MANORCARE AT HIGHLAND PARK
Facility I.D. Number 0045369
2773 Skokie Valley Road
Highland Park, IL 60035
Date of Survey: 07/19/01
Notice of Violation: 09/05/01
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 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 resident's 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.
Each resident shall have a 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.
Each resident shall have an up-to-date resident care plan for each resident based on the resident's comprehensive assessment, 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 plan 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.
The facility shall maintain all electrical, signaling, mechanical, water supply, heating, fire protection, and sewage disposal systems in safe, clean and functioning condition.
All exterior doors shall be equipped with a signal that will alert the staff if a resident leaves the building.
The facility shall not neglect a resident.
These requirements are not met as evidenced by:
According to the incident report, on Sunday 6/24/01 at approximately 2:00pm R1 was found in the south stairwell of the second floor of the facility. When found, R1 was lying in a prone position, on the left side, bleeding from the head with additional injuries to arms and chest. R1 was restrained to a wheelchair with a seat belt. The wheelchair was still attached to R1 and was on top of him at the time. Emergency services were summoned and R1 was transported to the hospital where R1 was admitted with a diagnosis of subdural hematoma.
Review of R1's face sheet and physician order sheet in the clinical record showed that R1 was admitted on 4/9/01 with diagnoses that included seizures, hx of CVA, hx of previous subdural hematoma from a fall, and dementia with agitation. Nurses notes from the time of admission, 4/9/01, show that R1 had exhibited wandering behavior with statements expressing the desire to go home. Between 4/9/01 and 6/24/01 nurses notes documented 6 wandering episodes and 1 attempt to "escape through the stairway door" on 6/1/01.
R1's most recent MDS dated 6/6/01 did not identify R1's wandering behavior. The latest care plan dated 4/9/01 had not been updated to address the issue of R1's wandering behavior or attempt at elopement on 6/1/01.
Interview of staff in person and by phone on 7/10/01 and 7/11/01 yielded the following. On 7/10/01 at 10:15am in the first floor dining room, E3 told surveyor that R1 "tried leaving many times. Usually by the stairs near the dining room in which case he was heard opening the door as the alarm sounded. Someone was always in the area ." E3 further stated that this day R1 went out the south side stairway door and "if visitors are around or the overhead page is going on, you could not hear the door alarm at the nurses' station."
E4 was interviewed by phone on 7/10/01 at 11:40am, and was the staff member who found R1 on 6/24/01. Z1 had arrived at the facility and was looking for R1. When R1 was not located in the activity, a search was begun. E4 said that while doing last rounds about 2:00pm, he heard that someone was missing. After checking all the rooms on the south hall he came to the exit door and decided to open it and check the stairwell. E4 found R1 face down at the bottom of the stairs. E4 remarked that when the door was opened there was no alarm heard. When questioned E4 said that R1 "did this a lot. R1 kept saying he wants to go home. It happened before...but they caught him."
During interview of E1 at 11:45am on 7/10/01 in the first floor dining room, E1 stated that a visitor to the resident of the room across the hall had been asked if an alarm had been heard. The visitor who had been there all afternoon said that no alarm had been heard from that door that day.
E9 was interviewed in the first floor dining room at 11:05am on 7/10/01. E9 said that both halls were quiet at the time of R1's disappearance. E9 went down the halls to look for R1. E9 said that R1 had been known for going down the south hallway and playing with the door in the past. E9 thought that R1 might have even pressed the elevator buttons, so he (E9) went outside to check. When E9 reentered the building he heard the page for a nurse to the south stairwell. E9 confirmed that R1 always spoke of going home. E9 heard no alarm himself at the time.
The alarm system that was in place at the time did not make the staff on the floor aware that R1 had made an attempt to exit through the door. On 6/24/01 the alarm system that was in place had an audible component that could be heard at the door itself on the second floor. On 7/10/01 at 10:45am during tour, this component was still present and was observed to be audible only in the immediate vicinity of the door. This was a long distance from the area of the nurses station. On 6/24/01 there was no annunciator panel at the second floor nurses station to notify staff of the door opening. The only annunciator panel at the time was located at the first floor nurses station, which is unmanned since the floor is not occupied by residents. It was the responsibility of the receptionist at the front door lobby to leave her desk, walk to the panel, disarm the alarm, return to her desk, and then call the second floor to alert the staff that a particular door alarm had triggered and request them to check its status.