SALEM VILLAGE NURSING & REHAB

Facility I.D. Number 0044057
1314 Rowell Ave.
Joliet, IL 60433

Date of Survey: 03/13/01

Notice of Violation: 06/20/01

Complaint Investigation

"A" VIOLATION(S):

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.

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.

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 observation, record review and interview the facility failed:

(1) to prevent a resident (R3) from wandering out of the facility on the early morning of 1/10/01.
(2) to prevent R4 from falling multiple times and sustaining hematoma’s and lacerations by not monitoring.
This applies to 2 of 3 residents (R3 and R4) in the sample.

The examples are:

I. R3's admission record review revealed that R3 is a 56 year old male and was admitted to the facility on 12/13/00. R3 has diagnoses including stage IV renal cancer, anemia protein calorie malnutrition and acute head injury due to a fall on 01/02/01. On 1/10/01, per nursing notes, at 5:00 am, upon rounds, R3 was not in his room. R3 was spotted across the street with crutches and fully dressed. E6 and E5 brought the resident back to the facility in a wheelchair. E4's written statement (part of facility investigation report) revealed that R3 was last seen at approximately 4:00 am. The nurses notes also revealed that R3 stated to staff that he went out the ramp door (southwest exit door) and the alarm did not sound to alert staff. R3 also stated he was outside for 10 or 15 minutes. The documented vital signs at this time were: blood pressure 110/80; pulse 108; respirations 18; temperature 94.2 (immediately after). R3 was transported via ambulance to the hospital emergency room at 5:45a.m. and admitted with Pneumonia.

Per Daily Herald Joliet Newspaper the temperature on 1/10/01 was below freezing; warmest being 20 degrees Fahrenheit and coldest being -1 degree Fahrenheit.

On 2/28/01 review of the hospital records revealed that R3 was placed in an another long term care facility on 1/16/01.

On 3/7/01 review of R3's records at another facility revealed that R3 had expired on 1/26/01.

On 3/7/01 confidential interview revealed that E5 was taking care of R3 at the time (1/9/01 night shift) R3 wandered out of the facility. E5 was on her lunch break between 3:45 am and 4:15 am and only E4 was on the unit with approximately 34 residents. R3 was not found during the 5:00 am rounds. E5 immediately paged E6. E6 was not in the building. At 5:15 am E6 and E5 found R3 in the parking lot across the street. The interview also revealed that R3 was found standing with the help of crutches, wearing blue jeans, a sweat shirt, socks and a pair of gym shoes. R3 was not wearing any coat. The interview further revealed that when R3 left the facility the front exit door did not have an alarm system.

Nurses admission notes, dated 12/13/00, and assessment dated 12/13/00, assessed R3 as alert and oriented. Review of social services notes, beginning 12/29/00, and nurses notes, beginning 1/3/01, stated resident confused, disoriented, becoming increasingly forgetful and starting to demonstrate changes in mental condition.

R3's wandering episode on 1/10/01 was not reported to the Illinois Department of Public Health (IDPH).

When R3 left the facility, R3 resided on the first floor unit (1 North) in room 107, which is located approximately 54 feet away from the southwest exit door. 1North has 3 exit doors (southwest, southeast, and the main entrance). Review of the facility investigation report reveals E4's written statement indicating R3 was last seen in the room at approximately 4:00am. Review of the nurse's notes, document that the resident was found missing on the 5:00am rounds. The review of the ambulance report stated that the facility staff had reported to the ambulance personnel that the resident has been out for ½ to 1 hour. Social services notes revealed that the resident was out for 10 to 15 minutes. Therefore, it is not clear as to the approximate time the resident left the facility.

Interview with E2, on 2/28/01 at approximately 11:00am, in the second floor conference room, revealed that during her investigation, E2 was told by the nursing staff that R3 had left through the southwest exit.

However, E2 thinks R3 left the facility through the main entrance. E3 stated that if R3 had left the southwest exit, a "huge pile of snow on both sides of the ramp and street" would have hindered R3's ability to leave through this exit. Nurse's notes on 1/10/01, document that the southwest exit door alarm control button was not working. Interview with E1 on 2/23/01, at approximately 3:30pm, in second floor conference room, revealed that the exit door alarms were working. E1 believes the staff on duty might have deactivated the door alarms. In addition, E1 stated that E4 and E5 were disciplined for "procedure/rule violation" related to this incident. The facility investigation report review also revealed that when E2 had interviewed E4, E4 stated that E4 had last seen R3 at approximately 4:00 am, "the nurse and the other CNA (certified nurse's aide) went on break then there were a lot of call lights". Review of Midnights Floor Schedule for 1/9/01 reveals E4 and E5 were the only staff on duty for 1 North. E6, the security guard on duty, was terminated from employment on 1/11/01. Interview with E1, on 2/28/01 at approximately 11:30am, in second floor conference room, revealed that E6 was hired as a housekeeper but during the week of this incident, E6 was assigned as the security guard for the facility. Review of the security guard job description states that one of the responsibilities are "conduct inspection rounds, checking to see the windows and doors are properly secured and report observed maintenance needs to the supervisor." No security reports were available for review for the month of January 2001. Interview with E9, on 2/23/01 at approximately 3:00am, in the Director of Building Services room on the basement level , reveals that he was hired in November 2000 as a maintenance worker and promoted to Director of Maintenance in December 2000. E9 could not provide documented records of maintenance inspections since June 3, 2000. E9 stated that he was in the process of formalizing a way to document such inspections.

