NEW ATHENS HOME FOR THE AGED
Facility I.D. Number 0033043
203 S. Johnson St.
New Athens, IL 62264
Date of Survey 7/20/00
Complaint Investigation 0042984
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 and personal care shall be provided to each resident to meet the total nursing and personal care needs of the resident.
Personal care shall be provided 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.
Maintain all electrical, signaling, mechanical, water supply, heating, fire protection, and sewage disposal systems in safe, clean and functioning condition. This shall include regular inspections of these systems.
AN OWNER, LICENSEE, ADMINISTRATOR, EMPLOYEE OR AGENT OF A FACILITY SHALL NOT ABUSE OR NEGLECT A RESIDENT.
Based on staff, resident, and physician interviews, the facility failed to provide adequate supervision for 1 confused resident (R2) to prevent elopement from the facility. The facility failed to:
Follow the care plan approach to apply a personal alarm to 1 resident to prevent the resident from wandering without staff awareness, and ensure that staff responded immediately to the exit door alarm when 1 confused resident left the building unattended.
1. Interview of E3, acting DON, on 7/12/00 at 10AM revealed R2 had eloped from the facility on 5/28/00 without staff knowledge until 2:55PM. E3 identified R2 as having Alzheimer's Disease.
2. Review of the 5/28/00 incident report, and the facility investigation revealed R2 had Progressive Dementia, and had eloped from the facility on 5/28/00, and was discovered at 2:55PM by E11, an off duty CNA. R2 was found laying in the supine position, on the ground in front of the facility near the sidewalk. It was noted that R2 had a swollen left wrist, left eye bruised with scrapes around the left eye. Both knees were scraped, and reddened (the right knee 4cmX3cm, and the left knee 3cm X3cm). R2 was observed to guard, and complain of pain in the left wrist.
3. R2 was sent to the hospital, and returned with a Diagnosis of fractures of the left ulnar, and radial bones of the left wrist.
4. Review of E11's written statement, and interview of E11 on 7/14/00 at 10AM revealed that on 5/28/00 at approximately 2:45PM she clocked out, and went to her truck. About 2:55PM she heard a loud crying, and moaning sound, over the sound of her radio. E11 stated she recognized it to be R2. E11 looked out the passenger side of the rear view mirror. R2 was laying face down, on the ground, across the sidewalk, next to the street.
E11 identified that R2 was approximately 9 feet to the left of the steps, near the street. R2 had her left arm under her. E11 stated R2 was crying "It hurts! It hurts!" E11 stated R2 was wearing a blouse, slacks, and socks and tennis shoes with long shoe laces that were untied. E11 stated R2 was alert to person, and pain only. E11 also indicated that R2 was not aware of the safety risks, and could not be out of the facility without staff supervision.
E11 stated she heard the facility's door alarm sounding loudly as soon as she got out of her truck. E11 said she ran inside the building, yelling that R2 was on the ground. E11 saw a nurse (E10) sitting at the north nurses station, on the phone with a personal call. E11 also identified that E15, a CNA, was standing with her arms folded, by the menu board, close to the nurses station. The alarm was still going off. There were 4 residents in the sun room making lots of noise, trying to get some help for R2.
As per E11's interview neither staff had responded to the alarm until E11 yelled out that R2 was outside on the ground.
5. Interview of E10 on 7/13/00 at 1:20PM.revealed E10 was on the phone at the north nurses station with a personal call when E11 came in the facility stating R2 was on the ground. E10 stated she got off the phone immediately, and went outside to help R2. E10 stated she did not hear the alarm sounding until she was going out the door to assist R2. E10 stated she was not aware R2 had left the building.
6. Interview of E8, an RN, on 7/13/00 at 9:50AM. revealed she was at the south end nurses station along with E5, maintenance, and E9, an LPN, when they received a page from the north end nurse (E10), who alerted them to "Come fast." E8 stated she did not hear a door alarm sounding until she was about half way down the hall toward the front door.
E8 identified that R2 had steady ambulation ability at the time of the incident; however, R2's mental capacity, and cognitive ability was declining. R2 would not even be able to determine if she was tired, and rest.
E8 stated that R2 was not cognitive about safety risks, and was not to be outside of the facility without supervision.
E8 stated that some time ago R2 had made attempts to go outside. At that time R2 was wearing a wander guard bracelet, and staff would respond to the alarm, and were able to stop R2 from leaving the building.
7. Interview of E9 on 7/13/00 at 3:20PM. revealed on 5/28/00 he came on duty at 2:30PM. He stated as he passed by R2's room he remembered seeing R2 in her bed. E9 stated he did not check to see if R2 had a personal alarm in place. E9 stated he was in report when he heard a page to "Come stat." E9 stated he did not hear a door alarm sounding until he was part way down the hall, toward the sun room door. When he got to the front of the building R2 was outside on the ground. R2 was sent to the hospital, and returned with a splint on her left hand.
