HARRISBURG CARE CENTER

Facility I.D. Number 0042580
1000 W. Sloan St.
Harrisburg, IL 62946

Date of Survey:07/24/01

Incident Report Investigation of 07/03/01

"A" VIOLATION(S):

The facility shall provide a Resident Services Director who is 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 preparation of their plan of care.

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 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 resident receives adequate supervision and assistance to prevent accidents.

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 regulations are not met as evidenced by:

Based on interviews, observation and record review, the facility failed to respond to the door alarms on 7-03-01 resulting in the elopement of 1 resident (R1), and the potential elopement of 3 residents (R2, R3, and R4) identified as at risk to elope, from the sample of 4. In addition, the facility failed to ensure that all door alarms were functional on 7-24-01 resulting in the potential for elopement for 4 residents from the sample (R1, R2, R3, R4).

The example is as follows:

1. R1 is a 75 year old female resident with diagnoses that include Alzheimer's Disease and Insulin Dependent Diabetes Mellitus. R1 has a court appointed guardian. R1's resident assessment dated 5-08-01 indicates that R1 has poor decision making skills, requires supervision and needs monitoring for an acute medical condition. R1 was observed on 7-24-2001 sitting in the entry area of the facility. R1 was noted to be oriented to person only, believing that deceased husband is still living. R1 stated that she was definitely not in Harrisburg when asked if she knew where she was living. R1 did not know the season or the year and did not recall the incident of 7-3-2001. Z1, a physician, was interviewed on 7-24-2001 per telephone at 2:00 PM and stated that he felt that R1 would need supervision at all times and would not be capable of recognizing dangers. Z1 further stated that R1's Diabetes puts her at increased risk due to her blood sugars which can get high suddenly.

R1's care plan dated for 5-15-2001 indicates that R1 is monitored for attempting to leave the facility and should be redirected and reoriented when attempts to leave.

Per review of the nurses notes for 7-3-2001 the facility received a call from a city police officer at around 6:00 PM , who asked if the facility had a resident by the name of (R1), and explained that R1 had been found in the cemetery across from the nursing home by a neighbor. R1 was brought back to the facility by ambulance. R1 was assessed by E4, a Registered Nurse, who noted no injuries or problems as a result of the elopement. The facility was unaware that R1 was missing from the building until the call was received from the police. This was verified by E4. E4 stated that R1 was dressed appropriately in her usual clothing and shoes.

Per SIU Weather, the temperature for 7-3-01 was 84 degrees, the relative humidity was 74 percent and there were thunderstorms in the local area. E4 verified that there was no rain or thunderstorms at the time of the elopement.

Z2, a police officer, was interviewed per telephone on 7-24-2001 at 10:30 AM and stated that he had responded, along with another officer, to a call concerning a female who was found sitting on the ground in the cemetery across from the facility by a neighbor. Z2 stated that he found (R1) to be sitting on the ground, partially in a ditch, at the west edge of the cemetery. Z2 stated that (R1) was very disoriented but they were able to get her name. An ambulance was called and then it was decided to call the nearby nursing home to check if they had a resident by the name of (R1). Z2 stated that he left after the ambulance arrived but that the other officer remained until the resident (R1) was taken to the facility. Z1 stated that no report was filled out.

Z3, an ambulance personnel, was interviewed per telephone on 7-24-2001 at 3:25 PM and stated that she had responded to the request made by police for transfer of (R1). Z3 stated that she responded to the west end of the cemetery, where there is a residential area just on the other side of the road, which is directly west of this cemetery. Z3 stated that she was told to take (R1) back to the facility by the officers present.

The facility's investigation stated that E4 had heard the door alarm sound and the alarm immediately shut off. This was verified by E4, who also stated that she did not go check the door, after hearing the alarm sound, because the alarm shut off immediately. The investigation report also stated that a housekeeper had heard the alarm sound then shut off and that she also thought it was a visitor. E5, a Certified Nurse Aide (CNA) stated per interview on 7-24-2001 that the alarm had sounded frequently on the evening of 7-3-2001 and when she would check alarms, it was always families coming and going.

The facility's door alarms are of the type where there is a key pad at each exit door which must have a code punched in to disarm the alarm or to shut it off once it sounds. At the time of R1's elopement, the code was posted at the front door facing the outside but could be read from the inside.

The facility is located in a residential area with a light traffic pattern. The facility faces south with Sloan Street running directly in front of the facility and a cemetery just south of Sloan Street. The West Hall doors open to a grassy incline. The dining room doors open onto a patio and grassy yard which is bordered by Parrish Street. The East Hall doors open onto a large grassy yard area which is bordered by Dennison street. According to the interviews with Z2 and Z3 and observations made by surveyor, R1 was found approximately 1/4 mile from the facility.

Per review of the current care plan, a date of 7-4-01 was noted which stated "Is able to shut off door alarm." E7 stated per interview on 7-24-01 that this was added based on the assumption that R1 had shut off the alarm herself. No changes were made to the care plan at this time to ensure that R1 did not elope again. E2, the Director of Nurses, stated that the code to the door alarm was changed and the numbers posted at the front door were reposted so that they could not be seen from the inside of the door, on 7-05-01.

On 7-24-2001 at 8:25 AM during a tour of the facility and check of the door alarms, this surveyor noted that the West Door alarm did not sound when the door was opened. This was verified by E2 who was with this surveyor at the time. It was noted that the door alarm was in the off position. E2 verified that staff on duty were unaware that the alarm had been turned off. All other door alarms were functional at this time.

When questioned as to the procedures for monitoring residents who are considered at risk for wandering and elopement, E2 stated that they are just monitored and then verified that there was no specific policy on how and when monitored.

R2, R3, and R4 were also identified by the facility as having a potential for wandering and elopement.