On 2/23/01, at approximately 2:45pm, surveyors, in the presence of E1, inspected the exit door control panel located behind the 1 North nurse's station. Surveyors observed that the alarm system could be deactivated at anytime by flipping a switch. Surveyors noted a written sign posted at this panel stating "do not turn off must leave on at all times." There were three visual monitors located on the top of the 1 North nurses station. On 2/23/01at approximately 4:00 pm revealed that these monitors are not always consistently monitored.

On 3/7/01, at approximately 11:30 am, phone interview with Z1, revealed that R3 had terminal cancer of his kidneys and R3 should not have been allowed to go outside unsupervised and unprotected in the cold weather. It was unsafe for the physical health of R3. R3 developed Pneumonia and had to be treated in the hospital, which was of no help to treat his renal cancer. Ultimately R3 expired on 1/26/01 in another facility due to acute renal cancer complications.

On 3/7/01at approximately 1:00 pm in the conference room on second floor surveyor interviewed E1, E2 and E10. E1, E2 and E10 collectively stated that:

(1) the facility had identified 25 residents as wanderers. Of 25 wandering residents 4 residents live on 1st floor, 8 residents live on the 3rd floor, 6 residents live on 4th floor and 7 residents live on the 5th floor. E10, based on nursing staff recommendation, was responsible to identify the wandering residents;

(2) criteria to identify the wandering residents was an informal understanding among the staff that the residents have either Dementia or Alzheimers disease with agitation, wander either by ambulating self or use a wheelchair;

(3) no formalized assessment or a care plan was developed;

(4) there was no system in place to ensure the wandering residents are safe in the facility. E1 and E2 stated that the charge nurses usually do the resident's head count at the change of shift but there was no documentation to show if the residents are monitored. Neither E1, E2 or E10 were aware of R3 wandering in the building.

II. R4's record review revealed that R4 is a 71 year old female who was admitted to the facility's 4th floor on 10/13/00 with multiple diagnoses including Diabetes and Cerebral Vascular Accident. R4's 10/27/00 assessment indicated that R4 had fallen in the past 30 days. The Resident Assessment Protocol (RAP) assessment for falls is not comprehensive to show why the resident is at risk for falling. It stated "at high risk for fall and fall related injuries due to resident is on psychotropic medication for depression, with mobility deficit, uses a wheelchair, has cognitive deficit and has history of falls." The 10/27/00 care plan interventions for falling problem are not individualized. The interventions are: use body alarm when in chair and when in bed, encourage to ask for assistance, observe, record and report unsafe conditions.

Review of nurses progress notes between 10/17/00 and 1/3/01 revealed that the resident was found on the floor 18 times due to her falling.

On 1/3/01 9:40 am nurses notes review revealed "resident was found under bed with head lying on the edge of the bottom drawer with her legs entangled in the telephone cord (wrapped around her leg), sent to the hospital for evaluation." Review of the incident report investigation of the resident falls revealed that the investigation is not thorough to show why the resident is falling. Review of R4's 10/27/00 MDS revealed that R4's memory is intact and she has some difficulty in decision making in new situations. Throughout the nurses notes it was documented that R4 is confused and disoriented. Review of 10/26/00 physician note indicated "have physical therapy evaluate to determine if the resident able to ambulate without staff assistance." Review of physical therapy evaluation revealed that R4 was evaluated on 10/17/00 and R4 was removed from physical therapy on 11/11/00 with a comment "has plateaued in treatment showing little improvement." There was no further plan to improve or maintain R4's physical functional ability.

Interview with E1 on 2/23/01 and 2/28/01 in 2nd floor conference room revealed that R4 was confused, disoriented, resistive to care and had severe behavior problems. E1 also stated that on 12/28/00 conducted a care plan conference, by then R4 already sustained injuries due to falling multiple times.

On 3/7/01, at approximately 11:30 am, phone interview with Z1 revealed that R4 is confused, disoriented, needed staff assistance with transfer, ambulation and activities of daily living and supervision to prevent from falling. Z1 also indicated that residents do fall in the nursing homes but, R4 had too many falls and injuries.