8. Interview of E18, a CNA, and E19, a CNA, on 7/13/00 at 3:20, and 3:40PM revealed they saw R2 in bed as they came on duty at 2:30PM. They stated they went down the hall to get other residents up for the evening. Neither staff looked to see that R2's personal alarm was in place. Both staff stated they never heard any door alarm sound, or personal alarm sound to alert them that R2 had gotten out of bed, or out the door.
9. Interview of E5 on 7/13/00 revealed he was at the south nurses station at the time of the incident on 5/28/00. E5 stated he could not hear the door alarm sounding from the nurses station. E5 stated he did hear the alarm when he was going down the hall, after being paged to the north hall. E5 stated he did check the alarm at the time of the incident, and found it to be working.
E5 stated that on 5/29/00 he turned the alarm up to it's maximum sounding, at the request of the E1, Administrator.
10. Interview of E1 on 7/20/00 at 8:30AM revealed that the alarm on the sun room door was a Radio Shack Home Theft Alarm with a piercing loud sound. When it was installed a piece of cotton was placed over the speaker to muffle the sound. On 5/29/00 the cotton was removed to activate the sound to it's original state.
11. Interview of E16, a CNA, on 7/13/00 at 1:40PM revealed she took care of R2 on the day shift on 5/28/00. She put R2 to bed about 1:30PM; however, she did not remember putting R2's personal alarm on. E16 stated she saw R2 last at 2:30PM, and R2 was in bed.
12. Record review of R2 revealed R2 was admitted on 1/25/97. R2's diagnoses in part are Senile dementia, Generalized Arteriosclerosis, Degenerative Arthritis, Organic Delusional disorder, and Impacted Fracture of the left Distal Radius and Ulna 3/26/00.
Review of the Physician Summary and Psychotropic Progress Notes for 3/22/00 revealed Z2 stated R2 has had increased confusion related to time and place, has had episodes of increased sadness, and flat affect, along with decreased mental status. Disorientated in all 3 spheres.
13. Interview of Z2 on 7/14/00 at 2pm per phone revealed R2 was severely confused. R2's cognitive ability was described by Z2 as nil. Z2 stated R2 would not be able to recognize safety risks of the environment. R2 would not be able to identify stairs, or hills as a safety hazards.
14. Interview of Z1 on 7/14/00 at 12:45PM revealed R2 was a pleasantly confused demented lady. Z1 stated R2 would not be able to identify safety risks of the environment, and should not have been outside unsupervised. Z1 stated some times she even questions if R2 was alert to person. Z1 also stated that R2 would not be able to navigate hills or steps without assistance.
15. Review of the Nursing Assessment dated 3/1/00 which was current at the time of the 5/28/00 incident revealed R2 had long, and short term memory problems, and congitive ability was scored moderately impaired- decision poor; cues/supervision required. R2's behavior of wandering, or elopement risk was not identified.
Review of the physical therapy assessment of R2 on 5/12/00 revealed R2 was assessed as capable of being up ambulating on her own, but continues to be a fall risk. Recommend resident to continue to wear Tabs monitor alert when in bed, or during high activity times (shift change, meals) to alert staff to ambulation. Supervise resident, and provide assistance if signs of fatigue are evident.
Review of the care plan that was current at the time of the incident revealed the above plan in place as one of the approaches for ambulation, and fall risk.
The care plan also identified that on 3/26/00 R2 had sustained a fall resulting in fracture of the left wrist.
Review of the nurses notes dated 5/15/00 revealed R2 opened the south outdoor twice, and was holding her ears as the alarm sounded. The notes also indicated that R2 wandered into other resident rooms uninvited seven times.
The nurses notes dated 5/20/00 10PM. revealed R2 opened the south door twice.
The notes dated 5/25/00 identified that R2 walked into the glass partition by the dining room.
On 5/26/00 the nurses notes stated that R2 again walked into the glass partition.
The nurses notes of 5/28/00 at 2:55PM documents the incident of R2's elopement.
Review of the 7/10/00 x-ray report revealed there was healing fractures of the Distal Radial and Ulnar Fractures.
16. Interview of the DON on 7/12/00, and 7/13/00 revealed that she did an investigation of the above incident, and 2 employees did not immediately respond to the door alarm on 5/28/00 at 2:55PM. R2 was found to have gone out the sun room door by the front door of the facility. E2 stated the door alarms, and wander guard alert alarms are used to assist staff to supervise residents.
17. The facility is located on a 2 way street. There was little traffic observed on 7/12/00 at 2:30PM, 7/13 at 3:00PM, and 7/19/00 at 12 noon. The front of the facility is located on a steep incline from the street, with 6 steps leading up to the sidewalk, and 7 steps from the sidewalk leading to the front door, and sun room door. There is one hand rail on the right side of the steps. The area just adjacent to the sun room door is concrete, and rock bordering the sun room. The steep incline to the street is grass covered.
R2 was found approximately 9 feet to the left of the stairs near the street. The sun room exit door is to the right of the stairs.