff that he saw an old woman walking along Hicks Road." The Old Hicks Road is to the east of the facility approximately 195 yards away. There is thick wooded area on either sides of the Old Hicks Road. The traffic on this road is moderate. The Rt. 53 is approximately 200 yards North from the facility. The speed limit on Rt. 53 is 45 miles per hour and the traffic on this road noted to be heavy. There is also thick wooded areas on both sides of Rt. 53. There was no documentation to show when the resident was last seen in the facility. There is no documentation to show if the facility had investigated these instances of R 2 wandering out of the facility. There is no monitoring system to ensure the safety of the wandering residents. Surveyor observed R 2 on all days of the survey on first floor walking in hallways. R 2 was alert but confused and disoriented and does not remember leaving the facility and walking on the Old Hicks Road. On 9/23/98 surveyor checked the exit door alarms in the presence of maintenance supervisor and found the following defects in the functioning of exit door alarms: The battery powered outside door alarm in the first floor stairwell by the kitchen did not work. This stairwell leads to a resident area on the second floor. The second floor door to the stairwell is alarmed but shuts off when the door closes. This door closed within couple of beeps. The battery powered outside door alarm on the first floor time clock stairwell was tested by the surveyor and maintenance supervisor. The door alarm turned off after 45 seconds. No staff responded to the door alarm. This outside door alarm could not be heard from the nurses station. The time clock stairwell inside door to first floor is not alarmed. Residents were observed walking in the corridor by this door. The time clock stairwell leads to a second floor resident area. The second floor door has an alarm that shuts off after two beeps. The outside exit door alarm on the first floor in the corridor by the kitchen was turned off. Residents have access to this corridor through doors by the nurses station. Staff interview reveals there is no preventive maintenance program to check door alarms. Review of incident reports shows that R 1 and R 2 who used to live on first floor have wandered away from the facility. R 1 sustained a fracture of the right hip. R 2 who is cognitively impaired wandered away from the facility on two different days in September, 1998 and was found by a passerby on Old Hicks Road. In the absence of effectively working door alarms there is continuous potential harm to cognitively impaired residents that are identified as wanderers. Currently the facility had identified 14 cognitively impaired residents as wanderers. All residents but R 1 (transferred to second floor after the incident) live on first floor.