MAPLEWOOD HEALTH CARE CENTER
Facility I.D. Number0043604
310 Banbury Road, P.O. Box 236
North Aurora, IL 60542
Date of Survey:09/06/01
Notice of Violation:10/26/01
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 residents 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.
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.
Each resident shall have an up-to-date resident care plan based on the residents comprehensive assessment, individual needs and goals to be accomplished, physicians orders, and personal care and nursing needs. Personnel representing other services such as nursing, activities, dietary, and such other modalities as are ordered by the physician shall be involved in the preparation of the resident care plan. The plan shall be in writing and shall be reviewed and modified in keeping with the care needed as indicated by the residents condition. The plan shall be reviewed at least every three months.
An owner, licensee, administrator, employee or agent of a facility shall not abuse or neglect a resident.
These requirements are not met as evidenced by:
Based on observation, interview, and record review, the facility failed to prevent a cognitively impaired resident, who is delusional and has hallucinations, from leaving the facility undetected on 8/7/01 for 1 of 1 resident (R23) who has demonstrated elopement risk behavior. This resulted in R23 being taken to a local hospital on 8/7/01 for heat exposure.
The findings include:
Review of medical record indicated that R23 was admitted to the facility on 8/19/96 with a diagnosis including Schizophrenia Disorganized Type with "agitative" behavior. According to R23's Minimum Data Set (MDS) of 6/5/01, R23 is 51 years old, ambulatory, cognitively impaired, and needs cues and supervision. R23 has both short term and long term memory problems and has poor decision making skills. R23 is delusional and has hallucinations. Review of R23's physician's order sheet of May and June 2001 showed an order, "May not go out into the community without supervision." Care plan reviewed, dated 5/29/01, was not updated to address R23's behavior of opening doors or trying to go outside, though this is identified in the nurses notes on several occasions.
On 8/7/01, R23 was found to be missing from the facility at 4:10 pm. According to the nurses notes dated 8/7/01, R23 was last seen in the facility at 3:50pm by Z2. The local police when notified went to the facility at 5:15 pm to get a description and picture of R23. At 7:00pm a call was received from a local hospital that R23 had been brought to the emergency room by "a person".
Further review of R23's nurses notes revealed the following information. Between 5/29/01 to 7/15/01, R23 was found five times outside the facility and three times making attempts to leave the building. Social service notes of 7/5/01 indicated R23's behavior continued to show "pacing, yelling out, and trying to go out the doors. Resident is delusional and difficult to redirect. ADAPT staff providing 1: 1 supervision."
Interview with E2 on 8/15/01 at around 10:45am in room 60 revealed that R23 is delusional and has hallucinations. E2 said, "He is on watch. He needs supervision, cannot recognize environmental hazard, and cannot be outside by himself." E2 stated that around winter or early spring she saw R23 attempting to get out of the window in the smoking room.
Interview with Z1 (in charge of the ADAPT program) on 8/15/01 at 1:40pm in room 60 revealed that R23 "lacks orientation and touch of reality." Z1 also said, "Most of the time he (R23) cannot recognize environmental hazards."
E1 stated when interviewed on 8/14/01 at around 2:30pm and 8/15/01 at around 9:30am, "I don't think that he (R23) is an elopement risk."
Z3 was interviewed by telephone on 8/20/01 at 2:04pm. Z3 stated that R23 should not go out to the community and/or leave the facility unsupervised.
The facility list of residents who "may not go out into the community unsupervised" was received on 8/15/01 and included R23.
Review of police report dated 8/7/01 revealed that "a call" was received at 5:08pm on 8/7/01. A local resident (Z5) reported seeing someone (R23) walking on Ekman Drive who "appeared disoriented." Police report revealed that R23 was found at 5:14 pm on Derby Drive at Ridgelawn Trail. When found he (R23) "appeared to be suffering from heat exhaustion!"
Data taken from the internet on 9/4/01 showed that Ekman Drive is in Batavia, which is approximately 1.9 miles away from the facility. Derby Drive and Ridgelawn Trail is also in Batavia, which is approximately 0.7 miles away from the facility.
The ambulance report dated 8/7/01 revealed that they arrived at the location at 5:39pm. Report states, "called to above location (Derby & Ridgelawn) to a possible 50 year old male pt (patient) that was reported to be outside since 1:00pm today.
Temperature outside today was 105 degrees. On our assessment pt (R23) was disoriented to person place and time. Pt. was diaphoretic and pt's temp was 101.9. IV's were started and ice applied to his arm pits, neck and to groin area. Vital signs where retaken and pt's temp was at 99.8." R23 was taken to the emergency room of a local hospital.
R23's hospital record was reviewed at regional office on 9/4/01. Record showed R23 arrived by ambulance at the hospital emergency room at 6:35pm and was discharged back to the facility at 8:30pm with a diagnosis of "heat exposure."