FRIENDSHIP CARE CENTER-MARION
Facility I.D. Number 0040758
1101 N. Madison
Marion, IL 62959
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 residents 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.
The DON shall oversee the nursing services of the facility including:
Overseeing the comprehensive assessment of the residents needs, which include medically defined conditions and medical functional status, sensory and physical impairments, nutritional status and requirements, psychosocial status, discharge potential, dental condition, activities potential, rehabilitation potential, cognitive status, and drug therapy.
Planning an up-to-date resident care plan for each resident based on the residents comprehensive assessment, individual needs and goals to be accomplished, physicians 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 plan shall be in writing and shall be reviewed and modified in keeping with the care needed as indicated by the residents 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.
These requirements are not met as evidenced by:
Based on observations, record review, facility reports, and interviews, the facility failed to do the following:
A) Failed to supervise a resident (R-1) identified as an elopement risk.
B) Failed to prevent the elopement of a resident (R-1) who the facility had identified as an elopement risk.
C) Failed to assess, develop, and implement initial, individualized care plan for a resident (R- 1) who was new to the facility and identified as an elopement risk.
D) Failed to ensure the exit door alarms are operating effectively to provide a safe environment for residents identified by the facility as at risk to wander. (R-1, R-3, R-4, R-5, R-6, R-7, R-8).
E) Failed to investigate an elopement incident to gather facts and insure that safeguards are in place and functioning in order to prevent further elopement incidents.
The findings include:
1. Per the clinical record review, R-1 is a 67 year old resident who was admitted to the facility on 12-29-00 and has a diagnosis that includes dementia with psychosis. Per physician's order sheet dated 12-31-00, a Wander guard was ordered by the physician on 12- 30-00 and applied 12-30-00. R-1 has received since admission Risperdal, 1mg, by mouth twice a day per the physician's order sheet.
The facility incident report dated 01-01-01 documents that R-1 "left the building by side door, slipped and fell in snow. Alert, neuro check as before, ROM as before, superficial abrasion (R) forearm, bruise (R) elbow, hand red and puffy." The date and time is given as 01-01-01 at 8:15 PM. The location is given only as outside. There are no additional comments and/or steps identified as taken to prevent recurrence.
The nursing notes found in the clinical record for R-1 indicate on 12-31-00 (6AM to 6PM), R- 1 is "very confused. Calm. Attempted to reorientate without success..." The nursing notes for that day continue to document confusion and behaviors of "urinating on table in the dining room, taking clothes off and ambulating in underwear, refusing to put clothing back on".
The behavior monitoring/intervention flow record for R-1 indicates that on 12-31-00, no time given, R-1 "went out side and sat in snow. Res. stated that he wanted to kill somebody or his self." There are two other entries for 12-31-00 that state respectively, "Res went out side door, attempted to leave facility. res seemed disoriented and was combative." and "Res attempted to leave facility..." These are not mentioned in the nursing notes.
The 01-01-01, 12:10 AM, the nursing note documents R-1's confused to place and person and oriented to name. The nursing notes for later that morning document behaviors of urinating on television set, putting on a female resident's night gown, and general confusion.
At 7:30 PM, on 01-01-01, the nursing notes document that R-1 attempted to leave the facility by hall 1 door and was redirected. The 8:15 PM nursing notes document R-1 "left the facility by the side door, slipped and fell in snow". R-1 received "superficial abrasion to the right forearm, bruise to right elbow, and his hands were slight red and puffy". Per the nursing notes of 01-01-01 at 8:15 PM, R-1's vital signs were taken and his temperature was documented as "96.8 degrees" F. and R-1 "complained of being cold" so warm blankets from the dryer were place on the bed. This was verified by E-6.
The condition of R-1's hands are documented daily in the nursing notes as slightly swollen bilaterally with continued bruising to the knuckles from 01-01-01until 01-06-01.
