Facility I.D. Number: 0036061
610 LOWRY STREET
PITTSFIELD, ILLINOIS 62363
Survey Date: 11/3/1999
Incident Report Investigation
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.
These regulations are not met as evidenced by:
R1 was a 78 year old individual who had resided at this facility since 1/97. R1 diagnoses included: Alzheimers, status post non-Q wave MI (Myocardial Infarction), Hyperglycemia, rule out Hemachromatosis, Prolapsed Uterus, and Coronary Artery Disease. Of note is that R1 was at risk for falls and did have a history of wandering.
R1 had resided in the special care unit of this facility (Alzheimer's Unit) until 7/16/99. R1 required hospitalization at this time due to deep vein thrombosis. R1 returned to this facility on 7/20/99. R1 was receiving coumadin therapy for her deep vein thrombosis and aspirin 5gr daily for her coronary artery disease. R1 was placed in a skilled bed.
R1 was moved to an intermediate care bed on 8/27/99 (not the Alzheimer's Unit). Per review of nurses, notes, R1 was confused and was unable to use the call light. R1 was to ask for assistance when she wanted to get up, but would often just get up on her own.
Nurse's note of 8/23/99 says "2p alert & confused amb/self enc to call staff non-compliant R/T (decreased) cognitive abilities. BLE discolored (both lower legs) when standing denies pain/disc..."
Nurse's note of 9/6/99 indicates "10 a.m. care plan progress notes - Res whereabouts is known by staff et must be monitored very closely for res. Does get up out of chair et ambulate. Is encouraged to sit down (with) ext. elevated. Skin is in gd. Condition (without) breakdown...is confused et disoriented..".
R1's care plan identified R1 as being at "...high risk for elopement/wandering..." and "...at risk for falls...related to: confusion, wandering, DX, alzheimer's dementia, unsteady gait, need for assist with ADL's edema in lower extremities, does not ask for help..."
Excerpt from nurse's notes are as follows:
"9/14/99 11:30 a.m. Staff member noted res go out through front doors brought back in (without) incident..."
"9/14/99 2 p.m. Res attempted to go out front door x 2. Redirected & has been combative + argumentative (with) redirection..."
"9/15/99 3 p.m. Attempted to go out front door x 3 + side door x 1..."
"9/17/99 2 p.m. noted attempt to go out West service door x 1 this shift. No agitation or combative behavior..."
"9/21/99 1:30 p.m. found on floor in DR. CNA called writer to DR (no) apparent injury. denies pain or disc. gd ROM..."
"9/23/99 2 p.m. attempted to go out front door didn't know why. Redirected amb about facility ad lib..."
"9/25/99 12:30 a.m. res bed alarm went off found res ambulating ad-lib (down) 200 hallway. LPN assist res back to room took to BR et back to bed (without) incident..."
"9/26/99 1:50 p.m. Pike Co. Sheriff's Office called asking if our facility was missing an elderly lady on Jill Street et took her to the hospital - officer states res. States her name is (R1's first name) - checked wandering resident list et noted (R1) to be on the list @ some time (local hospital) called asking if we were missing an elderly lady (with) the 1st name of (R1's first name) et needed information on this lady immediately. This writer contacted staff to East Hall where res. resides & unable to locate res. Hospital describes clothing res. Is wearing & staff member to East Hall states "Yes, that is the shirt (R1's first name) had on." (Local Hospital) wants information faxed immediately to (emergency room) & asked for oral report (with) report given of (history), medication, allergies + M.D. Report then faxed to (local hospital) E.R. of medication, code status et last admission noted...hospital wants someone to come to hospital to identify. (Director of Nursing) notified of above et will go to hospital to identify. Res was noted by staff member to be in D/R eating dinner @ 1:30 pm (with) no alarm sounding to notify staff of anyone coming into facility or leaving facility..."
Review of R1's Emergency Room record revealed that R1 arrived at the emergency room at 1359 with facial trauma and bleeding. CT scan was completed and revealed a sub-dural hematoma. R1 was intubated and condition declined. Family determined no heroics were to be done. R1 was pronounced dead at 1615 (per interim death certificate).
Interview of E3 revealed that she was the Administrative Staff on call on 9/26/99. E3 came to the facility as soon as she was called. E3 stated that all alarms were on and functioning upon her arrival. E2 was also called; E2 went directly to the hospital to attempt to identify R1.
E3 stated interviewing all staff that were on duty during R1's elopement.
E5 last saw R1 at 1:30 p.m.
E6 last saw R1 at 1:30 p.m. because E6 removed R1's silverware and bib.
E5 was vacuuming the dining room area by 2 p.m.; R1 was not in the dining room at that time. Also, a male and female stopped and came into the facility and told E5 that there had been a woman found over on Jill Street and wondered if she might have been from this facility.
Interview of Z1 revealed that Z1 and R1's family had discussed the risks versus benefits of R1 receiving coumadin and aspirin. Z1 indicated that a fall any place could've rendered the same results with R1.
However, Z1 indicated that the facility had been neglectful in that R1 had not been placed back in the Alzheimer's Unit. Z1 indicated that this would not have changed that potential outcome of a fall, but that she couldn't have gotten out of the facility. Z1 indicated that he had not specifically ordered the Alzheimer's Unit, but that the facility had always been good about putting individuals that needed those cares and supervision there.
The facility did have R1 screened for readmission to the Alzheimer's Unit on 9/16/99. Based on this screening, it was determined that R1 was a "Stage 4" Alzheimer's and would not benefit from the programs in the unit.
Per E2, it was felt that the unit would've put R1 more at risk as many of the individual's there pace; it was feared that those people might run into R1 or push R1 causing her to fall. (Yet R1 was already acknowledge to be at risk for falls. Due to her non-compliance with requesting assist for ambulation, an order was requested and received from her M.D. to allow her to be ad lib as she could not be kept in a chair or a recliner anyway).
This surveyor walked from the facility front doors over to Jill Street. To accomplish this, one must walk across the sloping front lawn of the facility, across Lowry Street (not a main thoroughfare, but fairly busy at times), across a small park, then one is present at Jill Street. Walking at a steady, although not fast paced, it took this surveyor a complete five minutes to get from the facility to Jill Street. The distance covered was approximately 1/4 mile. The terrain of these areas was noted to be grassy and rough. The park had areas of mole runs present.
There are some apartments across Jill Street from the park; it's believed that someone from one of these apartments called for the ambulance for R1; the ambulance is a part of the local hospital system.