LIVINGSTON MANOR

Facility I.D.0010942
Rural Route 1
Pontiac, IL 61764

Date of Survey: 10/02/01

Notice of Violation: 10/30/01

Incident Investigation of September 15, 2001

“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.

Overseeing the comprehensive assessment of the resident’s needs, which include medically defined conditions and medical functional status, sensory and physical impairments, nutritional status and requirements, psychosocial status, discharge potential, dental condition, activities potential, rehabilitation potential, cognitive status, and drug therapy.

Planning an up-to-date resident care plan for each resident based on the resident’s comprehensive assessment, individual needs and goals to be accomplished, physician’s orders, and personal care and nursing needs. Personnel representing other services such as nursing, activities, dietary, and such other modalities as are ordered by the physician, shall be involved in the preparation of the resident care plan. 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. The plan shall be reviewed at least every three months.

These requirements are not met as evidenced by:

Based on observation, interview and record review, the facility failed to provide adequate supervision for 1 of 5 sampled residents (R18) requiring supervision without an electronic monitoring device, failed to adequately monitor the front entrance of the facility while the door alarm was off and failed to accurately assess 1 of 10 sampled residents (R18) requiring supervision for risk of unnoticed absence from the facility.

This failure resulted in R-18 leaving the facility without the knowledge of facility staff on 9/15/01 between approximately 11:30 a.m. to 12:10 p.m.

Findings include:

1. Review of the current physician order sheet confirms that

R-18 has the following diagnoses: diabetes, anemia, transient ischemic attacks and hypertension. The nursing assessment dated 8/23/01 confirms that R-18 has a short term memory deficit and has modified independence with decision making. R-18 is assessed as knowing the current season, location of her room, staff names and faces and that she is in a nursing home. R-18 is assessed as independent with transfers and ambulation. R-18 is assessed on 8/24/01 to be at low risk for elopement. The care plan dated 8/29/01 does not reveal any approaches addressing R-18's attempts to leave the facility prior to 9/15/01.

Review of the nurses notes in R-18's record and staff interview reveal the following information:

"5/7/01-Res attempted to go out back door of facility. States, 'I was looking for my ride home'."

"7/6/01 at [4:15p.m.] sister here to visit [R-18] today. Concerned with res-res[R-18] voicing wanting to go home. Intimated that she would hitchhike/thumb sign when asked how she would get home. Assured sister all doors alarmed and we would keep an eye on her." E-11, the nurse, stated in interview on 9/27/01 at 10:35 a.m. that she did not think she told anyone of R-18's sisters concern; that she thought she put the information on the shift note.

"7/12/01 at 4:15 a.m.-2[times] tried to go out front door at H.S.[hour of sleep] No attempts during the night." E-14, the Care plan nurse, stated in interview on 9/27/01 at 9:25 a.m. that she was not aware that R-18 had tried to leave the facility and if she had known she might have scored the elopement risk assessment differently on 8/24/01. Review of the elopement assessment reveals that when a resident is assessed as a high elopement risk an electronic monitoring bracelet is applied to the resident.

"7/24/01 at 10:35 a.m.-Res seen by [Z-1] r/t change in mental status."

Review of the physician progress note dated 7/24/01 reveals that R-18 was "seen on rounds in followup of some altered mental status. She has been slightly more confused than usual. CT scan ordered."

Further review of the nurses notes in R-18's record and staff interview reveal the following:

"9/15/01 at 10:00 a.m.-Res has been wandering about facility this a.m. In good spirits." E-15 the nurse stated during interview on 9/27/01 at 11:00 a.m. that she told E-16 the receptionist, to keep an eye out for R-18 as she was wandering that morning (9/15/01).

"9/15/01-At 12:10 p.m. today it was reported to staff that res was out on highway. Res found to be walking behind her w/c[wheelchair] on the side of the highway. Stated, 'I'm going home'. Taken to D.R.[dining room] for lunch. Elopement policy initiated. Security[electronic monitoring] bracelet placed on lt. wrist."

E-15 stated in interview on 9/27/01 at 10:45 a.m. that the driver of a delivery van had notified the receptionist that R-18 was on the shoulder of Highway 66 and that the receptionist then paged her. E-15 stated that R-18 told her that she was going home. E-15 and the surveyor went outside at 11:00 a.m. and E-15 pointed out where she saw R-18 standing on 9/15/01 at 12:10 p.m..The location was approximately 300 feet from the door of the facility. E-15 stated that R-18 had crossed Highway 66 and was standing on the far shoulder of the road with her wheelchair in front of her, like she'd been pushing it. E-15 stated that R-18 had no visible signs that she had fallen. E-15 stated that R-18 seemed vague, but happy at the time. When asked if she {E15} thought that R-18 knew where she was, E-15 stated, "No".

