BRIAR PLACE
Facility Name I.D. Number 0031765
6800 West Joliet
Indian Head Park, IL 60525
Date of Survey: 7/27/00
Incident Survey
The facility shall notify the Department of any incident or accident which has, or is likely to have, a significant effect on the health, safety, or welfare of a resident or residents. Incidents and accidents requiring the services of a physician, hospital, police or fire department, coroner or other service provider on an emergency basis shall be reported to the Department. Notification shall be made by a phone call to the Regional Office within 24 hours of each serious incident or accident. If the facility is unable to contact the Regional Office, notification shall be made by a phone call to the Department's toll-free complaint registry number.
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 resident's 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.
These regulations are not met as evidenced by:
R#1, a 79 year old male admitted on 7-10-00 has diagnoses which include Alzheimer's Disease, Dementia, Urinary Retention, Arteriosclerotic heart disease, and a pacemaker. R#1 was assessed as a "pacer" and at high risk for wandering. A wanderer sensor device was placed on R#1's left wrist due to the high elopement risk. R#1's record revealed he was oriented to self only.
R#1's quarterly assessment dated 4-20-00 rates Cognitive skills for daily decision making as severely impaired. R#1 exhibited wandering behaviors daily and was independent in ambulation. The current care plan identifies problems of wandering and elopement risk and approaches included wander alarm and general supervision.
Nurse's notes of 5-22-00 document "tried to leave facility using west side exit x 1" and 5-25-00 document "went down 1 x using west side door".
R#1's nursing documentation on 7-14-00 at 10:15 a.m. reveals "resident at nurse's station (with) CNA (Certified Nurses Assistant)," and 11 a.m. documentation "Informed by CNA that resident is missing search of floor initiated by staff."
Per phone conversation on 7-19-00 at 11 a.m. E#1 stated that E#10, CNA, said on 7-14-00 R#1 was dressed in a tan short sleeve shirt, brown pants, shoes and socks.
The facility failed to notify the Department within the required time frame and failed to call the Department's toll-free number.
The facility incident report fax line documents "July 15 2000 1248" which is more than 24 hours after R#1 was reported missing.
The incident report included the notation "there was no answer, faxed report". July 15, 2000 was a Saturday and no evidence of report phoned to Regional Office on Friday July 14, 2000 and no evidence of call placed to the Department's toll-free number.
Surveyors toured the outside of the building on 7-18-00 before 11 a.m. and observed E#13 smoking outside of the delivery door located on the North side of the West end of the building. E#13 told surveyors the door is open all hours of the day and night.
E#5 states "bread delivery is before lunch" and the delivery person doesn't need to ring the doorbell because the door is unlocked and unalarmed.
Z#5 was interviewed on 7-25-00 by phone from the Regional Office and stated on 7-14-00 he delivered 10 to 20 packages at approximately 6:45 - 7 a.m. taking 30 minutes. Z#5 also stated the door is always unlocked in the a.m. and only saw staff the morning of 7-14-00. Z#5 stated he has been delivering to the facility for two months.
On 7-18-00 at approximately 11:15 a.m. surveyors toured the basement level and the door on the East side of the building was tested. NO audible alarm was heard. When the West side door was tested, the alarm sounded. The door was closed by the surveyors and the alarm ceased. Staff did not respond. The door was again opened, the alarm sounded and staff responded to the alarm. Surveyors then went back to the delivery door area and observed the door propped open. E#14 was observed mopping the floor and stated "needed some air."
On 7-18-00 E#4, the maintenance supervisor, joined the surveyors during the tour of the basement and stated he has been employed by the facility since February, 2000. E#4 denied seeing any documentation regarding the testing of alarms to exterior doors in the past, nor were the alarms tested by maintenance now. E#4 states "had an inservice of Code Alert Alarm System over the phone on 7-11-00."
On 7-18-00 E#3, staff nurse, demonstrated the Code Alert System monitoring done each shift on each wander bracelet and documented in each resident's Medication Administration Record. Surveyors observed test of the bracelets on 3rd floor, the only location where the wanderguard system is installed. The bracelet alarm signaled at the 3rd floor East, West and South stairwell doors and both elevator doors at approximately 12:45 p.m. on 7-18-00.
Surveyors then entered the North elevator accompanied by R#2 and R#3, both wearing bracelets on their ankles. No audible alarm sounded. Both residents rode the elevator down with the surveyors and got off on the first floor where there was no wanderguard sensor to detect their presence. Surveyors then informed E#1 of the observations.
