ROCKFORD HEALTHCARE CENTER
Facility I.D. Number0039610
310 Arnold Ave.
Rockford, IL 61108
Date of Survey:04/12/01
Notice of Violation:06/18/01
Incident Investigation of 03/24/2001
The facility shall provide a Resident Services Director who is assigned responsibility for the coordination and monitoring of the resident’s overall plan of care. The Director of Nurses or an individual on the professional staff of the facility may fill this assignment to assure that residents’ plans of care are individualized, written in terms of short and long range goals, understandable and utilized; their needs are met through appropriate staff interventions and community resources; and residents are involved, whenever possible, in the preparation of their plan of care.
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 needs of the resident.
All necessary precautions shall be taken to assure that the residents’ environment remains as free of accident hazards as possible. All nursing personnel shall evaluate residents to see that resident receives adequate supervision and assistance to prevent accidents.
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.
These regulations are not met as evidenced by:
Based on observation, interviews and record reviews, the facility failed to:
a) monitor the whereabouts at all times of a confused resident who is a known wanderer per R1's care plan to prevent the elopement of 3-24-01; and
b) develop a specific, aggressive, individualized plan of care to prevent further elopements.
This is for 1of 5 residents identified by the facility as being at risk for elopement. This resulted in R1's leaving the facility unnoticed by staff and on a cold day (24 degrees) and in a location near a large, busy intersection.
The findings include:
1) R1 has diagnoses of Alzheimer's, Dementia and Depression per review of R1's Physician Order Sheet of April, 2001.
R1 was assessed 6/10/00 as severely impaired in cognition and behavior of wandering occurred 4-6 days, but not daily, and R1's behavior was easily altered. R1's assessment of 9/5/00, 12/3/00, and 3/4/01 assesses R1 as being severely impaired in cogniton and behavior of wandering occurred daily and was not easily altered. R1 was also assessed on these dates as being independent in ambulation.
Review of R1's nurses' notes reveals 9 documentations of R1's wandering and exiting the facility between 12/13/00 and 3/23/01.
2) R1's Nurses notes reveals:
'3/24/01 5:45 P.M.- Received phone call from a nursing home facility stating resident was walking around outside. (R1) was returned to facility at 6:05 P.M. accompanied by two police officers. (R1) was taken to his room and body audit was done... Family called and informed that (R1) was found walking outside across the street... Staff had noted visitors here in the facility visiting with other residents. (R1) was noted last ambulating from South Dining Room (SDR) area toward front lobby. (R1) apparently had left out front door when visitors left. Door alarm on front door was not set off. (R1) also had been noted by charge nurse in South Dining Room maybe 20 minutes before phone call received...As charge nurse passed out meds in SDR door to back parking lot did not alarm. (R1) was unable to give explanation as to where he was even going outside.'
R1 has had numerous attempts to leave the facility and was on the outside on 2 occasions prior to the elopement of 3-24-01 and has exited the facility once since his elopement.
3) Review of facility's incident report of 3-24-01 reveals:
'(R1) eloped from facility. Returned to the facility without injury. Investigation in progress.'
Review of facility's investigation report of 3-29-01 reveals:
'At approximately 5:45 P.M., the facility was made aware of a resident that had eloped from the facility. (R1) was returned to the facility without further incident. The investigation revealed that the door alarm in one of the hallways was not functioning properly. It was revealed that one of the wires that trigger the alarm was wearing away. Our Maintenance Director immediately replaced this wire; furthermore, the facility checked the wiring on all alarmed doors in the building. These were found to be up to standard, so no additional replacement was needed. As a precautionary measure to prevent this from occurring again, the facility has placed checking the wiring, as part of the preventative maintenance schedule.'
4) On 4/05/01 at 9:30 A.M. E4 checked all the facility's door alarms on tour. E4 indicated that all door alarms were checked on a monthly basis. Review of facility log record for these checks revealed that the door alarms were checked on the following dates: 7/26/00; 8/9/00; 9/13/00; 10/9/00; 11/7/00; 12/25/00; 01/10/01; 02/7/01; and 3/27/01.
E4 indicated on 4-05-01 at 3 P.M. in the DON's office that the last door alarm check was later in the month because he had been ill and off work. E4 checks the door alarms daily now since R1 eloped.
5) On 4/05/01 interviews were conducted in the Director of Nurses' Office with the following: 8:30 A. M.- E1 stated, "(R1) has Alzheimer's; is a frequent wanderer; is on Risperdal; tried to leave several times; left out of front door possibly with a visitor; returned by police; found across the street". E1 was asked what clothing R1 had on when he left the facility on 3-24-01. E1 indicated she was not sure.
11 A.M.- E3 stated, "It's possible (R1) left when visitors left. Once code is in, there is a 15 second delay and (R1) may have left during that time. Not sure if he left through A-Wing door or if he left with visitors. (R1) had either sweats or jeans on. The facility does not use electronic monitoring devices".
On 4-05-01 at 1:35 P.M, R1 was observed sitting in the front lobby. R1 was asked questions to determine his cognitive status. R1's answers were incoherent and rambling.
On 4-05-01 at 2:45 P.M., Z1 was interviewed by telephone. Z1 stated, "(R1) has been out more than once. He's been out on several occasions and has had to be brought back in. (R1) absolutely does not have good survival skills. (R1) is pretty demented and survival skills are zero".
Review of R1's care plan reveals the approaches addressing R1's attempted elopements have not been revised since 6-14-00.
6) The weather report obtained on line (www.wunderground.com/history) on 4-04-01 revealed the following for the weather on 3-24-01:
Mean temperature 23.5 degrees Fahrenheit (F)
Max temperature 28.4 F degrees F
Minimum temperature 17.6 degrees F
Wind Speed 14.96 miles per hour
Maximum Wind Speed 17.26 miles per hour
Telephone interview with E2 on 4-06-01 at 3 p.m. revealed that R1's clothing on 3-24-01 consisted of sweat pants, flannel shirt, undershirt, socks and shoes.