WABASH CHRISTIAN RETIREMENT
Facility I.D. Number 0020610
Carmi, IL 62821
Survey Date 06/07/00
Incident Report Investigation 05/26/00
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.
These requirements are not met as evidenced by:
R-1 is a 91 year old resident with diagnoses that include Alzheimer's Type-Senile Dementia. R-1 was admitted to this facility on 10/29/93. R-1 is ambulatory without assistance, but does have a history of occasional falls. R-1 is care planned as a wanderer and wears a wanderguard alarm bracelet. E-2 stated that R-1 does have a history of wandering within the facility and of going out the front doors on occasion. R-1 is confused and does have a legal guardian.
Per R-1's nurse's notes, on 5/26/00 at 9:20 p.m., the facility received a call from the local police department stating that they had a person that they thought might be one of the facility's residents. E-4, who took the call, stated that she went to identify the resident and found that R-1 was the person in question.
Per interview with Z-3, police dispatch had received a call from a member of the community stating that she had found a confused female in front of the Campbell Funeral Home on Main St. and had taken her to her own home on Robinson St. Z-3 and another officer went to the Robinson St. address and observed a white female who was confused and was unable to tell them anything but her first name. Z-3 stated that R-1 was dressed appropriately in street clothes, a sweater and shoes. Z-3 stated that the other officer had noted an alarm monitoring device on R-1's ankle and they suspected that she was from a local nursing home. The officers called this facility and explained the situation to E-4 who confirmed that they did have a resident by R-1's first name. Z-3 stated that two staff from the facility came and positively identified R-1 as a resident of their facility. R-1 was transported back to the facility by Z-3 and the other officer.
Per interview with E-4, who was the charge nurse on 5/26/00 p.m. shift, the facility was not aware that they had any residents missing from the facility until they received the call from the police department. E-4 documented in the nurse's notes that after R-1 was returned to the facility she was checked for injuries and none were noted.
E-4 stated that she had interviewed staff working that night and determined that R-1 had last been seen at 8:45 p.m. in the lobby area off of wing 6.
Per review of the nurse's notes and the facility incident report, R-1 was put on every 15 minute checks after her return to the facility at approximately 9:30 p.m. and an I.D. bracelet was put on R-1 on 5/27/00.
On 6/6/00 at approximately 9:00 a.m., R-1 was observed in her bed. R-1 was confused and not interviewable. R-1 was noted to be wearing a wanderguard alarm device on her right ankle. Z-1, R-1's physician stated per interview on 6/6/00 that he felt that R-1 was not capable of remaining safe and free from harm in an unsupervised situation.
This facility is located on College Boulevard, a residential street which has a light traffic pattern. This residential street meets Main Street 2/10's of a mile from the facility. There are no sidewalks along this street and there is a very deep and wide ditch 1/10 of a mile from the facility which College Boulevard crosses over. Campbell Funeral Home is located 2/10's of a mile north of College Boulevard on Main Street.
Main Street is a heavily traveled main thruway which runs through Carmi Robinson St., where R-1 was taken by the person who found her, is located three blocks east of the Campbell Funeral Home.
S.I.U. Weather was consulted and it was determined that the weather condition for 5/26/00 at 9:00 p.m. was dry and 72 degrees.