MOMENCE MEADOWS NURSING CENTER
I.D. Number: 0028480
500 SOUTH WALNUT
MOMENCE, ILLINOIS 60954
Survey Date: 6/9/99
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.
This requirement is not met as evidenced by:
R1 admitted to the facility 12/18/1998 has a diagnosis which includes Alzheimers and Dementia with psychosis.
Assessment of 12/31/1998 reflects that R1 has memory problem and is moderately impaired requiring supervision. Assessment also identifies R1 has a daily wanderer and a high risk for falls.
The 12/31/1998 care plan states "due to history of wandering staff will check on resident frequently, monitor door alarms and when resident attempts to leave facility through front door staff will re-direct, counsel, find out reason and provide re-assurance".
Record review and staff interview revealed R1 is a known wanderer with frequent elopement attempts since admission 12/18/1998. Due to R1's mental status he is unable to recognize environmental hazards and provide for his own safety.
Nurses note of 12/19/1998 document "Resident (R1) out in the parking lot, returned per staff".
On 12/26/1998 as documented in the nurses notes and verified by staff (E3), R1 wandered out of the facility without staff knowledge.
E3 stated that on 12/26/1998, around 10am she got a phone call from an unknown person informing facility that R1 was found wandering in downtown Momence which could be reached from the facility by crossing the Kankakee river bridge on Route 1 (main highway) and is about 7 to 8 blocks away. E3 said that staff was not aware that R1 was out of the building until the call from outside the facility alerted them. E3 who brought R1 back to the facility stated that the temperature outside was very cold. According to E3, R1 was wearing a coat and a hat. The outside temperature that day (12/26/1998) ranged from 10 to 15 degree Fahrenheit as reported by Z-3 of the Kankakee library.
Facility administrator told surveyor she has no knowledge of this incident (12/26/1998) and this was confirmed by E3 saying "I only notified his (R1) family". The department was not notified about this incident (12/26/1998) nor was an incident report made.
Staff stated that after R1 was back at the facility all of the exterior doors were checked and found that all the alarms are on and functional.
Again on 02/21/1999 resident (R1) was found by a family member wandering by the Shell gas station which is about 2 to 3 blocks away from the facility. Family member took the resident (R1) home. R1's wife called facility around 10:45 a.m. to make them aware of the incident and his (R1) whereabouts. R1 when found by family member was not wearing a coat saying he was cold. Temperature that day (02/21/1999) as reported by the Kankakee library was cold and on the low 17 degree Fahrenheit.
It was unknown to staff how R1 had gotten out of the facility on 12/26/1998 which is a Saturday and 02/21/1999 which is a Sunday because all exterior doors are alarmed. Staff stated on weekends the front door and all exterior door alarms are on all the time. Monday to Friday the front door alarm is turned off when the receptionist comes in and turned on when she leaves the facility.
Interview of the physician on 06/09/1999 reveals that resident (R1) should not be allowed to be out of the facility unattended. R1 is in need of constant supervision due to his history of wandering and elopement attempts. Physician states he is not aware of the 12/26/1998 and 12/19/1998 incident.
Facility failed to ensure that R1 who was identified as a wanderer with elopement attempts while at the facility was properly supervised to prevent accidents.