Highway 66 runs in a north/south direction in front of the facility. The facility sits to the west of Highway 66. R-18 was found on the east side of Highway 66 on the shoulder of the road. The shoulder of the road was observed to be gravel and approximately 2 inches below the road surface. At 11:00 a.m. on 9/27/01 automobile and semi truck traffic was observed on the highway. The posted speed limit is 55 miles per hour.

When asked if he thought that R-18 had any safety awareness, Z-1, the physician, stated in interview on 9/28/01 at 10:15 a.m. "I have my doubts about whether she[R18] thought she was in any danger that day". Z-1 also stated that R-18 is better on some days than on others.

E-2 and E-7, both titled the Directors of Nursing, stated in interview on 9/27/01 at 10:00 a.m. that they were not aware that R-18 had tried to leave the facility on 3 occasions before 9/15/01. E-2 stated that R-18 did not normally try to exit the facility and that she viewed that behavior as unusual for R-18. E-2 stated that if she had been aware of R-18's prior attempts to exit the building she would have put an electronic monitoring bracelet on her.

During interview on 9/26/01 at 3:50 p.m., R-18 was able to accurately recall her birthday, that she had a daughter in California and that she lived in Forrest, but was staying here at the facility. R-18 stated she did not remember the incident on 9/15/01 or being on the highway.

Review of the Folstein Mini Mental Status Examination dated 12/11/00 reveals that R-18 scored 26 out of 30 possible points. A score of 24 or above is considered normal mental function. Review of nurses notes reveal that R-18 had a decline in mental status documented on 7/24/01. E-1 the Administrator confirmed in interview on 9/27/01 at 10:00 a.m. that a Folstein Mini Mental Status Examination had not been done following R-18's change in mental status.

E-4, an activity aide, stated during interview on 9/27/01 at 2:00 p.m. that R-18 was very confused the morning of 9/15/01 and was wandering up and down the halls. E-4 stated that R-18 was "antsy" all morning. E-4 stated that she did not think that R-18 was aware of the danger of being hit by a car.

E-5, a CNA(certified nurse aide), stated in interview on 9/27/01 at 1:00 p.m. that R-18 seemed to be more confused on 9/15/01, like "she was in her own world".

E-2 stated in interview on 9/27/01 at 11:30 a.m. that she had interviewed all the staff in the facility working the day shift on 9/15/01 but was unable to say for sure how long R-18 had been out of the facility. E-2 stated that she thought R-18 might have followed a family out of the front door at approximately 11:30 a.m. E-2 stated that dietary staff said that R-18 did not show up for lunch that day. E-2 stated that when E-15 called her it was about 12:10 p.m. E-2 stated, "In my mind it was a 45 minute period that she[R18] wasn't accounted for."

E-15 stated in interview on 9/27/01 at 10:45 a.m. that she had seen R-18 at 11:00 a.m. down on the B-wing. R-18 resides on the A-wing.

E-12 the certified nurse aide (CNA) assigned to R-18 that day stated in interview on 9/27/01 at 12:00 p.m. that she usually checks on her residents before she goes to lunch and thought that she saw R-18 in the hallway at 11:30 a.m. on 9/15/01.

E-1, the Administrator, stated in interview on 9/27/01 at 9:15 a.m. that the front exit door is audibly alarmed with a wander security system which alarms if a resident wearing an electronic monitoring bracelet gets too close to the front door. E-1 stated that the front door is also alarmed with a door alarm that is turned off at 8:00 a.m. and back on at 9:00 p.m. E-1 stated that the front door is supervised and monitored by the receptionist from 8:00 a.m. to 9:00 p.m. seven days a week E-1 stated that the receptionist is relieved by other staff for breaks and lunch. When asked by the surveyor that if the front door was being supervised at all times by the receptionist when the door alarm is off, then how did R-18 get out of the facility, E-1 replied, "[R- 18] had the right to go out of the facility as she wasn't assessed as a high elopement risk".

E-16, the receptionist, stated in interview on 9/27/01 at 10:25 a.m. that R-18 did not have an electronic monitoring bracelet on, and she did not see her go out of the facility as there were a lot of visitors coming in and out of the facility and the phone was ringing a lot that day (9/15/01). E-16 stated that she was told that the ones with the bracelets on were the ones to be concerned with.

On 9/27/01 at 2:30 p.m., 3:00 p.m., 3:20 p.m. and 3:25 p.m. the receptionist was observed to leave the front door unsupervised. The receptionist left her desk by the front window and took the surveyor to an office to use a phone. The area was not monitored for several minutes each time the receptionist was away from her desk. At 2:30 p.m. three residents without electronic monitoring bracelets were observed to be present in the front lobby.