Facility I.D. Number 0043398
14500 S. Manistee
Burnham, IL. 60633
Date of Survey: 7/19/01
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 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.
Objective observations of changes in a resident's condition, including mental and emotional changes, as a means for analyzing and determining care required and the need for further medical evaluation and treatment shall be made by nursing staff and recorded in the resident's medical record.
The DON shall oversee the nursing services of the facility including planning an up-to-date resident care plan for each resident based on the resident's comprehensive assessment, individual needs and goals to be accomplished, physician's orders, and personal care and nursing needs. 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.
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 neglect a resident.
These requirements are not met as evidenced by:
Based on observation, interviews, and record review the facility failed to provide adequate supervision for one resident (R30) exhibiting behavior changes to prevent elopement.
R#30 was admitted to the facility May 27, 1998. On July 8, 2001 at 8:30 p.m. staff noted that R#30's dinner tray had not been touched and began to search for the resident. Staff were sent out to search the nearby area and do a room to room search of the facility. R#30 could not be located. The facility notified the police and staff conducted another search of the facility and the resident could still not be located. E#2, the Director of Nursing, contacted the State Guardianship office on July 9, 2001 to inform the office of R#30's elopement. E#2 had the facility security guard search the local stores and establishments for the resident. Area hospitals and emergency rooms were notified and given R#30's description. Local hospitals did not report admitting or seeing R#30. As of July 18, 2001 the resident had not been located.
During the daily status meeting of July 17, 2001, E#1 (facility administrator) and E#2 (director of nursing) stated they did not know how the resident got out of the facility. E#1 stated the resident did not have a pass and was not supposed to leave the facility. E#1 stated that the facility did not know where the resident was. E#2 stated that R#30 never left the floor and was very isolative. E#2 stated that R#30 never socialized with others and was mostly on the third floor or in her room. In an interview with E#1 on July 18, 2001 at 8:30 a.m., E#1 stated that the facility believed that R#30 left the facility around 6:30 p.m. but he was not sure. E#1 stated that the facility had checked all door alarms and reported that all doors alarms were functional. E#1 stated that most likely R#30 had gone out the front door. E#1 stated the facility conducted an investigation of this incident, however the survey team was not provided a copy of the report. The survey team requested this item numerous times.
E#4, the facility social worker, was interviewed on July 18, 2001 at 9:20 a.m. in the conference room. E#4 stated that R#30 had never tried to leave the facility before and in fact that R#30 would never even leave the floor. E#4 also stated that R#30 did not take any money from her trust fund until about two to three weeks before the elopement. E#4 stated that R#30 had recently developed a close relationship with one of the social service assistants, E#11. E#4 stated that R#30 had left all her belongings at the facility. E#4 showed surveyor a clear plastic bag filled with several items of clothing, the resident had no other personal belongings.
E#11 was interviewed on July 18, 2001 at 9:40 a.m. E#11 stated that usually R#30 was isolative and stayed to herself. E#11 stated that the last few weeks R#30 had been "hanging on my side." E#11 stated that R#30 was getting upset because she wanted to call Z#3, a dentist from R#30's past who is not involved R#30's life. According to E#11, Z#3 did not wish to talk to R#30 and requested that the facility prevent R#30 from paging and calling. E#11 stated that R#30 did call Z#3 sometime in June and had taken money from her trust fund to do so. E#11 stated that R#30 became more and more insistent about calling Z#3 because Z#3 was her "family." E#11 stated that this was not like the resident since she usually was isolative and kept to herself. E#11 stated that R#30 did not usually leave the floor and stayed mostly in her room.
A review of R#30's medical record reveals that R#30 is a ward of the state and has a guardian. R#30 had diagnoses of Schizophrenia and Depression and received the following medications: Haldol Decan Injection once per month, Haldol 5mg tablet twice a day (BID), Paxil tab 20mg once a day. A review of the psychiatric evaluation of June 1, 2001 reveal that the resident remained uncooperative, hostile and delusional. A review of R#30's MDS dated June 5, 2001 reveals that the resident was coded by the facility as being moderately impaired for decision making, having periods of altered perception, periods of restlessness and varied mental function. The MDS also indicates that the resident resisted medication and care daily. Resident care plan addressed the resistance to care, delusions and nutrition. Care plan for R#30 states, "Res appears to be restless and mental function varies. Resident believes that money is no good, she paces on the unit holding her head down." A review of R#30's nursing notes reveal an incident in December of 2000 in which the resident was verbally and physically aggressive with staff and a few days after this incident resident was noted to be delusional and mumbling about Z#3. E#11 charted on June 4, 2001, "gives no response to questions as to what might be troubling her." E#11 also charted the residents sudden desire to call Z#3. E11 charted on March 1, 2001, "quiet, isolates herself, no involvement with others." Nursing notes dated July 2, 2001 state: "Received a call from 1N that res. was in another res' bed and refused to get out. Res. stated '(Z#3) told her she could move downstairs.' Resident became more agitated. Res. assisted to the 3rd fl per 2 staff where she continued to try to move to the lst floor, continues delusional statements." A review of R#30's trust fund record indicates that R#30 took $4.00 out of her account June 6, 2001. The remaining funds were transferred to savings, there are no other resident withdrawals from the funds. According to E#11, R#30 used this money to call Z#3.
Throughout the survey of July 15, 16, 17 and 18, 2001 surveyors noted that staff did not closely monitor the front door. In addition surveyors noted that the security camera was not closely monitored as per protocol. Surveyors noted that residents would wait out in front of the building for the transportation to workshop or just go out to smoke. The reception area does not have visible access to the front entrance of the building. Several times during the survey, it was noted and reported to E#1 that the receptionist had been reading a book and not monitoring the door and or security cameras. E#1 stated that "someone should be at the front door at all times, if not the receptionist the security guard." According to E#1, the enclosed patio is to be monitored by the receptionist for problems. Residents gather in this area to smoke and socialize, yet numerous times the surveyor noted that the security camera was not monitored. In addition, throughout the survey residents were noted to be without identification bands. On July 16, 2001 it took 5 facility staff to positively identify R#17 because he had no identification band and was seated with other residents in the annex day room.
The facility failed to adequately supervise R#30 and act upon and monitor changes in this resident's condition to prevent elopement. The facility failed to monitor the exit doors to ensure residents without a pass remain in the facility. The lack of supervision and monitoring resulted in R#30 leaving the facility without pass and without a physician's order in a confused and delusional state with nobelongings or money.