NORTH PLAZA NURSING CENTER

Facility I.D. Number 0045021
438 West North Street
Decatur, IL 62522

Date of Survey: 08/20/01

Complaint Investigation

"A" VIOLATION(S):

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.

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.

All exterior doors shall be equipped with a signal that will alert the staff if a resident leaves the building. Any exterior door that is supervised during certain periods may have a disconnect device for part-time. use. If there is constant 24-hour-a-day supervision of the door, a signal is not required.

These regulations are not met as evidenced by:

1. According to current admission records and physician's order sheet, R2 is 89 years old and was admitted to the facility on 6/26/01 with diagnoses of agitation, senile dementia, Alzheimer's, Hypertension, Congestive Heart Failure, Chronic Obstructive Pulmonary Disease and Peripheral Arterial Insufficiency. R2 had outpatient surgery to remove a tumor on the forehead with skin grafting on 7/30/01. The initial Resident Assessment Instrument (RAI) of 7/8/01 assesses R2 as having memory problems and severe cognitive impairment. The RAI also states that R2 is independent for transfers and cognizant of safety hazards . . . impaired decision making. Has problem understanding others. . ." An elopement potential assessment dated 6/27/01 states that R2 "wanders thru all hallways. . . wandering is a behavior as a result of dementia. . . no cause can be determined due to dementia." The Care Plan of 7/12/01 states to "redirect to another area when attempting to elope" and "monitor res. whereabouts every 15 minutes."

According to an incident report and nurses notes of 8/6/01, R2 was first noted to be missing at 5:00pm. The resident location monitoring log shows R2 was observed in his room from 1:15pm to 3:00pm by nurse (E4), again in resident room at 3:00 and 3:15 by nurse (E3), in the hallway and nurses station from 3:45 to 4:30, then in another resident's room at 4:45pm, all documented by E3. Interview with E3 per phone on 8/15/01 approximately 4:15pm stated that when E3 could not find R2 for the 5:00 check, she asked Certified Nurses Aide (CNA, E9) to help look. When they could not locate R2, E3 notified E1(administrator), and facility and grounds search was initiated at 5:15pm. At 5:45pm, the facility received a call from the hospital emergency room that R1 had been picked up at a site east of the facility and taken to the hospital. R2 was returned to the facility by ambulance at 8:15pm with no apparent ill effects.

According to follow-up investigation notes dated 8/7/01 and interview with E1 on 8/15/01 at 3:30pm, E1's initial investigation indicated that R2 possibly exited through the back kitchen door that is not alarmed. E1 stated that she confirmed with E3 and E9 that R2 had been seen at 4:45pm. All door alarms were checked and found to be in working order. An additional hook and eye latch was placed on the back kitchen door with instructions to staff to closely monitor surroundings for potential wanderers. Additional slide bolts were also added to each outside gates. E1 also stated that a name band was placed on R2's wrist.

Review of hospital records and interview with hospital staff (Z1) by phone on 8/15/01 at 2:00pm reveal that R2 arrived at the hospital at 5:17pm by ambulance, accompanied by police (Z2). R2 had a dressing over the left temporal area, was disoriented and unable to state where he lived. Upon removing R2's shoes and seeing the name written on them, Z1 surmised that R2 had come from a nursing home, so Z1 and Z2 started calling around to facilities. Z1 stated that Z2 found that R2 had come from this facility. At 5:45pm, Z1 spoke to E3 per phone, and E3 told Z1 that E3 had seen R2 in a room at the facility at 4:45pm, and 15 minutes later R2 was gone. The emergency record states at that time that "{Z2} states he received the call to go to {place of business} at 4:11pm, estimating that R2 probably arrived there at 4:00pm. R2 was released from the emergency room at 7:42pm to return to the facility via ambulance. Laboratory results done at the time show an elevated blood urea nitrogen of 35 mg/dl (normal 6-22) and creatinine of 1.5mg/dl (normal 0.6-1.2), which are indicative of mild dehydration. Discharge instructions sent with R2 state "Watch patient carefully to keep from wandering off."

Telephone interview with the records clerk (Z5) at the police department on 8/15/01at 2:40pm revealed a call from the place of business at 200 E. North Street regarding a disoriented man coming in was logged in on the computer at 4:11pm on 8/6/01. Interviews with Z3 and Z4, employees of the business, on 8/15/01 at 4:45pm, stated that R2 entered their business on his own, went in to one of the offices and sat down. Z3 and Z4 stated that the time had to be between 3:00 and 3:30pm, and they confirmed that time with the appointment schedule. They state that R2 had a bandage on his head, gave them two different names, and was otherwise disoriented but pleasant. They stated it was quite hot that day and his face was flushed, and that he had "wet himself." Z3 stated that they discussed for quite a while what to do, and that it was at least a half hour to forty-five minutes before they called 911 and the police and ambulance arrived. Z1 stated that a mental health professional had responded with the police and convinced R2 to go to the hospital.

This place of business where R2 was picked up was observed to be approximately 3 ½ blocks east of the facility. There are three streets with 2-way stops, where cross-traffic does not stop, and one 4-way traffic signal at Main Street. According to the Illinois State Water Survey, weather conditions for Decatur on 8/6/01 between 3:00 and 4:00pm were 88 degrees F and 49% humidity, making a heat index of 95 degrees.

Random observations of R2 during the days of 8/15/01 and 8/16/01 revealed R2 to wander throughout the facility, laying down on his bed, opening doors and entering other residents' rooms at times. Most of the time R2 was easily redirected by staff. Interview of E5 on 8/16/01 approximately 3:15pm stated "you see him laying down sleeping now, but just like that, he could be up and gone." Multiple attempts to interview R2 revealed that he responds to his name but is unable to answer other questions appropriately.

E1 stated that they had done further investigation based on the time that the police call was logged. E1 stated that approximately 3:00pm on 8/6/01, the maintenance director (E6) and housekeeping staff (E7) were helping a former shelter care resident move back home. In doing so, E6 had disarmed the door alarm and propped open the door and the patio gate until approximately 3:30pm.

Upon interview on 8/16/01 at 12:20pm, E6 stated that he first turned off the alarm and propped open the door about 3-3:15pm, while carrying out the first load of belongings. E6 stated that at that time, R2 followed him out and down the ramp. E6 stated that he put down what he was carrying, and walked with R2 back into the door and through dining room. E6 stated that R2 walked into the main hall and turned toward the east hall. E6 stated he then finished carrying out the load of stuff to the truck, and as he was coming back in, E7 was coming out with a load. E6 stated that they continued like that, he and E7 alternating going in and out with loads of stuff, for approximately a half hour, in such a way that the door was never totally unattended. E6 stated he did not see R2 or any other residents during this time. E6 stated that after the last load, he closed the door, and reactivated the alarms. E6 estimated that time to be 3:30 to 3:45pm.

Upon interview on 8/16/01 at 9:45am, E8 (social services) stated that she was out on the patio with the smokers approximately 3:00pm. E8 stated that she observed R2 go out with E6 about that time but that E6 accompanied R2 back inside. E8 stated that E8 did not see R2 or any other residents come out that door after that. E8 stated that she and the smokers came back inside about 3:10 to 3:15pm.