IL VETERANS HOME AT MANTENO

Facility I.D. Number 0042218
1 VETERANS DRIVE
MANTENO, ILLINOIS 60950

Date of Survey: 07/09/01

Notice of Violation: 08/28/01

Incident investigation of 6/2/01 AND 6/14/01

“A" VIOLATION(S):

An owner, licensee, administrator, employee or agent of a facility shall not neglect a resident.

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 shall be provided to each resident to meet the total nursing care needs of the resident.

These requirements are not met as evidenced by:

Based on observation, record review and interview, the facility neglected to provide supervision for a resident (R3) who has cognitive impairment, who wandered out of the facility undetected by staff, climbed over a chain link fence and got off of facility grounds on 6/14/01.

Findings include:

Review of R3's medical record face sheet revealed that R3 is an 85 year old male who was admitted to the facility on 2/24/00. R3 has multiple diagnoses listed which include Arteriosclerotic Dementia Paranoid State, Benign Prostatic Hypertrophy, Hypertension, Depression and Osteoarthritis. R3's 2/24/00 initial health and medical history narrated in the social assessment read, "last two years his memory gotten worse... the family had to take the car away in 1999... he began to get lost while out driving and had at least two accidents... he was hospitalized for depression and suicidal threats... sent to a nursing home where he was monitored for wandering risk... he does have many leisure interests, loves working with his hands (wood working, etc.) playing pool, music, reading, bingo, dancing, gardening, taking walks and political discussions."

R3's 2/26/01 Minimum Data Set (MDS) indicated that R3 has short term and long term memory impairment, his judgement is impaired and has wandering behavior problems. R3's Resident Assessment Protocol summary indicated R3 "displaying behavior symptoms of wandering and resisting care... goes off the unit unsupervised... recently had more difficulty following directions back to his unit... staff has had to get him from other units and escort him back to his unit."

R3's evaluation dated 3/19/00 by Z1, psychiatrist, revealed that R3 could not recognize Z1 approximately 15 minutes after R3 was interviewed. Z1, in his recommendations included:

"(1) Allow supervised outings away from this facility in order to decrease R3's stress level.

(2) Given the memory deficits and history of getting lost, there would be some risk in having R3 in open unit."

R3's 3/5/01 care plan for memory impairment, behaviors and activities was reviewed. The interventions are generalized, vague and not individualized to his wandering behavior, his life style and leisure activities. There was no documentation to show why R3 is demonstrating the wandering behavior and how the facility will supervise R3 to ensure his safety at all times.

R3's 6/14/01 nurses notes read "member brought back to the open unit via security, member was climbing fence and went off grounds of Illinois Veteran's Home at Manteno (IVHM)." Review of 6/14/01 investigation report of the incident revealed that an employee of a local bank had called the facility switch board operator alerting the facility to get two gentlemen, possibly residents of the IVHM. R3 was found outside of the chain link fence off the grounds of IVHM, and R2 was in a wheelchair on the inner side of the chain link fence on the grounds of IVHM. The report also indicated that R3's foot got stuck in the fence and R3 was able to come down the fence with the assistance of the bank employee. The height of the fence is approximately five feet. There is grass on the facility ground and the ground on the other side of the fence is hard and rough. The facility security staff recovered the residents and returned them to their respective units.

Review of the facility member census report revealed that R3 lives in the R-2 East unit (an open unit), and R2 lived in the R-1 West unit (an open unit) at the time of the incident. The chain link fence where R2 and R3 were found is approximately 2 and ½ blocks south from R3's unit and is approximately 2 blocks south from R2's unit.

On 7/5/01 at approximately 11:45 a.m. in the Medical Director's Office, in regards to R2, Z2 stated that R2 was an 87 year old male who used to be dependent on wheelchair for his mobility. Z2 also stated that R2 had multiple terminal diagnoses including Chronic Renal Failure (CRF) and Congestive Heart Failure (CHF) and he expired on 6/28/01 due to CRF and CHF.

None of the facility staff interviewed knew how these two residents, who were identified at risk for their safety, had left their units and reached the chain link fence. The interviews are as follows.

E3, on 7/3/01 at approximately 4:00 PM in E2's office, stated that on 6/14/01 at approximately 6:20 p.m. "R3 left the unit saying he was going to play pool. The pool table is located in the recreation room, which is located in the R-2 West wing. There are approximately 9 exits, turns and two inner connecting tunnels to get to the pool table. R3 usually goes to play pool, sometimes he comes back to the unit on his own, sometimes has difficulty finding the unit and other unit staff brought R3 back to the unit, but this time he ended up off grounds of IVHM and more likely it will happen again. It is very difficult to supervise R3 with the availability of limited staff."

E2, on 7/3/01 at approximately 12:30 p.m. in Medical Director's office stated, "R3 lately has been more confused finding his way back to his unit." E2 also stated that after the incident of R3's wandering off grounds, the facility had involved R3 to install pink 'Flamingos' in front of the unit to aid R3 to identify the unit. The interview with E2 also revealed that there are, "Usually 3 to 4 staff working in the evening on the unit (R-2 East), including the nurse and aides. On the day of the incident there were 4 staff to manage 38 residents. Out of 38 residents, 17 are totally dependent on staff for their activities of daily living (ADLs), 15 are partially dependent on staff for their ADLs, 15 are incontinent of bowel and bladder and 2 are fed by gastrostomy tube. There is no evening or weekend activity staff to provide activities to keep the residents occupied."

Z2, on 7/3/01 at approximately 2:30 p.m. in the Medical Director's office stated, "R3 is alert, self ambulatory, confused and disoriented to time, place and person, extremely forgetful, especially has no short term memory." The interview also revealed that "R3 either needs to be in a closed unit or needs to be supervised closely in open unit."

It was observed on 7/3/01 that the unit has multiple (approximately 8) exits. Three of the 8 exits are unalarmed from 7:00 a.m. to 7:00 p.m.

After he wandered off of the facility grounds, R3 was evaluated on 6/21/01 by Z3 at the request of his family. Z3, in his report, suggested "daughter needs to be made aware and provide more one on one supervision to be with R3 in pool hall, otherwise, if the staff on the floor can't manage, R3 will have to go back to the Dementia unit."

On 7/3/01 at approximately 2:00 p.m. and on 7/5/01 at approximately 11:00 a.m., surveyor observed R3 leaving the unit unsupervised to play pool. He was accompanied by another resident. On these two days R3 was observed to be alert, self ambulatory, pleasant, cooperative, social, confused, forgetful and disoriented to time, place and person. Surveyor met with R3 in the pool room. Approximately 15 minutes after the meeting with him in his room, R3 could not recall the surveyor meeting with him. R3 had no recollection of wandering out of the facility on 6/14/01.

On 7/5/01 at approximately 12:30 p.m. in the Medical Director's office E1 stated that, "R3 was in the Dementia (locked unit) unit after R3 was admitted to the facility, but he was moved to the open unit at the request of R3's family." E1 also stated that "The Dementia unit is fully occupied to its capacity and there are no empty beds available."

There is no individualized plan to supervise R3. A review of the Resident Safety Concern Checklist revealed the facility does the wandering residents' face checks at 7:00 a.m., noon, 3:00 p.m., 5:00 p.m., 8:00 p.m., and 11:00 p.m. daily. On 7/3/01 at approximately 1:30 p.m. surveyor visited unit R-2 East where R3 is living. At this time the wandering residents' face check was not done at noon. The charge nurse stated that she was busy feeding residents and could not ensure doing the wandering residents' face check.