MANOR AT LINCOLNWOOD PLACE
Facility I.D. Number 0039727
7000 N. McCormick Blvd.
Lincolnwood, IL 60645
Date of Survey: 01/04/01
Notice of Violation: 03/19/01
Incident Report Investigation
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.
The DON shall oversee the nursing services of the facility including:
Planning in-service education, embracing orientation, skill training, and on-going education for all personnel and covering all aspects of resident care and programming. The educational program shall include training and practice in activities and restorative/rehabilitative nursing techniques through out-of-facility or in-facility training programs. This person may conduct these programs personally or see that they are carried out.
These REQUIREMENTS are not met as evidenced by:
Observation, staff interviews, and record review revealed the facility failed to adequately supervise one resident R1) in the facility on the skilled care unit resulting in the resident's elopement from the facility and subsequently being found expired outside in freezing weather the following day.
Review of R1's clinical record reveals that R1 was an 80-year-old ambulatory female admitted to the facility on 11/02/00, with diagnoses including progressive dementia. The assessment completed for R1 on 11/13/00, reveals the following information: R1was assessed as being moderately impaired- decisions poor, cues/ supervision required. Under behavioral symptoms R1 was assessed with Wandering, behavior of this type occurred one to three days in the last seven days. Cognitive loss and Behavioral symptoms were both present in the assessment. In the care plan for R1 under Mood/ Behavior, problems/ needs, the care plan states: "has episodes of wandering/sleeps in the other room." Under approaches: resident's whereabouts are to be monitored. Under cognitive impairment it is noted that R1 is "generally confused and disoriented." Nurses' notes reflect numerous entries regarding R1 wandering the halls disoriented, confused, and not knowing where her room is.
Based on facility incident report and staff written statements and oral interviews the following information was obtained: On 12/27/00, R1 was observed sleeping in her room at 10:45 p.m. by E5. At 12:30 a.m. E5 returned to answer the call light for the other resident in R1's room and noticed that R1 was awake. At 1a.m., R1 is seen walking the hallway back and forth passing the nurses' station and going to the dining room on the east end of the hallway. R1 was redirected to her room by E5. Between 1:15a.m. and 1:45a.m.
E2 stated that (she)E2 was at the nurses' station and observed R1 again walking back and forth from her room at the west end of the hall past the nurses' station in the center of the hall and continuing to the dining room at the east end of the hall. E2 stated that R1 was redirected back to her room at 1:45 a.m.. At approximately 2a.m. E2 stated that she left the nurses' station and went to the treatment room to prepare to do her rounds. E2 then went to R1's room and discovered that R1 was not there. E2 informed E5 and security. A search of the facility was initiated and E5 made a search outside of the building yielding no results. At 3:15a.m. the police were notified and they searched the building and the surrounding outside area of the facility with no results. E2 stated that at 5a.m. the police returned and searched again with no results. Nurses' notes written at 7:55 a.m. on 12/28/00 reflect that R1 was found in the parking lot next door to the facility. The run sheet obtained from the fire department EMS system reflects that R1 was found by a worker at the automobile dealership which was approximately 1000 ft away from the west end of the facility. R1 was found face down in the fetal position between 2 cars in the snow. The run sheet reflects that R1 had lividity in the extremities and in her face. R1's extremities were frozen and her temperature was low. The cardiac monitor showed asystale. R1's temperature in the emergency room registered below 80 degrees F. Nurses' notes written at 12 p.m. on 12-28-00 reflect that the facility was informed by the police that R1 was deceased.
The temperature outside that night was between 8 and 10 degrees F. Staff written and verbal statements reflect that the last time R1 was observed she was noted to be wearing a pink housecoat and no shoes.
During interview with E1 on the morning of 12/29/00, surveyor asked E1 if facility has a wander guard system. E1 stated that the facility does not have such a system and facility has no known wanderers but does have residents who are confused. During tour of the 1st floor skilled unit where R1 resided, E1 explained that the east exit on the 1st floor unit is also used as an entrance for the assisted living section located on the 2nd floor and requires a key card for entry on the exterior doors but there is no alarm or card required for exit.
This area includes a foyer and another set of interior doors leading to the skilled unit. Both the exterior and interior doors at the east end of the building were not alarmed at the time of the incident nor during the initial tour. The skilled unit's nurses' station is located in the center of the unit and contains a box with 6 switches on it which are connected to the alarm system. The switches can be flipped to the left or right. The switches give no indication which doors they are used for and there was no label on the alarm switches to indicate whether they were on or off.
E2 was assigned to the unit on 12/27/00, night shift. E2 stated that switches 1,2, and 3 alarm the front door but did not know what the other 3 switches were for. E2 further stated that she was not familiar with the east exit door, that it was out of her visual range. E2 stated, " I assume all the doors are alarmed because the switches are on."
E5 was also assigned to the unit on 12-27-00, night shift and stated it was not unusual to see R1 up at night walking around. E5 stated that R1 was always saying she wanted to go back to Florida. When asked by surveyor on 1-4-01 about the alarm system, E5 did not know what switches1,2,4,5, and 6 were for but that #3 was for the front door. E5 stated that she was not familiar with the east door.
E4 was interviewed on 1-4-01 also and stated that the bottom 3 switches on the alarm system are for the north entrance and was not sure what the top 3 switches were for. E4 stated that while searching for R1 at approximately 2:30a.m. she checked the east exterior doors and that is when she realized that it was not alarmed. E4 stated she opened the east exterior door and no alarm went off. E4 stated," I knew the west end alarm is always on and I know the north entrance alarm was on."
E3 was assigned to the 2nd floor on the night in question but stated she has been at the facility for 10 years and used to work on the first floor and is very familiar with the alarm system. E3 further stated that she thought that the east exit was alarmed. E3 stated that switches 1,2,and 3 are for the north doors, switch 4 is for the west doors but was not sure about 5 and 6. E3 stated she went to the 1st floor to punch her time card at approximately 1a.m. and saw R1 walking to the dining room on the east end of the hall and redirected R1 back to her room.
E7 stated that he was on the unit on 12/28/00 (12:55a.m.) and stated " I checked the alarms, I flipped the top 3 switches." When asked by surveyor if the switches control all the alarms he stated "yes". R7 denied any knowledge of a problem with the east exit doors.