CASTLEHAVEN CARE CENTER
I.D. Number 0042515
225 CASTELLANO DRIVE
SWANSEA, ILLINOIS 62226
Survey Date: 5/11/99
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 the safety of residents at all times.
These REQUIREMENTS are not met as evidenced by:
Based on record reviews, incident report reviews, interviews of facility staff and physician and direct observations, it was determined that the facility does not always ensure that each resident receives adequate supervision to prevent an elopement for 1 resident in the sample.
The findings include:
R1 was admitted to the facility on 11/23/98, with diagnoses, in part, of dementia, Alzheimer’s with behavioral symptoms, paranoia, and glaucoma. R1 was, and continues to be, independent with ambulation and transfers per the Minimum Data Sets (MDS) dated 12/4/98 and 3/9/99. R1 was assessed on these MDS’s as moderately cognitively impaired with long term/short term memory problem. Interview attempts by the surveyor during the survey revealed R1 to be confused and unable to answer questions in a coherent, reliable manner.
R1 was also assessed as having numerous falls and an unsteady balance. R1 is assessed as high risk for falls and has had several lacerations and fractures due to falls at the facility. R1 receives Mellaril 25 mg twice a day and 50 mg at the hour of sleep.
The care plan dated 12/18/98 noted R1 is a high risk for elopement due to wandering aimlessly through the facility and diagnoses. The approaches stated to “be aware of resident’s whereabouts, check q 30 minutes.” The care plan does not address the need for the electronic monitoring bracelet until 3/27/99 after R1 eloped, even though E5 states that R1 did not have a electronic monitoring bracelet on at the time of the elopement and had worn one for some time. R1 did not have an order for a electronic monitoring bracelet until after the elopement.
R1 is also identified on the 12/11/98 care plan for falls as high risk due to the medication, diagnoses, and unsteady gait. One of the approaches notes to be aware of R1's whereabouts.
R1 resides in room 116 which is located on the alarmed Alzheimer’s Unit. On 11/23/98, R1 was assessed as high risk for wandering and was placed on the “Wandering Resident Monitor” every 30 minutes. This requires staff to visually locate the resident and document on the “Wandering Resident Monitor” sheet for R1 at 30 minute intervals.
On 3/27/99, R1 eloped from the facility. R1 should have been monitored at 10:00 a.m. and this documented on the “Wandering Resident Monitor” sheet for R1. Per staff and Administrator interview, R1 was observed at 10:00 a.m., however, the “Wandering Resident Monitor” sheet for 3/27/99 is missing.
Per interview with staff and record and incident report review, R1 was last seen at approximately 10:00 a.m. on 3/27/99 on the unit by E5.
Per interview with E6 and review of the incident report at approximately 10:15 a.m. the door alarm to the solarium door sounded. E6, who was hired 3/25/99 and was orientating with E5, responded to the alarm alone and saw R29 at the door. E6 stated she stepped outside but did not see anyone else outside. There is a 5 foot tall fence surrounding the solarium door exit and adjoining courtyard which partially blocks the view to the front of the building. E6 turned off the alarm thinking R29, who also wears a wanderguard, had set off the wanderguard alarm at the solarium exit door but did not make sure all other residents were accounted for.
E5 then asked a direct care staff to do a head count and the direct care staff noted that all
residents were on the unit. When the Swansea Police Department called the facility to inquire if a resident was missing, E5 confirmed with the direct care staff that a head count had been done when E5 asked her to do a head count after the alarm had sounded at 10:15 a.m. and the staff stated that it had been done and all residents were accounted for. Per the Administrator, the accuracy of the headcount was questionable. Per E5, R1 did have a electronic monitoring bracelet on prior to and after the elopement.
At 10:40 a.m. the Swansea Police Department called the facility to inquire if a resident was missing. A “Code Yellow Unknown Resident” was called and it was then determined that R1 was missing. R1 was returned to the facility at 10:45 a.m. by the Police Department, uninjured. R1 should have been visually monitored at 10:30 a.m. on the “Wandering Resident Monitor” per his care plan. The “Wandering Resident Monitor” form for 3/27/99 for R1 is missing. Maintenance checked all door alarms and electronic monitoring bracelets immediately following the elopement and found all to be in working order.
Although staff are unsure how R1 left the facility R1 did travel to a residential neighbor’s house located approximately 535 feet away from the closest edge of the nursing home and knocked at the back door. The neighbors invited R1 in thinking he was a homeless person looking for a job. R1 was dressed in jeans, flannel shirt and socks only. R1 did not have shoes on. The recorded temperature on 3/27/99 was 52 degrees Fahrenheit, sunny with mild winds. Per the neighbor R1 could not say his name or say where he was from or going. The neighbors called 911 and the Swansea Police Department responded. R1 had cookies and a drink while the neighbors waited for the police. Interview with the police officer revealed that R1 did know his name but could not say where he was from or going. Realizing the facility was near, the police officer called to see if a resident was missing. Interview with the neighbors revealed R1 acted confused.
Interview with R1's attending physician revealed that R1 should not have been outside unsupervised. The physician stated that it was questionable if R1 had any safety awareness and if he would be able to recognize any dangers.
The attending psychiatrist did not return calls to the surveyor after the surveyor made three attempts to contact him.
Interview with staff revealed that R1 tried to leave the facility shortly after he was admitted to the facility from a bedroom window. There is no documentation of this attempt. It was noted during the survey that 6 screens were missing from resident windows on the Alzheimer’s Unit. R1's window could easily be raised in his room as well as other resident rooms. These rooms are on the side of the building next to the parking lot which is open to the front and back of the facility.
The neighbor’s house R1 went to was in a residential area on a street at the front of the facility with a 20 mile per hour speed limit. Cars were observed traveling on this street and R1 would have had to cross the parking lot driveway of the facility to get to the neighbor’s house. The neighbor’s house was located at the second house and a lot down from the facility.
The backyard of the first and the neighbor’s house was enclosed by a fence and the only way R1 could have reached the back door of the neighbor’s house was to go between the two houses. R1 would have gone through the first house front yard with no sidewalk or the street to get to the neighbor’s house. Other hazards in the area include a ravine with a 60 degree slope 20 feet behind the facility and a lake approximately 1000 feet behind the facility. There is a wooded area adjacent to the facility and the parking lot is uneven asphalt.
The facility failed to adequately supervise and monitor R1, a cognitively impaired resident with a history of falls, to prevent R1 from leaving the facility unsupervised.
There have been no reported or identified elopements since R1 eloped on 3/27/99.