CONVALESCENT CARE CENTER ID NUMBER 0036897 P.O. BOX 209 1000 PALM MATTOON, IL 61938 As a result of a complaint survey conducted on September 30, 1998, by representative(s) of the Department, it has been determined the following violations occurred. "A" VIOLATION(S) The facility shall provide a Resident Services Director who assigned responsibility for the coordination and monitoring of the resident's overall plan of care. The director of nurses or an individual on the professional staff of the facility may fill this assignment to assure that residents' plans of care are individualized, written in terms of short and long range goals, understandable and utilized; their needs are met through appropriate staff interventions and community resources; and residents are involved, whenever possible, in the preparations of their 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 the safety of residents at all times, such as but not limited to: nonslip wax on floors, safe equipment, assistive devices properly maintained, and proper use of physical restraints and adaptive equipment. The DONS/HSS shall oversee the nursing services of the facility. This person's duties shall include: Planning an up-to-date resident care plan for each resident based on the resident's individual needs and goals to be accomplished, physician's orders, and personal care and nursing needs. Personnel, representing other services such as nursing, activities, dietary, and such other modalities as are ordered by the physician, shall be involved in the preparation of the resident care plan. The plans shall be in writing and shall be reviewed and modified in keeping with the care needed as indicated by the resident's condition. The plan shall be reviewed at least every three months. 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. Based on review of facility documentation, including clinical records and incident reports, interviews with staff, facility policy review, and observations made on 9-25-98, it was determined that the facility failed to ensure that each resident receives adequate supervision to prevent accidents. The facility failed to ensure that R3 was supervised by staff on 8-29-98 so that his whereabouts were known in order to prevent an unnoticed absence from the facility. Failure to provide supervision for R3 on this date resulted in an unnoticed absence from the facility that subsequently resulted in harm and avoidable exposure to outside elements that compromised his existing medical condition. In addition, the facility failed to provide adequate supervision for R7, who left the facility unnoticed by staff on 5-28-98. Failure to provide adequate supervision for this resident who was assessed as an elopement risk, put R7 at risk for avoidable potential harm. Examples of findings follow: 1. R3 is a 79 year old male that was admitted to the facility on 8-18-97. R3 has diagnoses that include Chronic Dementia, Alzheimer's disease, Senile Dementia Alzheimers Type with Psychoses, Ischemic Heart Disease, Chronic Atrial Fibrillation, Coronary Artery Disease, Peripheral Vascular Disease, Chronic Obstructive Pulmonary Disease, Non-Insulin Dependent Diabetes Mellitus, and history of Myocardial Infarction. R3 is a left below the knee amputee and a right above the knee amputee who, at the time of the 8-29-98 incident, self propelled himself about the facility with a motorized wheelchair. According to record review and interview with staff, R3, at the time of the 8-29 incident, and currently, is assessed as independent with wheelchair ambulation, has short term memory problems, and is moderately impaired for cognitive/decision making ability. R3 has a history of wandering about the facility and at the time of the 8-29-98 incident, was assessed as an elopement risk. The facility Social Service notes document the following: 2-10-98 "R3 does continue to have episodes of wandering. He does have periods of confusion." 5-4-98 "He does have periods of confusion, staff should be aware of his whereabouts." 