ASTA CARE CENTER OF PONTIAC
ID NUMBER 0043968
300 W. LOWELL
PONTIAC, IL 61764
     As a result of an incident survey conducted by representative(s) of the Department on February 10, 1999, it has been determined the following violations occurred.
                         "A" VIOLATION(S)     The facility shall provide a resident services director who is assigned responsibility for the coordination and monitoring of the resident's overall plan of care.  The director of nurses or an individual on the professional staff of the facility may fill this assignment to assure that resident's plans of care are individualized, written in terms of short and long range goals, understandable and utilized; their needs are met through appropriate staff interventions and community resources; and residents are involved, whenever possible, in the preparations of their plan of care.
     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, safe equipment, assistive devices properly maintained, and proper use of physical restraints and adaptive equipment.
     The DONS/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 plans 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 a 24 hour a day supervision of the door, a signal is not required.
     Based on observations made on 2/8/99 and 2/9/99, staff interviews, and review of clinical records, policies and facility incident investigation report, the facility failed to provide adequate supervision to prevent R1 from leaving the facility without staff's knowledge which subsequently resulted in injury on 1/28/99. 
     The findings include the following:
     1.     R1 is an 82-year-old resident who was admitted to the facility on 10/02/98. R1 has diagnoses which includes Alzheimer's disease, Parkinson's, dementia, organic brain syndrome, osteoporosis, kyphosis and coronary artery disease. R1's most recent assessment of 12/23/98 identifies both short term and long term memory deficits, moderately impaired decision making skills, and a behavior of daily wandering. R1's current care plan stated that R1 is unable to walk unassisted, requiring the use of a merry walker to provide independent mobility. R1 has weakness due to Parkinson's Disease, unsteady gait with potential for falls and cognitive deficits. The care plan also addresses R1's wandering on the East wing and getting into other residents' belongings.
     Approaches include monitoring the resident's whereabouts and redirect as needed.
     Per facility incident investigation report, staff interview and facility documentation, on 1/28/99 at approximately 3:20 p.m. R1 was discovered lying outside of the facility in the south parking lot. The parking lot is located at the end of a sidewalk approximately 60 feet south from the east solarium exit door.
     The 1/28/99 nurse's notes document, "3:20 p.m. Resident found outside lying on ground with walker when this nurse arrived, E2 was there. Resident has a large goose egg bump to left temple with abrasions and contusions and small abrasions to the left shoulder and right wrist." 
     The physician was notified and R1 was transported to the hospital for evaluation. The radiology report from the C.T. scan documents a large subcutaneous hematoma without intracranial hemorrhage or fracture. The left shoulder x-rays were negative for fractures or dislocation.
     R1 returned to the facility at 8:15 p.m. on 1/28/99. The surveyor entered the facility on 2/8/99 at approximately 9:15 a.m. The surveyor observed R1 ambulating independently with the use of a rolling merry walker. R1 was in a sitting position and propelled self using feet. R1's face was severely discolored with bruising from the fall. Both of the resident's eyes were bruised, as well as the bridge of the nose and entire left side of the face. A bump was noted on the left temple with a scabbed abrasion that was also bruised. The resident had a scabbed skin tear on right wrist with a healing bruise.
     According to interview with E2 and review of the facility's investigation report, R1 was last observed by E2 in the east wing solarium at approximately 3:00-3:15 p.m. by E2. At approximately 3:20 p.m. E6 discovered R1 laying in the parking lot outside of the east wing. The facility staff was not aware that R1 had left the building.
     The east wing solarium is located adjacent to the east nurse's station and resident wings. The nurse's station does have visual control of the solarium when staff are present and the double smoke doors are open.
     The east wing solarium was not supervised at the time of the incident, as E3 who had been implementing the day programs had left the area to talk with two east wing residents about coming to an activity, E14 was passing medications on the east wing, E13 had been reassigned to the west wing, E11 was in the whirlpool room with a resident, and E12 was assisting a resident in a bathroom.
     According to the facility's report, E12 stated that she heard a door alarm go off while she was assisting R6 in the bathroom. E12 finished assisting R6 and when she came out of the room the alarm was no longer sounding.
     Z1 was also present at the nurse's station and reported hearing alarms going off on two occasions but did not know what they were for or if anyone responded.
     The surveyor interviewed the staff involved and received the following information; E11, E12, E13, last observed R1 in her merry walker in the east solarium some time before 3:00 p.m. The staff reported that E3 was also in the solarium. E11 and E12 then took a resident to the whirlpool room. At approximately 3:10 p.m. E2 entered the east wing and told E13 to go to west wing. E2 also instructed E13 to have staff change R1 who was in the day room. E13 stopped at the whirlpool room and told E11 and E12 that she was leaving and also told them that R1 needed changing.
