ILLINOIS KNIGHTS TEMPLAR HOME I.D. Number 0010058 450 FULTON STREET, P. O. BOX 49 PAXTON, ILLINOIS 60957 As a result of a survey conducted by representative(s) of the Department, it has been determined the following violations occurred. "A" VIOLATION(S): The facility shall have written policies and procedures governing all services provided by the facility and these policies shall be followed. 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. Each resident shall have an up-to-date care plan based on the resident's individual needs and goals to be accomplished, physician's orders and personal care and nursing needs. The plan shall be in writing and shall be reviewed and modified in keeping with the care needed as indicated by the resident's condition. 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. The facility shall not neglect a resident. These requirements are not met as evidenced by: Based on observations, record review, and staff interviews it was determined that the facility failed to supervise one resident in the sample of 4 from eloping from the facility, and the facility failed to monitor and respond to the facility alarm system, which resulted in an unnoted absence from the facility and in harm to R-1. R-1 suffered a fracture of the right wrist and lacerations to the right eyebrow area. It was determined that other residents are at risk for wandering and unnoticed elopements. Findings include: R-1 is a 79 year old female resident who was admitted to the facility on 4-8-1996. R-1 has diagnoses that include cognitive decline, hallucinations, depression, osteoporosis, bi-polar disorder, anemia, and organic mental syndrome. Per the Resident Assessment Instrument dated 12-23-1998, R-1 has impaired memory and decision making ability and is independent with transfers and mobility. R-1 has physician's orders for a wanderguard bracelet and per interview with E-2, R-1 has worn this bracelet most of the time she has been in the facility. In staff interview with E-2 staff stated that R-1 had eloped from the facility 2 times prior to the elopement of 1-28-1999. The care plan for R-1 did not identify R-1 as a wanderer or as an elopement risk. The wanderguard bracelet is addressed as an approach under a moderate risk for falls. R-1 was found 4 blocks from the facility in the middle of the road on 1-28-1999 at 6:50 a.m. by Z-1. Per interview, Z-1 stated that he was driving to work when he saw R-1 in the middle of the road. Z-1 stated that he did not know who R-1 was but that R-1 was trying to get up and had herself propped up so he assisted her up. Z-1 stated that R-1 was incoherent and was unable to stand when he got R-1 up, so he leaned R-1 against the passenger seat of the van while he opened the cargo door to sit her down. Z-1 stated that R-1 appeared to have something wrong with her right side. Z-1 stated that he noted that R-1 had bleeding from the right eyebrow area but did not notice any other injuries. Z-1 stated that once he got R-1 sitting in the van, he ran 2 houses down and found someone home and called 911. The ambulance responded about 20 minutes later he stated. The ambulance report indicated that the ambulance arrived on the scene at 7:03 a.m.. The report states that R-1 had about a inch laceration of the right eyebrow with minor bleeding, bruising to the right forehead area, bilateral abrasions to knees, and mild deformity and pain to right wrist. The report stated that a dressing was placed on the laceration of the right eyebrow and an ice pack applied. Hot packs were applied to axilla and feet. R-1 was cool to the touch and found without a coat. Skin was dry and pale in color. R-1 was placed on a cardiac monitor, an IV was started and oxygen was started. R-1appeared disoriented. Ambulance transported R-1 to Gibson City Hospital Emergency Room. Report from Gibson City Emergency Room stated the following. R-1 escaped from the nursing home and was found on the road. R-1 had a deformity of the right wrist, and fingers were slightly swollen. R-1 had an abrasion lateral to the right eye. Diagnoses on discharge from the emergency room was a fracture of the right wrist and abrasion of the left forehead. An appointment was made with a physician for the following day for a follow-up on the right wrist fracture. Nursing assessment from the emergency room indicated that R-1 had a body temperature of 98.5 degrees F. Outside weather conditions as recorded by the Illinois State Water Survey, Champaign-Urbana on 1-28-1999 included: the high temperature was 38 degrees F. at 4 p.m. and the low temperature was 31 degrees F. at 10 p.m.. No wind or precipitation data was available. Surveyor arrived at the facility on 02-03-1999 at 8:45 a.m.. The front door of the facility was not alarmed and nostaff were present in the area. The surveyor had to proceed down 2 halls before finding staff at the nurses station. The staff then directed the surveyor to the administrator's office on the lower level. Per interview E-5 she stated that she shut off the alarm to the front door about 8 a.m. on 02-03-1999. The front door alarm can be shut off by a switch at the nurses station so it will not alarm. In interview with E-1 he stated that staff would not be available this day to monitor the front door until 10 a.m. E-1 stated that staff are normally in their offices to monitor the front door at 8 a.m.. E-2 was interviewed and stated that R-1 was found 4 blocks from the facility and the staff felt that she had exited the facility through the front door. E-2 stated that R-1 was "pretty stable with walking" and was "very confused and had a history of paranoia". E-2 stated that R-1 had been at the facility for quite a while but had declined cognitively the last 2 months. E-2 also stated that R-1 has tried to leave the facility before and wore a wanderguard bracelet pretty constantly since admitted. E-2 also stated that R-1 had removed her wanderguard bracelet prior to leaving the facility on 01-28-1999 