BEL-WOOD NURSING HOME ID NUMBER 0004499 6701 WEST PLANK ROAD PEORIA, IL 61604 As a result of a complaint survey conducted by representative(s) of the Department on February 17, 1999, 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. The facility shall maintain all signaling devices in safe, functioning condition. All exterior doors shall be equipped with a signal that will alert the staff if a resident leaves the building. The facility shall not neglect a resident. These requirements are not met as evidenced by the following: Based on observations, clinical record reviews, staff interviews, the facility's in house investigation of the 12/22/98 incident, and the facility's incident/accident report reviews, the facility's system to monitor residents leaving the facility was not always functioning properly; and although facility staff were aware of the problem, supervision was not provided at the front door from 12 midnight to 6 a.m. on 12/22/98. Subsequently R1 left the facility without staff knowledge and sustained injury. Findings include R1 is a 92 year old male resident who was admitted to the facility on 12/03/91. R1 has diagnoses that include organic brain syndrome (psychotic), history of deep vein thrombosis, anxiety, depression, cardiovascular disease and congestive heart failure. Per R1's annual assessment dated 7/22/98, R1 is identified to have short-term and long-term memory deficits. R1 is identified to be forgetful, not always aware of time and place. R1's care plan of 10/29/98 identifies R1 to receive monitoring during transfers due to "unsteadiness or complaint of joint pain/weakness/dizziness". R1's care plan dated 10/29/98 identifies R1 to have "episodes of inappropriate voiding." Per R1's care plan dated 10/29/98 R1 is identified to receive psychotropic medication for anxiety/depression/threats, being abusive to staff and peers and for complaints of insomnia. The approach in part reads, "Monitor for safe environment, do safety check every 30 minutes." Per R1's Care Plan Card with date of 10/29/98, R1 is identified in need of "Elopement Precautions - Safety Checks." Review of the facility's incident report, the nurses' notes dated 12/22/98 at 5:30 a.m., the internal investigation, and staff documentation of R1's accountability prior to 5:30 a.m. on 12/22/98 identified the following: 1. E3, at approximately 5:30 a.m., was driving East on Rt #116, also known as Plank Road, going to Bel-wood Nursing Home. She observed a resident in a wheelchair approximately 18" off of the right side of the road. The resident was waving a small garbage can. E3 "was unable to stop due to traffic". 2. Per interview of E1, E2, and E18 on 2/9/99, it was noted that the front lobby was not monitored from 12 midnight through 6 a.m. on 12/22/98. This resulted in R1's elopement without facility's knowledge. R1 was out of the facility from approximately 5:15 a.m. until 5:30 a.m. when R1 was observed across the highway as indicated by E3 per her written documentation. Plank Road is approximately 500 to 600 feet from the facility's driveway as it exits to the highway. R1 was an additional 100+ feet across the road, heading west on the side of the road. 3. Per interview of E2 on 2/9/99, it was noted according to the "NOVA" report that the outside temperature on 12/22/98 was 5 degrees above zero. In addition the facility had documentation on a 8 1/2" x 11" sheet of paper with "Omnicare Pharmacies of Illinois" heading that "the wind chill was minus 16 degrees." 4. Per written documentation, E3 went to Bel-wood Nursing Home to get staff to help. E19 and E3 returned to the site. R1 was on the road by this time. R1 had blood on his left hand, a lot of mucous on his face, and his pants were down. R1 was yelling loudly over and over that his "hands hurt". R1 was dressed in pants, hat, sweater, undershirt, socks and shoes. Per R1's nurses notes dated 12/22/98 at 5:30 a.m., it was noted that R1's pants were down over the buttocks. R1 was carrying a silver trash can in his left hand, which was bleeding. The trash can had urine in it. When R1 was brought back into the facility his vital signs were documented as follows: temperature 88.3; pulse 60; respirations 12; and blood pressure 130/56. R1 was given warm coffee, his hands were soaked in tepid water, and warm blankets were applied. R1's vitals approximately 15 - 20 minutes later were documented as follows: temperature 93.3; pulse 88; respirations 24; and blood pressure 154/78. R1 was sent to the hospital and per the facility's transfer form dated 12/22/98, R1 was identified to complain of severe pain to the digits of his hands and feet. R1's family and attending physician were notified. R1 was evaluated at the Methodist Medical Center on 12/22/98 at 0550. Per Methodist Medical Center Emergency service documentation, R1 was identified to have "mild hypothermia." Per nurses notes dated 12/22/98 at 11 a.m., it was documented that there were "Blisters noted on fingers - also multiple cuts on hands and fingers". Per documentation at "1 p.m. Blisters continue to get bigger on fingers". According to the nurses notes dated 12/23/98 at 4:30 a.m., R1 received Darvocet N 100 for pain with fair results. R1's finger tips were edematous with fluid. Per nurses notes dated 12/23/98 at 8 a.m., R1 was identified to have large blisters on all fingers of the right and left hands with complaints of pain. Per nurses notes dated 12/27/98 and universal notes R1 was identified to receive Vicodan for severe pain. Per doctor's orders and universal notes R1 was identified to receive Keflex 500 mg for a yellowish drainage from the blisters on 12/25/98. On 12/26/98 the attending physician assessed R1 to have frostbite with debridement of blisters. 