Facility I.D. Number: 0012765
414 S. Wesley Av.
Mount Morris, Illinois 61054
Survey Date: 03/09/2000
Annual Licensure Survey
The facility shall have written policies and procedures, governing all services provided by the facility. These written policies shall be followed in operating the facility.
The facility shall maintain a file of all written reports of serious incidents or accident involving residents.
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 resident's 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.
Based on observations, interviews, and record review, the facility failed to provide safety and supervision for the residents by failing to:
R27 and R28 are both residents of Pinecrest Terrace (The Facility's Alzheimer and a Special Care Dementia Unit). On 03/08/2000 there were 28 residents on the unit. All doors on the unit are alarmed. There is an automatic entrance door that requires staff assistance to exit the unit.
On 10/08/1999 at approximately 6:30 a.m., R27 and R28 both eloped from the Terrace Unit. Staff verified that R27 and R28 are not aware of their surroundings and require a safe and secure environment.
Review of R27's March 2000 Physician Order Sheet identifies R27's diagnosis as Alzheimer's Disease with Aggressive Manifestations. R27's Minimum Data Set(MDS) of 10/05/1999 identifies R27 as having short and long term memory problems and being moderately impaired in cognitive skills for daily decision making. R27 had behaviors of wandering, verbal and physical abusive behavior, socially inappropriate behaviors, and resisting care. These behaviors occurred 4-6 days in the last 7 days and the behaviors were not easily altered.
The MDS identifies R27 as being independent in transfers and ambulation. The care plan of 10/06/1999 states, "He exhibits altered thought process...For safety and supervision he needs a secure unit/environment."
Review of R28's March 2000 Physician Order Sheet identifies R28's having diagnoses of but not limited to Dementia Alzheimer's, Hypertension, Arthritis, and Osteoporosis. The MDS of 12/17/1999 identifies R28 as having long and short term memory problems and as being moderately impaired in cognitive skills for daily decision making. R28 has behaviors of wandering and socially inappropriate disruptive behavior that occur daily and are not easily altered. R28 is independent in transfers and ambulation.
Review of the incident report on R27 dated 10/18/1999 stated, "Resident with female peer managed to leave unit and residents took walk across property and down country road - this resident fell and skinned his knees, hands, and left side of cheek - found by staff and returned to building."
CNA charting for 10/08/1999 stated, "Resident was found approximately ½ mile (from facility) hand in hand with another resident walking down the street. He had fallen in a ditch and had cuts on his fingers, face, and knees. See nurse's notes."
The nursing note written on 10/08/1999 (6:40 - 7:30) states, "Resident up early - ambulating halls with female peer - entering others rooms and setting off door alarms at end of halls multiple times - approximately 0645 received call informing that residents seen outside of building - nurse and CNA went looking for the residents when this resident found, he had fallen. Abrasions on both knees, hands, fingertips, and cheek - was returned to unit and abrasions cleaned and bandaged."
During an interview on 03/08/2000, E20 stated, "We had assumed that R27 and R28 had left through the front door. No one in the facility knew they were gone. They walked to the end of the road where it became gravel (Verified by E8). About 6:45 a.m. someone called to report that they saw the residents outside."
"The night nurse had left the unit around 6:30 a.m. and we think that the residents went out when she left the unit."
During interview with E25 on 03/09/2000, E25 stated, "I came to work around 6:40 a.m. and I was told that the residents were off the unit. The unit had done a head count and R27 and R28 were missing. I went out the Terrace exit, up to the road and I didn't see anyone on the road but I didn't have my glasses on. A white car came down the road and stopped and told me that there was a gentleman down the road and he needed help. I drove down the road and saw R27 lying on the left side of the road in a ditch. There were two young kids with him. R28 was standing next to him. It was a nice day and I wasn't wearing a jacket. R27 and R28 were dressed in appropriate clothes. E8 arrived in the truck and took R27 back to the facility and R28 rode with us in the car."
At 1:30 p.m. E8 and E25 drove surveyor to the spot where R27 and R28 were found on 10/08/1999. It was clocked on the surveyor's car to be a distance of 7/10 of a mile.
It is assumed that R27 and R28 left through the door of the Terrace when a staff member failed to wait 15 seconds until the door closed. R27 and R28 then proceeded out the front door of the Terrace and walked up to the roadway, turned right and walked approximately 1 block to where the road became a gravel road. There are no sidewalks on this country road. There is a drainage ditch on both sides of the road and there is evidence that corn and soybean fields were on both sides of the road for approximately 4/10 of a mile.
The Resident Elopement policy states, "The automatic unit entrance doors on Pinecrest Terrace have a 5 second pause while they are opened. Special care should be taken to ensure that our residents do not wander to areas where they would be unsafe during the 5 seconds that the door is open."
On 03/08/2000, the automatic door was checked and it took 15 seconds for the door to open and close. This was verified with E9.
There is no documentation that an investigation of this incident took place. There is a lack of documentation of when the residents were last observed on the unit and when they first were noted to be absent.
During and interview with E8 and E9 on 03/09/2000, they stated that on 10/08/1999 around 7:00 a.m. when the residents had been returned to the unit, E8 and E9 had maintenance check all the alarms on the unit and all were functioning perfectly.
They stated that immediately after noting that the residents were missing they interviewed E27 who stated that she had not waited for the door to close when leaving the unit so they assume that was how R27 and R28 left the unit.
E27 and the rest of the staff on the unit were immediately given verbal reminders about staff responsibility to make sure that the door closes when exiting.
During the survey, there was a sign on the door reminding staff to be sure the door closes after they exit. This sign has been in place since the facility opened the unit.
During interviews on 03/09/2000, E8, E9, E25, and E20 all stated that there have been no other residents that have successfully exited through this automatic door.
The facility failed to follow their policy and procedure for completing incident and accident reports. Review of the incident report of 10/08/1999 for R27 lacks the time and date that the doctor was notified of the elopement and injuries. The names and titles of witnesses of the elopement were not included in the report. The steps to prevent further elopements were not identified. The facility failed to notify Illinois Department of Public Health of the elopement and injuries.
An incident report was not made out for R28 who had eloped from the facility on 10/08/1999 with R27.