During an interview with E-6 on 01-16-01 she indicated that R-1 had tried to get out hall 1 door earlier in the evening on 01-01-2001. E-7 went outside to get a special snack for a resident and found R-1. E-7 brought R-1 back inside the building and told E-6 that R-1 had fallen in the snow. R-1's pants were wet at around the knees. E-6 stated she did not know R- 1 was outside and did not hear any alarms go off. All door alarms were found to be working except hall 3 door. E-6 found this door to be cracked open but the alarm did not sound. She shut the door, reopened it and the alarm sounded. E-6 stated that she last saw R-1 at 8 PM in the dining room. E-6 described R-1 that night as alert with some confusion and was wandering around as usual. He was cold when he was brought back inside and it took approximately 30 minutes to warm him.
E-5 also indicated during an interview on 01-16-01 that she last saw R-1 at approximately 8 PM on 01-01-01 and did not hear any door alarms go off.
Z-2 stated during a telephone interview on 01-16-01 that on 01-01-01 he was giving his order at the drive thru window at the Dairy Queen which is just north of the facility and across the street when he heard a person calling something like, "Hey, Hey!" Z-2 looked over to his right to the edge of the parking lot and observed a man on his hands and knees, climbing through the snow up the rock incline. Z-2 instructed a Dairy Queen worker to call the nursing home and see if this was their resident. Z-2 assisted R-1 into the Dairy Queen and sat with him until someone from the facility came to get him. (This conflicts with the information obtained per interview with E-6 on 01-16-01.) According to Z-2, R-1 had on overalls, short sleeve t-shirt, and socks (No shoes). The knees of R-1's pants were wet and stiff from the wetness freezing. R-1's socks were wet and his hands were very cold to the touch. Z-2 stated R-1's hands were "white from the knuckles down with no color under the fingernails".
Z-3 was interviewed on 01-16-01and stated that on 01-01-01 she heard someone saying "Help, Help!" and looked to see who it was. Z-2 told her it was a man on his hands and knees. Z-3 went to help and observed Z-2 almost carrying R-1 into the Dairy Queen. R-1 was observed by Z-3 to have socks soaking wet and hands very cold and white looking.
R-1 was interviewed on 01-16-01 and indicated he thought he was outside a long time and was very cold. R-1 thought he got to a convenience store and they called the facility. R-1 said his "hands were very cold and icy and his knees were hurt bad".
E-8 stated in an interview on 01-17-01 that on 01-02-01 he was asked by E-1 to check the alarm on hall 3. E-8 stated that the battery was dead so he replaced the battery. At the present time E-8 checks all door alarms daily when he is here and the housekeeper does it when he is not at the facility.
Per telephone call to Southern Illinois University weather station, the weather conditions for 01-01-01 at 8 PM for the Marion area were "Clear skies, temperature of 10 degrees F. and wind chill of 7 degrees F". There were several inches of snow on the ground.
On 01-11-01, R-1 was transferred by family to another facility. Per clinical record reviews on 01-16-01, there was no assessment in place to assess the reason for the elopement attempts, monitor the time of elopement attempts, monitor success and failure of interventions tried, and monitor other behaviors that may be related to the elopement attempts.
Per clinical record review and interview with E-1 and E-3, the facility did not have an initial plan of care that addressed R-1's risk for elopement. No resident specific interventions were implemented to address concerns of elopement and other behaviors.
The facility did not investigate this elopement incident that took place in 10 degree F. weather at 8 PM on 01-01-01. The facility did not investigate and document last time observed in the facility, where R-1 was found that evening outside the facility, how R-1 got outside the building, and why R-1 left the facility.
The facility is located at the corner of North Madison Street and East Carter Street in Marion. The facility is one block south of Illinois Route 13 (DeYoung Street) which is a heavily traveled four lane state highway. Carter Street separates the facility property from the Dairy Queen Restaurant property. The Dairy Queen building and surrounding parking lot is higher than the grassy area just south of the parking lot. The slope at the south edge of the parking lot is approximately 45 degrees and is rock covered.