MERCY HEALTH CARE REHAB CENTER
Facility I.D. Number: 0025940
19000 Halsted Street
Homewood, Illinois 60430
Survey Date: 8/26/99
Annual Licensure Investigation & Complaint
Adequate and properly supervised nursing and personal care shall be provided to each resident to meet the total nursing and personal care needs of the residents.
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.
All exterior doors shall be equipment 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 record review, employee interview and observation, the facility failed to provide adequate supervision to prevent resident's on the locked Alzheimer's unit from eloping. Door alarms that are used to assist staff with resident supervision are not functioning properly at all times.
On 08/19/99 at approximately 9:40p.m., R35 was noted to be missing from the facility. R35 is described as an able bodied 84 year old resident needing supervision who has Alzheimer's disease and confusion with delusions, who was determined to leave the facility since admission on 07/26/99. R35 had made numerous attempts at trying to leave the facility and had exited through the doors on several occasions, only to be stopped because the staff was alerted by the door alarms. On the evening of 08/19/99, R35 had made three unsuccessful attempts to leave only to be stopped by staff because the alarm sounded. When R35 was noted to be missing at approximately 9:40p.m., no alarm had been heard. Staff interview confirmed that there was no way of knowing which door R35 had used to leave the facility since that night both the 300 unit exit door and the 400 unit exit door were not alarming when they opened them to search for R35. A search was initiated, and at about 10:30p.m. R35 was returned by the local police. R35 had been found about 1 & 1/2 miles from the facility. The facility sits on a very heavily traveled street with commercial, residential, and wooded areas along the way. There is no sidewalk and currently there are construction barriers on the street outside the facility. When returned by the police R35 was found to have torn pants, a scratch to the leg, and a small puncture wound to the L hand. R35 claimed to have received the injuries from climbing over a fence.
E4 was called to the facility to check the alarms that night. Together with the security guard they tested the door alarms for the locked unit. E4 recounts that the door alarms functioned five of the six times tried, but the sixth time they failed to function. The batteries were checked and registered good on the voltage meter. Review of security guard reports show previous instances of there being a problem with the door alarms prior to the elopement of R35. As far back as 07/25/99 the guards reported having problems with door alarms not activating, such as the 300 stairwell door, and on 07/27/99 there was problem activating the locks for the backyard exit door.
An August 13 note to the security guards regarding the dining room door locking concludes that "the locking mechanism is just not right. Apparently the mechanism was not engaging correctly."
Again on 08/22/99 during rounds the guard found that the exit door alarms on the 300 and 400 units were not armed and suggested that the arming procedure be explained to staff again to prevent future walk-aways.
Since the incident the 300 and 400 unit outside alarms have been replaced with new alarms, and new hard wired alarms are being ordered that will tie into the fire and emergency circuits. A secondary alarm will be added to the outside doors that will sound at the 300 and 400 unit nurses station if the door is opened even if the access code is used. Interview with E1 and E5 confirmed that they were aware of the intermittent malfunctioning of the door alarms, however they did not take any additional precautions to safeguard the residents. They continued to rely on the audible alarms to alert them of any attempts by residents to leave the facility. These units continue to have high risk dementia residents with wandering behaviors.