MANORCARE AT NORMAL
Facility ID Number: 0027532
Normal, Illinois 61761
Survey Date: 9/8/99
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 the safety of residents at all times.
These requirements are not met as evidenced by:
Based on observations, record review, and interviews with facility staff, it was determined that the facility failed to ensure that each resident receives adequate supervision to prevent accidents.
The facility failed to provide adequate supervision for one resident who left the facility unnoticed on 8-19-99 and sustained an injury as a result of a subsequent fall.
R1 is a 95-year-old resident admitted to the facility on 6-29-99 with diagnoses that include organic brain syndrome, dementia, confusion, and angina. R1 is assessed by the facility (7-12-99 Resident Assessment Instrument) as having impaired short term memory, being moderately impaired for cognitive/decision making ability with periods of altered perception, no behaviors, and is independent with ambulation.
Current physician orders (Sept. 1999) reflect that R1 "may go on LOA (leave of absence)/Pass attended with medications".
The Department was made aware on 8-20-99 at 4:40 p.m. (via fax) of an incident involving R1. R1 (according to the transmitted incident report) "left the facility without staff knowledge. Resident ambulated approx. 100 yards. She was away approx. 10 min.--while away from facility-resident fell resulting in lacerations and bruises. Res. has Dx of confusion. She is independently ambulatory. She has 0 left the facility without staff knowledge prior to this incident."
Review of nurse's notes in R1's clinical record states as follows: "8-19-99 7:05 p.m. A visitor came into dining room & stated (R1) was on walking trail & had fallen down, 0 door alarm had gone off, writer, 2 CNA, & another nurse went out & a biker had stopped to help & someone had called 911, nose was bleeding & had laceration, bruised L wrist, 0 shortening of limbs, 0 outward rotation, writer sent other nurse into MCHS (facility) to get papers for transport to St. Joe's, D.O.N. called at 7:10 p.m.".
Nurse's note "8-20-99 11-7 Res. slept well, both eyes black, dressing intact...".
Nurse's note "8-20-99 late entry for 3-11 8-19 Res. had been seen at front desk at 6:45 p.m. by Chesapeake nurse, visitors were at this time coming in & out, res. has in pass tried to leave building & is watch for this."
Review of the facility investigation report reflects that it was "unknown" how R1 left the building, "either family, visitor, or (R1) pushed alarm" at the main entrance. According to the facility investigation and interview with staff, there were no staff eyewitnesses to R1 leaving the building or the exterior door alarm sounding.
Review of the facility investigation report and interview with E1 reflects that R1 was found lying on her back, on a grass and gravel embankment between a concrete culdesac curb and a asphalt bicycle path. R1's head was on the downslope of the embankment with feet on the upslope toward the curb. According to the facility report, R1 "was bleeding from nose, has bruising on face & left wrist, & possible left wrist fracture". E1 stated that R1 appeared to be bleeding from the corner of the right eye, had a laceration across the bridge of her nose, and was alert/oriented and conversing when assessed at the site of the incident. R1 was immediately transported to the hospital via ambulance.
Nurse's note "8-20-99 2:30 p.m. late entry 8-19-99 @ 10:40 p.m. res returned to facility from OSF (hospital) via ambulance...accompanied by daughter VS stable...res had a dry et intact drsng to top of nose, both eyes were blackened. Res was alert, confused to time et place which she has been for some time...denied pain...neuro checks within normal limits...prior to res returned rec'd phone call from OSF ER that res had 8 stitches in half moon shape circle on bridge of nose & was to be on Keflex 500 mg QID X 5 days per ER Dr. Head to toe check done and 0 other injuries were noted...".
According to information available in the clinical record and interview with E2, R1 sustained no fractures as a result of the fall.
Interview with E1 indicated that R1 "was being watched" by nursing staff for the possibility of her trying to go out of doors. E1 stated that R1 had been seen standing at the main entrance pushing on the doors prior to the 8-19 incident. E1 stated that nursing staff other than herself were aware that R1 would stand at the front door and push on the doors.
E3 stated that she was made aware "3 to 4 days prior" to R1 leaving the building that R1 "had made the comment that she was going home and was packing her things". E3 stated at this point R1 was being considered a possible elopement risk, and that staff were monitoring her whereabouts closely.
E2 indicated that she was unaware of any past attempts to leave the building. E2 stated that she was first aware of nursing staff's observations when she reviewed nurse's notes dated 8-20-99 in R1's record.
Prior to 8-20-99 there was no assessment in R1's record to indicate that she was at risk for elopement nor did the care plan indicate any elopement risk or interventions.
All exterior doors in the facility are equipped with audible signals that are designed to alert staff if a resident leaves the building. All exterior door locations, except for two, are equipped with numeric keypads that allow the alarm signal to be temporarily silenced to permit passage out of doors. The alarms then automatically reactivate after the doors are closed.
The two sets of doors without numeric keypads, the main entrance and rear parking lot entrance, are equipped with a single green push button that, when pushed, silences the door alarm to permit passage out of doors. The alarm automatically resets after the doors close.
Documentation in R1's record reflects the following: nurse's note "8-27-99 6:30 p.m. Res was seen pushing button on front door to stop alarm to go out, was taken to room, writer put alarm on res. to alert staff & will check q ½ hrs."
Nurse's note "9-2-99 late entry CNA observed res leave the building going out the front door Res brought back in safely. Did not leave the property."
According to interviews with E2 and E3 and review of facility documentation, there are 13 residents in the facility who have been assessed as "wandering risk residents". Facility policy addressing residents at risk for wandering states that "these residents have all been assessed for cognitive ability and based upon that assessment, it has been determined that none of these are to be allowed outside by themselves, however, should be checked on every 15 minutes to ensure their safety."
These 13 residents reside in non-closed units of the facility and have unrestricted access to the two facility exits with single push button door alarm silencing devices.
Since the 8-19 incident, E2, E3, and E4 stated that the facility has sought bids and corporate approval to install electronic hardware to better equip the facility with aids in supervision of residents (i.e. numeric keypads at all exterior doors, bracelet devices for at-risk residents that will trigger alarms during exit seeking). As of 9-8-99 the system has not been installed.
Failure of staff to adequately supervise R1 has resulted in an unnoticed absence of R1 from the facility and subsequent injuries related to a fall that occurred while R1 was away. Failure of staff to adequately supervise, puts R1 and 12 other identified vulnerable residents at risk for unnoticed absence from the facility.