After 3 p.m. on 7-18-00 the surveyor was at the first floor nurse's station when the door alarm sounded for the front ramp door. E#15 failed to check the doorway. E#15 told E#2 he saw some visitor near that door and presumed the visitor sounded the alarm. E#2 told E#15 the door should have been checked and secured.
The following interviews were conducted on 7-18-00 at the facility:
E#3 described R#1's behavior as "pacing at various times of day and night, toward exit doors and toward medication room and sometimes in nurse's station." E#3 states R#1 would pace with head down when he would be tired and walked with an even gait.
R#4 is alert and oriented and was interviewed about R#1. R#4 stated "(R#1) could say one sentence and then another was not connected, just could not carry on a conversation."
E#1 states R#1 had a problem hearing – would have to raise her voice to have him respond.
A 7-20-00 interview of E#10 reveals she was R#1's caregiver on 7-14. R#1 was already dressed on 7-14-00 at 7:15 a.m., was wet, got changed, then to dining area at 8:30 a.m. R#1 ate his breakfast and finished at about 9:15 a.m., then toileted, shaved, and placed in a chair with a magazine. E#10 went to shave another resident, returned to area, could have been 10:30 a.m., and noticed R#1 was not where she had left him. E#10 told E#20 and told other CNA's and started to look for R#1 on the 2nd floor, 1st floor, outside, also looked at 7-11 and Walgreens. The 7-11 and Walgreens is in the East direction.
A 7-20-00 interview with E#19 reveals that on 7-14-00 E#19 had a break at 10:15 a.m. to 10:30 a.m. at the back delivery door with other employees. E#19 states heard no alarm when the door was opened and did not have to ring a bell to come back in. E#19 changed another resident at 10:30 a.m. and started to look for R#1 at 11 a.m., searching rooms, then outside toward apartments, then searched floors again, under beds and in closets. E#19 assisted residents with lunch, then changed residents, had another break at 2:10 p.m. to 2:30 p.m. at the back door which was again not locked and not alarmed. E#19 stated R#1 was always walking toward the doors and constantly past the South door. When questioned, E#19 stated R#1's alarm went off 3-4 times a day.
A 7-20-00 interview with E#2 reveals that after hearing R#1 was missing on 7-14-00, E#2 "ran the perimeter of property", then got into his truck and drove behind facility, then eastbound to Willow Springs Road, then North into subdivision, then into area of condos and checked back by phone in the car every 20-30 minutes until at least 3-3:30 p.m.
E#2 and E#18 went through the cemetery and south side of street and into business toward the Southwest.
A 7-25-00 interview with E#20 reveals that on 7-14-00 E#10 did R#1's a.m. care and put R#1 in a chair in the Activity area and "thought he was asleep". E#20 heard the alarm ring, R#5 pointed to the East hall, E#20 went to the East hall, opened door, looked around the stairwell, believes that E#6 turned off the signal, and then returned to the nurse's station. E#20 states went downstairs and outside to the car, came back up to the 3rd floor. E#20 states E#10 "couldn't find (R#1)", then notified E#1 and E#16. E#20 states R#1 was wearing cotton shirt and pants, and can't recall if he had on shoes.
A 7-20-00 interview with E#16 reveals E#16 received a phone call from E#20 between 11 a.m. and 11:15 a.m. on 7-14-00. E#20 called to the 2nd floor, told the 1st floor and called E#5 in the basement. "Everyone responded quickly." E#17 went to the 3rd floor. E#16 went to the 1st floor–did the high numbered side and E#18 did low side.
E#6 went into the car, to the bank, inside bank, to the apartment complex, near the swimming pool, looked into the pool because the gate to the pool was open. E#16 continued to drive around to the back of the apartment building, slowly to look into the parking stalls, to the next complex, through the parking area, North to Wolf Road, then back to the water. E#16 continued to cut into every cul-de-sac, went to Plainfield Road, to Willow Springs and observed very few people out.
On 7-25-00 an Indian Head Park Police report was faxed to the Regional Office and documents "last seen wearing ..shirt..tan: pants..tan or black: shoes..light blue slippers." "Last seen at ...1130 hrs" Report dated "14 July 00 1258 hrs." The Cook County Sheriff Police state R#1 was found with a T-shirt, sweatpants, and slippers on. Report to follow.
The body of R#1 was found on 7-19-00, 6 days after the elopement approximately 1710 feet West of the facility in a shaded overgrown area near Joliet Road (Route 66) a heavy traveled four lane road.