     E3 stated that she was in the solarium prior to 3:00 p.m. and when she left to get residents for activities, she did not see R1 in the room. E3 stated that she normally does not leave the residents unattended unless someone else is there. E3 stated the rehab room, which is in a room off the solarium was still open but she wasn't sure if anyone was in the room. E3 stated the only resident that was in the solarium was R5. E3 stated she felt she could leave for a short time because R5 "stays put". E3 stated she did not hear any alarms going off and when she returned to the solarium, several staff were bringing R1 back into the facility.
     E7 stated that she had seen R1 in the solarium about 15 minutes before the incident. E7 stated R1 was at the east solarium door and was pulling at the window blinds. E7 stated she pulled the blinds up so R1 could see better. E7 did not remember if there were other staff or residents present.
     E12 stated that when she came out of the whirlpool room she noted R6's call light was sounding. E12 then responded to the resident's room which is at the far north end of the hall. E12 stated that while she was in the process of standing R6 up to transfer to the toilet, she heard the alarm going off. E12 stated she spent 3-4 minutes with R6 and when she left the room to go up to the nurse's station the alarm was no longer sounding. E12 stated that E14 and Z1 were at the desk. E12 stated she did not ask them about the alarm because she assumed one of the staff must have taken care of it. E12 stated that E14 then talked to her about going to the kitchen for supplements when E1 entered the unit stating "R1 is outside". E14 grabbed a wheelchair and went out with E1 to the parking lot.
     E6 stated that she had left her office which is located behind the east wing nurses station and walked through the east solarium to go to the housekeeping office to talk to E8 at about 3:20 p.m. E6 didn't recall any alarms going off prior to this time. She had been working in her office with the door closed. E6 stated that E8 wasn't there so she went out the back boiler room doors to have a cigarette in the parking lot. E6 stated she was shocked to see R1 laying tipped over in the parking lot with head bleeding freely. E6 immediately went in and yelled for a nurse and then went back to assist R1.
     E6 stated that R1 must have gone out the east solarium door with her merry walker down the sidewalk, and when she got to the parking lot she turned right on the sidewalk and continued another 6-8 feet before the merry walker wheels slipped off the sidewalk and R1 fell. The surveyor and E6 went to the spot where R1 was found. R1 would not have been visible from the east solarium windows once she had turned the corner.
     Per interview with E1, E6, E9 and E15, at the time staff discovered R1 in the parking lot, the door alarms were set and were not sounding.  E1 and E9 entered the solarium from the west double doors to obtain a wheelchair and E15 entered east wing to get towels and blankets. The staff did not hear any alarms. E9 stated that he noted when staff exited out the solarium door that the alarm did go off. E9 found no problem with the alarm system.
     The east nurses' station is equipped with a door alarm panel that monitors the two east wing doors, east solarium door, rehab room door and the boiler room and dumpster room doors. When the alarms are on, the panel shows a red light at each button. When the alarm is activated a high pitched beeping noise plus a flashing light on the panel indicates which door has been activated. To silence the alarm staff push the button once and this turns the light green or off. The button is then set again by pushing the button again to turn the light red or on. E9 stated that he didn't have a formal system of checking the alarms. He stated that each day several of the alarms are activated by staff, visitors and residents, and that no problems had been identified. E15 stated a quarterly check of exit doors is done for Maintenance Quality Assurance rounds; the last time documented was 1/21/99. The only item listed on the audit sheet pertaining to door is #9 which states: Are exit doors kept unlocked and equipped with panic hardware? This item is answered "yes" or "no."
     Per interview with E1, E2 and nursing staff, the facility did not conduct a resident head count to determine if any other residents were missing. The east wing has three other residents with history of wandering on the unit.
     Per interview with E1 and E2, after the incident occurred, the facility conducted an inservice on 1/29/99 with staff on the exit door alarm system to insure all staff are aware of protocol for security alarm system. This was signed by 25 staff members. When the surveyor asked to see the policy that was discussed the facility stated that they did not have a written policy on response to door alarms. They did have an elopement policy which is to be implemented once it is recognized that a resident is missing. The facility formulated a written policy on 2/8/99 which included staff responsibility to check the doors when any alarm is activated to determine the cause of the alarm and if any resident was in jeopardy. Staff are to leave the alarm sounding until the doors have been checked. The facility included a new policy to also conduct a count of residents deemed to be at risk for wandering or elopement if the alarm was unwitnessed.
     Staff's failure to adequately supervise R1 and failure to respond appropriately to the door alarm system allowed R1 to leave the facility in a merry walker without staff's knowledge and subsequently receive an injury to the head, shoulder and wrist.