Facility NameI.D. Number: 0016758
5668 STRATHMOOR DRIVE
ROCKFORD, ILLINOIS 61111
Survey Date: 8/17/1999
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 the safety of residents at all times, such as but not limited to: nonslip wax on floors, safe equipment, assistive devices properly maintained, and proper use of physical restraints and adaptive equipment.
Based on interviews, record review and observations, the facility failed to provide adequate supervision to prevent R1's elopement from the facility on 07/18/1999.
The findings include:
R1 has a diagnoses of Alzheimer's Disease, Dementia, Non Insulin Dependent Diabetic and Hypertension.
R1 was admitted to facility on 07/14/1999. During interview with Z6 he stated, "R1 resides on a secured unit due to his history of wandering and severe cognitive deficit and has no regard for his own safety".
Review of R1's incident report of 07/18/1999 indicated, 'R1 was discovered missing from the facility at 9 p.m. on 07/18/1999. Facility was searched thoroughly as well as grounds. Acting Administrator was notified...Hospital and local police had been notified to assist in the search. Resident was spotted by hospital security police walking across hospital property. Search ended when city police found resident sitting on deck of home near facility and hospital property. Resident was returned to facility in good spirits and condition at 10:34 p.m. Security system was checked OK and working. Fifteen minute checks were ordered to monitor resident...'
On 08/09/1999, R1 was observed on the secured unit. R1 responded to his name. During attempts to interview R1, he was unable to respond to questions of what day it was, who was the president and where he lived. When R1 was asked why he left the facility R1's response was garbled with no meaning.
Review of R1's nurses' notes revealed:
(07/17/1999) 'R1 was wandering after being taken to R2 on E-wing and went out C-wing door (C-wing door is an exit door to the outside of the facility). Also R1 jumped the fence at the end of our fenced in area...'
(07/18/1999) 'Patient repeatedly attempting to leave building by means of side door (exit door). R1 attempted to follow aides out of the corridor when his wife returned to E-wing. R1, was seen by writer (E10) at 8:45 p.m. sitting quiet in hallway. Aides reported unable to locate R1 at 9 p.m. No alarms had sounded on doors...'
During interviews with staff and outside sources:
E5 stated, "I was looking for R1 to put him to bed and I could not find him. It was about 8:15-8:30 p.m. when I last saw R1 sitting at the end of the hallway by the locked exit door" (leads to the center of the facility).
E5 was asked, how R1 got out of facility? E5 stated, "Around 8:30 p.m. Z2 was leaving the facility and since R1 was a new resident, Z2 did not know that R1 was a resident and he must have followed Z2 out of the facility. We searched for R1 and we could not find him. E6 asked the hospital security guard and he said he saw a man walking through the bushes into the woods. The day before, R1 jumped the fence. R1 walks real fast".
E3 stated, "R1 is easily redirected, but he still wants to go. R1 is very confused. The other day (07/17/1999) he tried to climb over the fence. R1 is having a hard time adjusting to the facility".
E4 stated, "R1 got out with one of the resident's family members. He was pacing that evening. We were watching him the best we could".
Telephone interview with Z1 on 08/09/1999 at 10:45 p.m., she stated, "R1 was found on 07/18/1999 at 10:15 a.m. in a subdivision north east of the facility about ½ mile away".
Telephone interview with Z6 on 08/17/1999 regarding R1's survival skills, Z6 stated, "R1 has no survival skills. R1 has no cognitive ability and no self preservation skills. I don't think he can cross the street safely".
Observation of the area where R1 wandered to was a wooded area, with a empty lot and residential backyards. The area has multiple cul-de-sacs and dead end streets.
During interview with Z3 she stated, "I was amazed that R1 got to my patio, it's approximately ½ mile from the facility. R1 was found on my patio playing with a Citronella candle. It was late, dark, the air conditioner was on and it was a hot night. I just happened to look out the door and saw R1 sitting on the deck. Then I called 911. I don't know how long R1 was out there before I saw him".
During a phone interview with Z5, she said, "The 911 call was placed at 2210".