8-4-98 "At times R3 wanders, moving with no purpose, seemingly oblivious to needs or safety." A note made by the activity director dated 8-4-98 states " He now has motorized cart and goes all over facility. He comes to office, parties and music. He often becomes confused and ends up leaving before activity is complete." R3 was found outside the facility unbeknownst to staff on 8-29-98 at 3:45 p.m.. Staff interviews confirm that R3 was found sitting in his motorized wheelchair outside on the east side of the facility. The motorized wheelchair was positioned just off the sidewalk in the grass near the end of the northeast wing which was closed for renovation. The wheels of the chair were reported by staff to be in a soft, slightly depressed area of the ground. When found by staff, the motorized chair was not functional. Outside weather conditions as recorded by the Midwestern Climate Center Champaign reporting station at the time of the incident were: 3 p.m. 84 degrees F., 50% relative humidity, and winds 5-9 mph from the NNW. R3 was reportedly first seen through a window by an aide from inside a resident's room on the annex east wing while giving care. Staff were dispatched to R3's location just outside the adjacent northeast wing. According to nursing staff interview, R3 was approached and was found to be "sleeping", his skin was "warm and pink". R3 was aroused and assisted to a manual wheelchair, transferred to bed once inside, and vitals taken. Vitals were: oral temperature 102.8 F., Blood pressure 170/80, pulse 104, respirations 52. Record review and nursing staff confirmed through interview that R3 was cooled with moist cool towels, oxygen was administered, vital signs re-taken, a Tylenol suppository was administered, physician was notified, and R3 was transferred to Sarah Bush Lincoln Health Center emergency department per ambulance for evaluation related to possible heat stroke. According to facility staff interviews and review of facility investigation documentation, staff were unaware of R3's absence from the facility. According to staff accounts, R3 was last observed inside the facility at approximately 1:30 p.m. and not discovered until 3:45 p.m. on 8-29-98. According to staff interviews, it is not known how R3 came to be outdoors on the east side of the building. Observations made on 9-25-98 and interviews with maintenance, nursing, and administrative staff confirmed that all exterior doors are equipped with 24 hour a day audible signals that require a keypad code to pass through to the outside without sounding the alarms. All exterior doors, with one exception, are equipped with alarm signals that can only be deactivated at the door by entering a code. The exception is the south (main) entrance which can be momentarily deactivated by the receptionist who has visual control of the door. All exterior doors are equipped with signals that automatically reset to "on" within 10 seconds of the door closing. According to staff accounts and interviews, no staff person claims to have heard any such alarm between 1:30 p.m. and 3:45 p.m. on 8-29-98. According to R3's clinical record, nurse's notes dated 8-29-98 7:20 p.m., R3 was admitted to the hospital with a diagnosis of dehydration, urinary tract infection, and septicemia. Blisters were found to be present on R3's left upper arm and left knee. Hospital documentation, history and physical data, reflective of the 8-29-98 emergency room visit documents in part "...a blister about 2 cm in diameter anteriorly on the left thigh....Impression: 1) Patient probably has urosepsis which made him confused and go to another wing. 2) Heat stroke was a possibility. 3) Sunburn left thigh. 4.) Probable silent myocardial infarction....." The Medical History that was dictated on 8-30-98 states the following: "In the emergency room he was almost unresponsive. He was stuporous but he was found to have elevated blood sugar and leukocytosis of 18,600. Patient was felt to have urosepsis and possible heat stroke." R3 was hospitalized until 9-1-98 at which time he was readmitted to the facility with a Foley catheter, was placed in a non-motorized wheelchair, and housed in a locked residential unit. Per interview with facility nursing staff R3 was readmitted to the facility with arms described as "dry, scaly, dark red" and had "two water-type blisters on top of the left thigh which measured 2.5 cm and 3.0 cm". As of 9-30-98 facility nurse assesses R3 to have "one blister measuring 2.0 cm, scabbed, dry, no signs/symptoms of infection". It was determined that the facility has 25 residents who are ambulatory and assessed as elopement risks. Seventeen (17) of the 25 reside on a locked, fully supervised (24 hrs/day) unit. The remaining eight residents reside on SE, Annex west, and NE wings. The northwest wing is currently unoccupied by residents but is kept open for therapy and staff offices during the day. During the course of the investigation it was determined that when exterior door alarms are sounding on the southeast, annex west, and northwest wings, and when staff are