BLUE ISLAND NURSING HOME
Facility I.D. Number 0035394
2427 West 127TH Street
Blue Island, IL 60406
Date of Survey: 08/02/01
The facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of the resident, in accordance with each residents comprehensive assessment and 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 that the residents environment remains as free of accident hazards as possible. All nursing personnel shall evaluate residents to see that each resident receives adequate supervision and assistance to prevent accidents.
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.
These REQUIREMENTS are not met as evidenced by:
Based on observations, record review, and staff interview, facility failed to provide supervision for R#1, a confused resident who made frequent attempts to leave the building; failed to provide proper supervision making it possible for resident to elope from the facility unnoticed by staff; and failed to implement a plan of care for resident identified by staff for wandering and in need of supervision. There are two residents (R#1, R#6), out of a census of 29 that were identified by facility as a high risk of elopement.
During interview on 7-26-01, Z#4 stated that at 1:00a.m. on 6-30-01 she saw R#1 outside of the facility alone. Z#4 stated she banged on the facility door and got no response from anyone in the facility. She then called the facility from her home and the phone rang a long time before anyone answered. She informed a staff person that R#1 was locked out of the facility.
Observation on initial tour on 7-27-01 at 1:30p.m. with E#3, revealed that R#1 was in the day room sitting in a chair the facing window, alert and answering simple questions, following simple commands, but did not remember leaving the facility at any time.
Review of the facility's Employee Warning Notice form ( a discipline notice for employees ) for E#4 and E#5 states; "According to the report of a staff nurse (E#3), Employee who apparently sleeping in the facility when on duty, a couple of weeks ago. A resident (R#1) who was left outside and the resident apparently was helped by a person outside who noticed that the resident was outside of the facility early AM. The person helping the resident apparently knocked on the door and the door was only opened after they called the facility and the phone rang several times". On the disciplinary notice under the employee response states: "Employee stated that she was having diarrhea that night and had to use the toilet often, she also took care of laundry and all the incontinent residents. She acknowledges not doing enough supervision of the resident on the night of the incident." E#5 had signed and dated the discipline notice.
According to record review, R#1 was admitted to the facility on 5-31-01 from the hospital with diagnoses of history of falls, Parkinson Disease, mild dementia, syncope and deep vein thrombosis. On the initial Resident Assessment, cognitive patterns, R#1 was assessed as a 1 having memory problems. The initial Social Service Assessment states the reason for admission is that R#1 needs more supervision.
R#1 who is cognitively impaired was put at risk by eloping from the facility into a very hazardous and busy traffic route. The facility's location is on 127th Street and Western Avenue with eight lanes of traffic going in each direction (N, S, E, W).
There were 10 staff members remembering the incident of R#1 eloping from the facility unnoticed by staff.
(E#1, E#2, E#3, E#5, E#6, E#7, E#8, E#9, E#10, Z#1, and Z#2). E#5 was the only staff person who could give detailed information about the incident.
Interview conducted on 7-27-01 at 2:00p.m. with E#3 in Administrator's office. E#3 stated that R#1 is a wanderer and goes in and out of other residents' rooms and needs re-directing frequently. E#3 also said, that once someone leaves out of the back door and the door closes it automatically locked and it cannot be opened from the outside. Someone must open the door from the inside of the building.
Interview conducted with E#8 on 7-27-01 at 3:15p.m. in Administrator's office. E#8 said she knew about R#1 leaving the facility about 1:00a.m. E#8 said R#1 is a wanderer, is confused and needs supervision. E#8 said to surveyor "I don't know why (R#1) was not assessed for a wandering device. (R#1) is constantly going in and out of other residents' room and frequently tries to go out of the back door".
Phone interview conducted with E#5 on 7-31-01 at 10:30a.m., E#5 said she was the Certified Nurse Aide on duty the night R#1 left the facility. E#5 could not tell surveyor the exact date the incident occurred, or give any time the incident happened. E#5 told surveyor the charge nurse, E#4 was in the office all night with the door closed after taking pain medication for a wisdom tooth extraction. E#5 said E#4 had her head on the desk and saying she was feeling nauseous and wanting to go home. E#5 said she did resident rounds at 11p.m. and R#1 was in the bed asleep. She did not check on residents again until approximately 2:30a.m. or 3:00a.m. E#5 said this is when she saw R#1 and the neighbor outside on the patio and let R#1 into the facility. E#5 said she stayed in the front of the facility by the administrator's office most of the shift. E#5 also said she did not hear the alarm on the door go off which would have signaled that someone was leaving the facility. E#5 said "there had been some problems with hearing the buzzer in the past , sometimes the buzzer is very faint (low) and you cannot hear it at all". E#5 stated there were no policies as to how often resident rounds are done.
Phone interview conducted with Z#2 on 8-2-01 at 12:15p.m. Z#2 told surveyor "(R#1) is clearly chronically depressed, and has effect and thought process deficits which is the sign of Major Depression. I can give her (R#1) all the medication to treat her illness, but if the facility fell down on their job or not watching their own shop, nothing is going to work. (R#1) clearly needs more and better supervision. (R#1) is slowly declining in her condition (mental) and the facility failed on the responsibilities for (R#1)".
Phone interview conducted with Z#1 on 8-2-01 at 11:05a.m., R#1 is slightly dementia and was moved from one nursing home to another because she needed more supervision.
Interview conducted with E#9 on 7-27-01 at 3:30p.m. in Administrator's office. E#9 told surveyor she knew about R#1 leaving the facility on the 11p.m.-7:00a.m. shift, but did not know any details. E#9 also said the 3:00p.m. to 11:00p.m. nurse is the person responsible for locking the door at 8:00p.m. every night.
Interview conducted with E#10 on 7-27-01 at 3:45p.m. in Administrators's office. E#10 told surveyor R#1 is a constant wanderer and is confused and needs lots of re-direction because she goes in and out of other residents' rooms and has tried on numerous occasions to get out of the door.
The elopement assessment scale done on 8-1-01 for all 29 residents identifies R#1 and R#6 as high risk for elopement.