5. Per documented staff interview, it was noted that R1 was last observed between 5 a.m. and 5:15 a.m. per E8. R1 was on the Norwood Wing, with a bucket, looking for his room. R1's room was identified for him by E8, and the light was turned on for him. R1 turned off the light and said it was the staff's room. E8 documented that R1 "Stays up almost every night and sometimes leaves the floor to go to the vending machines or the Bellevue wing." E9 and E10 acknowledged per documentation that R1 was observed on 12/22/98 at 5:10 a.m. at the nurses desk on Norwood Wing. Per interview of E1, E2, and E18 it was noted that the facility practice was not to monitor the front entrance from 12 midnight to 6 a.m. Per interview of staff at random, on 12/22/98 R1 was not observed to leave the facility but it was believed that he left from the front entrance/exit doors. 6. The facility, as part of its monitoring system, uses a second alert system that uses "sensor tiles" and/or "bracelets". Per staff interview on 2/9/99, it was identified that on 12/22/98 R1 was not in his personal wheelchair and the sensor tiles were not in place at the time of R1's elopement due to the need for R1's wheelchair to be repaired. 7. R1 was observed on 2/10/99 to be up in a wheelchair with sensor tiles in place and to be in the front lobby area checking on the vending machines and propelling his wheelchair per his feet. Per interview R1 was aware of person but failed to follow the conversation at all times. R1's hands were observed to be pinkish red (like new skin) and swollen. 8. Interview of direct care staff and management staff and review of facility's policy and procedures, it was noted that the sensor posts system (wander guard) and the front entrance door alarms are designed to sound on the Bellevue and Glasford units, as well as the front entrance door. Bellevue and Glasford units are the front resident care units in the facility. Per interview of E1 and E18, it was noted that the facility's goal was to have the front door alarm and sensor posts system sound on all units in the facility. On 2/9/99 at approximately 4:00 p.m., R1 was positioned at the sensor posts in a wheelchair with two sensors tiles attached to R1's wheelchair with E2, E20, and surveyor present. It was noted per Glasford nursing staff and the surveyor that although the sensor system was heard at the Bellevue unit, it was not heard on the Glasford unit. The surveyor requested that staff test a sensor tile that was not attached to any resident. The alarm from the sensor post was heard at the Bellevue unit, but again it was not triggered at the Glasford unit. E20 activated the front entrance doors at approximately 3:45 p.m. on 2/10/99. Per observation with E20 and E2 present, the door alarms were activated and heard at the front entrance, Bellevue and Glasford units. The alarm units were noted to sound for approximately 5 - 10 seconds, at which time the alarm automatically shut off. 9. The facility was aware of problems with the alarm systems. Based on observation, interviews, and the facility's documentation of the need for repair services, the following was noted: A) The facility had identified per the fire disaster and safety meeting dated 11/3/98 the following: a) Door alarms: Poor sounding system especially if staff is in rooms - maintenance to fix as soon as possible and place sensors on the Glasford wing. b) When interviewed on 2/10/99, E18 offered the Quality Assurance meeting notes dated 12/9/98, which identified elopement issues and that the front sensors were not functioning yet. c) A photo identification book was implemented for all residents to assure the safety of those residents who wander throughout the building. d) Fire disaster & safety meeting dated 1/6/99 identified the front entrance/sensor pillars were being worked on to restore normal function. Staff is closing fire doors to the front to "Detour Wanderers at night." During tour of the facility, the individual exit doors of the units were activated and found to be working. These exit doors have individual alarms that have to be manually shut off. The exit doors to the closed courtyard are automatically alarmed per facility practice only during the evening and night hours. At approximately 5:00 p.m. they are turned on and at 6:00 a.m. are turned off.