DU PAGE CONVALESCENT CENTER
Facility I.D. Number 0008201
400 N. County Farm Road, P. O. Box 708
Wheaton, Illinois 61087
Date of Survey 1/28/00
Incident Report Investigation
Personal care, as defined in Section 300.330, shall be provided on a 24-hour, seven day a week basis.
All necessary precautions shall be taken to assure that the residents' environment remains as free of accident hazards as possible.
An owner, licensee, administrator, employee or agent of a facility shall not abuse or neglect a resident.
These regulations are not met as evidenced by:
Based on record review and staff interview the facility failed to adequately supervise R1 on November 20, 1999 from 5:30 p.m. to 6:10 p.m.
R1's record review revealed that R1 wandered away from the dining room and fell down the stair well.R1 suffered a fractured neck, fractured hand, and lacerations to the forehead that resulted in hospitalization of R1 and subsequent death from pneumonia, encephalopathy, and neck fracture. Record review of incident report reveals R1 was brought to the One South Dining Room table at approximately 5:35 p.m.. When R1's tray was delivered at approximately 5:45 p.m. the staff noticed R1 was gone. The incident report states staff looked for R1. In an interview with E1, E1 said the staff thought R1 would come back.
R1 was a l00 year old resident with diagnoses of Hypertension, Hypothyroidism, Glaucoma, Dementia, and Constipation. R1 was in a wheel chair. R1 was known to roam around the facility, but was not considered a wanderer at risk for elopement.
R1 rolled away from the One South Dining Room without being observed by staff. R1 rolled through the Center Unit without being noticed by staff. R1 rolled past the One North nurses's station, One North dining room, and down to the end of the East Wing corridor without being noticed. Apparently R1 opened the East Wing stair well door and went into the landing.
The stair well door has an alarm that is hard to hear and turns off when the door closes. According to the incident report and staff interview, E2 was working near the stair well in room 1111 and heard cries for help coming from the stair well. E2 found R1 in the stair well at the bottom of a ten foot flight of stairs with the wheel chair on top of her at approximately 6:10 p.m..
The paramedics were called and arrived at 6:30 p.m.. R1 arrived at the Central DuPage Hospital Emergency Room at 6:44 p.m.. R1 died at the hospital on December 4, 1999 at 4:30 a.m..
A review of the paramedic report dated 11-20-99 showed R1 sustained a 5" laceration to forehead and a 4x4 dressing applied to control the bleeding. There was no documentation of the measurement of R1's laceration from the incident and nurses notes reviewed on 12-30-99.
The Du Page County coroner's report states R1 died as a result of a fall she took at Du Page Convalescent Center. The coroner's report quotes Z3 "That her broken neck lead to other medical conditions which resulted in her death." "That an appropriate cause of death would be; Pneumonia, Encephalopathy, and Neck Fracture."
The facility failed to supervise R1 from 5:35 p.m. to 6:10 p.m. on November 20, 1999.