THE A. R. C. OF JACKSONVILLE, LTD.
Facility I..D. Number: 0032938
1316 Tendick
Jacksonville, IL 62650
Survey Date: 6/24/99
Complaint Investigation
A RESIDENT SHALL NOT BE GIVEN UNNECESSARY DRUGS.
In addition, AN UNNECESSARY DRUG IS ANY DRUG USED:
IN AN EXCESSIVE DOSE, INCLUDING IN DUPLICATIVE THERAPY;
FOR EXCESSIVE DURATION;
WITHOUT ADEQUATE INDICATIONS FOR ITS USE;
These Regulations are not met as evidenced by:
Based on clinical record review and staff interview, the facility failed to ensure that a resident's Activity's of Daily Living (ADL's) did not diminish.
Findings include:
1. R3 is a 70-year-old resident with diagnoses of dementia and psychotic combativeness. R3 is moderately impaired cognitively. R3 was discharged to a skilled nursing facility in May 1999 due to, according to facility administrator, decline and need of a Skilled Nursing Facility (SNF).
R3 was admitted to facility on 9-3-98 with admission medication of Tylenol grX q4hr. R3 was ambulatory, continent and ate 100% of meals. R3 weighed 168 lbs. at the time of admission. On 9-9-98 at 2 a.m. R3 was observed screaming "freezing, freezing, freezing", this continued until 4 a.m. On 9-12-98 facility staff called physician re: problem at night, physician ordered Ativan 0.5 mg q4 hrs prn. Ativan 0.5mg was given on 9-12-98.
On 9-14-98 R3 was yelling and at 9 p.m. Ativan 0.5mg was given. On 9-24-98 at 6 a.m., Ativan 0.5 mg was given at 3 a.m. for increased restlessness. On 9-25-98 at 12:30 Ativan 0.5mg was given for yelling. On 9-29-98 Depakote 500mg was ordered po bid and also Trazodone 75mg q HS. On 9-30-98 nursing documentation revealed R3 was yelling but ate 100%. R3 continued yelling behaviors through October 1998 and on 10-2-98 Trazodone was increased to 150mg HS. On November 11, 1998 physician decreased Trazodone to 100mg HS. R3 continued yelling behaviors through November 1998. On December 3, 1998 physician ordered Ativan 0.5mg BID. R3's appetite was documented on 12-22-98 as "good". On January 11, 1999 physician was called re: frequent outbursts and physician ordered Trazodone 50mg q AM. On 1-13-1999 R3's nursing notes revealed R3 was incontinent of urine. On 1-17-99 R3 was incontinent of urine. On 1-23-99 R3 was found on the floor. On 1-30-99 R3's nursing notes stated, "resident could hardly walk to bathroom, ate 50%". R3 had also been evaluated at a local hospital for pain, and was found to have a right sided fecal impaction. On 2-2-99 R3 refused to walk and ate 50%. On 2-3-99 R3 was incontinent of urine. On 2-4-99 R3 was incontinent of urine and ate 20% and could not walk by herself. On 2-5-99 R3 was incontinent of urine, fed by staff, ate 30% of lunch and 15% of supper. On 2-6-99 R3 ate 25% of supper and leaned forward and to the right and walked sideward and had to be wheeled to and from the dining room. On 2-8-99 R3 was in a wheelchair. On 2-9-99 Ativan 0.5mg was decreased to 0.5 qHS. On 2-10-99 R3 was incontinent and ate poorly. On 2-13-99 R3 refused to eat, leaned to right, was not breathing and had no pulse. R3 was admitted to hospital with a diagnosis of syncope and generalized apnea and decreased heart rate (40's). On 2-14-99 R3 was back to the facility per wheelchair and incontinent of urine. On 2-14-99 Ativan 0.5 mg qHS was dc'd. On 2-15-99 R3 was started on Zoloft 25mg HS. On 2-16-99 physician changed Depakote to Depakene. 2-17-99 R3 ate 10%, 2-18-99 ate 10%. 2-23-99 R3 found with bruise on right cheek, abrasion right buttock, bluish discoloration right upper arm and right forearm. 2-24-99 ate 50%. 2-27-99 R3 "can only walk 5 steps". 3-1-99 R3 refused to eat. 3-7-99 refused to eat. 3-8-99 refused to stand. 3-13-99 wheelchair, poor appetite. 4-1-99 speech evaluation ordered (for swallowing). 4-1-99 speech evaluation dc/d due to fact facility could not find a speech therapist to do evaluation. 4-18-99 R3 found on floor, fell out of bed - nasal fracture. 4-25-99 open area on sacrum. 5-12-99 order for hi protein, hi calorie diet. 5-17-99 order for Trazodone 25mg qAM, 50 MG qHS x 2 days. Zyprexa 2.5mg qHS x 2 day. 5-24-99 R3 to SNF. R3's weight on 5-24-99 was 135 lbs.
"A" VIOLATION(S):
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.
General nursing care shall include at a minimum the following and shall be practiced 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. All nursing personnel shall evaluate residents to see that each resident receives adequate supervision and assistance to prevent accidents.
These regulations are not met as evidenced by:
Based on record review and staff interview the facility failed to ensure supervision for R13 which resulted in an elopement from the facility without staff's knowledge.
The findings include:
1) On 5/21/99 at approximately 10:59 a.m. the Jacksonville Police Department received a call to check the well- being of a disoriented subject at a restaurant approximately 1.8 miles from the facility. The officer that responded picked up R13 and drove him back to this facility.
2) R13 has a diagnosis of dementia, hypothermia, vitamin deficiency, acute agitated behavior, alcohol abuse, alcohol induced cirrhosis and congestive heart failure. R13 is identified as being moderately impaired cognitively and has wandering behaviors. R13 was identified as having intermittent decisional capabilities and has unsteady balance while standing but has not been identified as having any recent falls. R13's picture is posted in the front office and was identified as being an elopement risk.
3) The restaurant is located approximately 1.8 miles from the facility. The route to get there would be to walk down Tendick street, which is a moderately used road to Morton Street, a four lane heavily used road through town. It is approximately 1 mile to the restaurant after turning west on Morton from Tendick. To get to the restaurant, Morton street would have to be crossed at some point.
4) Several staff were interviewed. None had been aware that R13 was missing until returned by the police. E1 stated that if they would have known R13 was missing they would have been out looking for R13.
5) Facility documentation revealed that R13 did not sustain any injuries during his elopement. Through staff interviews and staff written statements, it was determined that the door alarms were checked after R13 was returned and found to be operating properly. In the nurses notes it stated R13 was last seen in the facility at 10:30 a.m. by staff. It was not determined which staff person saw R13 last.
6) The facility's investigation report revealed that they felt R13 left the building when other residents were leaving for transportation to day programing. The facility implemented a policy which requires a staff person to be at the front entrance when residents are leaving for programming and to identify the residents leaving using a checklist. The policy was written on 5/21/99. An inservice was given to staff on the policy on 5/24/99.
7) No door supervision, or resident supervision problems were observed during the survey. The door alarms were working properly during the survey.