and to her knowledge had never removed the bracelet before. The wanderguard bracelet was found on R-1's bedside table, not cut and working properly. E-2 stated that R-1 would not have known she would have to remove this bracelet before leaving the facility and R-1's daughter also felt that the bracelet must have been irritating R-1 and that R-1 would not know to get rid of the bracelet to get out of the facility. E-2 stated that the alarm on the front door is shut off at times. E-2 stated that when the alarm is on and someone enters the building they have to push a button to silence the alarm. The alarm is located close to the top of the door on the inside of the second set of doors. When someone exits the facility someone has to push the button on the door to silence the alarm. E-2 stated that alarms are usually turned off about 8 a.m. after staff are in the front offices to monitor the front door. The alarm rings at a panel at the nurses station and by the sound of the alarm staff can tell that it is the front door alarm. The alarm cannot be shut off until staff check to see who went out the door. Staff have to physically check. E-2 stated that on 01-28-1999, the day of the incident with R-1, the alarm should have been on at the front door. The nurse at the desk at the time of the incident would have to come to the front door to check who went out and to shut off the alarm. E-2 stated that on the day of the incident R-1 was wearing a sweatshirt, slacks, shoes and socks when she eloped from the facility. E-2 stated that Z-1 found R-1 on the road on his way to work and called 911. The ambulance responded and the ambulance person recognized R-1 as a resident of the facility and called the facility at 7:10 a.m. and reported the above. Two facility staff went to the scene to check on R-1. E-2 stated that 1 other resident had left the facility and was found uptown about November. No other residents had got out of the facility that she could remember. Per interview with E-3 on 02-03-1999 at 11:20 a.m. the wanderguard for R-1 had been checked by the night nurse at 5 a.m. 01-28-1999 and was on R-1's arm and was working properly. Documentation on the wanderguard monitoring sheet supports that the wanderguard was checked. E-3 stated that "the front door alarm rang about 10 minutes" and "no one checked the door as sad as it is to say, and someone finally turned it off". E-3 did not know who turned off the front door alarm and no one had admitted to turning off the alarm. E-3 stated that she conducted an investigation of the incident and the above was the outcome. E-4 was interviewed on 02-03-1999 and stated that R-1 was observed assisting another resident in the area close to the nurses station where the nurses were getting report between 6 a.m. and 6:30 a.m.. E-4 stated that she went to get her medication cart to give R-1 her medications about 6:40 a.m. R-1 was not by the desk and E-4 thought she might be in the bathroom and checked and she was not there. E-4 thought that R-1 had gone to her room and did not look any farther for her. E-4 said she heard the alarm ringing for about 10 minutes and thought itwas the night crew leaving so did not check the door. E-4 stated that the phone rang about 7:10 a.m. and the ambulance person told E-4 that R-1 had been found on the road and was being taken to the hospital. E-4 stated that this was the first she knew that R-1 was not in the facility. In interview with E-5 on 02-03-1999 she stated that the nurses were getting report at the nurses station and R-1 was seated in a chair by the nurses station between 6 AM and 6:30 AM. E-5 stated that the light and alarm went off on the front door and rang about 10 minutes. E-5 stated that she started down the hall to check on the alarm but she got stopped in the hall and the alarm went off before she got to it. E-5 stated that the phone rang about 7:10 a.m. and the caller reported that R-1 was found in the road. E-5 stated that she took a CNA with her and went to the scene to check on R-1. E-6 was interviewed on 02-03-1999 and stated that the nurses were getting report at the nurses station between 6 a.m. and 6:30 a.m. and R-1 was helping another resident straighten her sweater. E-6 said she got R-1 to sit down. After report E-6 went down the west hall to give Insulin and came back and heard the alarm. E-6 stated that she did not go down to check the alarm herself because she thought it was the night shift leaving. E-6 did not know how long the alarm had been ringing. The facility is located in a residential area and according to E-2 is very quiet with little traffic at the time R-1 left the facility. E-2 stated that there is a school in the area but usually is not much traffic until about 7:45 a.m. The surveyor checked the route that the facility supposed R-1 took to the area she was found in the road. R-1 would have to have crossed 1 intersection to the west of the facility and 2 intersections north of the facility. E-3 was interviewed on 02-03-1999 regarding a facility policy for elopements of residents from the facility and the facility had no specific policy regarding elopements. E-3 did state that 9 residents of the facility wear wanderguard bracelets and are at risk for wandering and eloping. An inservice was held on 01-29-1999 after the incident of 1-28-1999 regarding door alarms and wanderguards; but the policy does not address any method of checking the residents that are elopement risks or assuring that all residents are present in the facility when an alarm sounds and the cause of the alarm cannot be determined. In interview with E-1 he stated that the front door alarm has been a problem and that the facility is trying to get approval for mechanical key pad doors where the wanderguard alarm doors are presently located. Failure to provide adequate supervision for R-1 resulted in direct harm to R-1. R-1 sustained a fracture of the right wrist and a laceration and hematoma to the right lateral eye.