concurrently not present on these wings (i.e., during meals in the dining rooms), the exterior door alarms cannot be heard from theseremote locations. Therefore if a resident were to leave the dining room and exit to one of these exterior doors, staff would not immediately be aware of the resident's departure from the building. The director of nursing confirmed that this is a problem and a concern when these units do not have staff physically present. Remaining wings, Southwest, annex east, and Northwest are all physically staffed 24 hours a day. Failure of staff to provide adequate supervision for R3 resulted in R3's exposure to outdoor elements which resulted in direct harm. 2. Interview with facility staff and review of facility records revealed that another resident left the facility unnoticed by facility staff approximately three months prior to the incident involving R3. Record review and staff interviews confirmed that R7 left the facility unnoticed by staff on 5-28-98. R7 is a 79 year old female that was admitted to the facility 12-1-97. R7 has diagnose that include Alzheimer's, hypertension, depression, transischemic attacks, cardiovascular accident, and osteoarthritis. R7 at the time of the 5-28-98 incident was independent with ambulation, assessed as moderately impaired for cognitive/decision making ability, had daily behaviors that included wandering and pacing, as well as verbal and physically aggressive behaviors. R7 was assessed as a potential elopement risk according to facility documentation and staff interviews. R7 resided on the annex east unit (a closed, dementia care unit) at the time of the 5-28-98 incident. Nurse's notes dated 5-23-98 2:30 p.m. reads, "res was attempting to leave AE CNA tried to distract her and get her away from doors. Res then got mad and started kicking and hitting res. CNA got a hold of res arms to prevent res from hitting her and res bit CNA on R bicep." Nurse's note dated 5-28-98 9:45 a.m. states in part "...pacing off and on, setting off alarms on doors...." R7's plan of care dated 2-23-98 reflects needs/problems/concerns as "wandering in inappropriate places...res has the behavior of pacing back and forth which at times leads to wandering off the unit, others rooms...res resides on special care unit (closed corridor)." R7 was found to be out of the facility unbeknownst to staff on 5-28-98 at 3:45 p.m. at which time she was observed by a facility staff person who was in his vehicle on his way home. According to interview with staff, R7 was recognized to be a facility resident. The staff person returned to the facility to report R7's whereabouts which was on a sidewalk, westbound, at 15th street and Rudy Drive, approximately 3 blocks from the facility. Weather conditions at the time of the incident as recorded by the Midwestern Climate Center, Champaign reporting station were: 3 p.m. 86 degrees F., 4 p.m. 87 degrees F., 45% relative humidity, and winds 10-15 mph out of SW. According to staff interview, R7 was appropriately clothed and appeared to be in no distress. Facility staff retrieved R7 and returned her to the facility. Nursing assessment documentation reflects no apparent injury, vitals were taken with following results: axillary temperature 97.6 F., pulse 76, respirations 18, blood pressure 110/64. Staff interviews revealed that it was not known how R7 left the unit since R7 resided on a fully alarmed, locked, staffed unit (24 hours/day). It was unknown how R7 left the building since all exterior doors were alarmed, functioning, and required a predetermined keycode to exit without sounding exterior door alarms. Nurse's notes dated 5-30-98 10:00 a.m. reads "as of this time res has been outside x 2, very aggressive with staff, attempted to kick, bite, scratch, hit when staff was bringing res back to unit...." Nurse's note 5-30-98 10:10 a.m. "res set off alarm again, scratched this nurse when attempted to remove res from door to prevent elopement...". Nurse's note 5-30-98 1:20 p.m. "...res continue to pace, set off alarms, leaving unit thru east door, very physical and verbally aggressive...." Failure of staff to adequately supervise R7, puts R7 at risk for unnoticed absence from the unit and from the facility. Unnoticed absence places R7 at risk for potential harm given her cognitive and medical status. Failure of staff to recognize deficiencies in the facility's response system to door alarms and failure to promptly initiate corrective measures unnecessarily put R3, R7, and other residents assessed as potential elopement risks in jeopardy.