RIVER BLUFFS NURSING AND REHABILITATION CENTER

Facility I.D. Number 0042713
3354 Jerome Lane
Cahokia, IL 62206

Date of Survey 2/4/2000

Annual Survey/Complaint Investigation

The facility shall notify the Department of any incident or accident which has, or is likely to have, a significant effect on the health, safety, or welfare of a resident or residents. Incidents and accidents requiring the services of a physician, hospital, police or fire department, coroner, or other service provider on an emergency basis shall be reported to the Department.

Notification shall be made by a phone call to the regional office within 24 hours of each serious incident or accident. If the facility is unable to contact the regional office, notification shall be made by a phone call the Department's toll-free complaint registry number.

A narrative summary of each serious accident or incident occurrence shall be sent to the Department within seven days of the occurrence.

A descriptive summary of each incident or accident shall be recorded in the progress notes or nurse's notes for each resident involved.

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.

General nursing care shall include at a minimum the following and shall be practiced on a 24-hour, seven day a week basis:

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 each resident receives adequate supervision and assistance to prevent accidents.

Based on staff interviews, record review, information received from police department, and information received from local hospital; facility failed to adequately supervise one resident in the sample to prevent an elopement from the facility on 04/04/1999. Facility also failed to investigate the incident, and failed to report incident to IDPH.

Findings include:

1. R1 is a 52-year-old with diagnosis of delusional psychosis, organic affective disorder, paranoid schizophrenia, depression, seizure disorder, CAD, osteoarthritis, HTN, sinus tachycardia. Per MDS assessment, this resident is moderately impaired for decision-making ability, has both long and short term memory problems, exhibits wandering behavior, verbally and physically abusive behavior, socially inappropriate behavior, disorganized speech. This resident had been assessed by the facility as an elopement risk.
   
   On 04/04/1999, at 5:30 a.m., the Cahokia Police Department received a call from this facility to report a missing resident. The Police Officer with the Cahokia Police Department responded to the facility and spoke with Z1. Z1 reported R1 was discovered missing. Employees had checked the interior and surrounding exterior of the building and were unable to locate the resident. R1 was last seen wearing a maroon colored house coat. The Cahokia Police were unable to locate R1.
   
   At approximately 7:30 a.m., R1 was located in Monroe County, Illinois, which is approximately 17 miles from this facility. R1 was discovered lying down on a median, next to the highway. R1 was transported via ambulance to the nearest hospital, which was St. Clement Hospital in Red Bud, Illinois. Upon evaluation by the emergency room physician, the following notation was made:
   

   "...Brought in by ambulance, being found on the road about 20 miles away from the nursing home. The staff at the home reported her missing since 5 a.m. today. Pt. is not oriented in time and place...and not answering questions. Was cold and all covered in mud ... only knows her name."

   
   Vital signs obtained in the emergency department are recorded at 11 a.m. BP 140/88, P 80, R 20, T 94.4. Emergency department diagnosis is: confusion/hypothermia/multiple injuries. X-rays were obtained of cervical spine, right and left knee. There was no evidence of fracture on any x-ray. EKG, and CBC with differential, urinalysis, were all obtained in the ER with no abnormal results. R1 was given 1000cc IV warm normal saline, and returned to the facility late in the afternoon.
   
   Weather information for 04/04/1999, was obtained from Scott Air Force Base Weather Center. Weather Center states that 04/04/1999 temperature at 7 a.m. was 61 degrees, calm, no rain.
   
   Surveyors entered the facility 01/25/2000, to do annual survey and 7-day complaint which included above-stated information. Facility administrative staff was asked to bring all information regarding elopements for the previous year. Facility administrative staff brought one incident report, dated 12/13/1999, which stated that R1 attempted to leave the facility on that date, had been observed by staff in the parking lot of the facility, and was brought back into the facility. Surveyors requested additional information regarding R1, were told by the DON, and Consultant Nurse (who had been facility administrator at the time of the incident), that neither "could recall" any other incidents involving R1. Surveyors then obtained a copy of the police report from Cahokia Police Department, which indicated R1 was reported missing by facility staff, Z1. St. Clement Hospital in Red Bud, Illinois, was contacted and report from emergency room for 04/04/1999, was obtained. Facility administrative staff (DON and consultant nurse) continued to deny any knowledge of this elopement. There was no evidence of investigation of this elopement by the facility. The incident was not reported to the department, verified by a phone call to the local IDPH office.
   
   During extended survey, 1999 inservices for staff were reviewed. Only one inservice (dealing with door alarms being monitored) was done. This inservice was dated 05/03/1999. Inservice was attended by 18 CNAs. There were no other inservices dealing with elopement issues until surveyors communicated concerns to the facility.
   
   
2. Based on interviews with previous and current staff the facility failed to adequately supervise one resident, (on two separate occasions), to prevent the resident from eloping, and failed to conduct an investigation or notify IDPH of the incidents.
   
   R6 is a 64-year-old male with diagnosis in part of severe COPD, schizophrenia, tobacco abuse, and CHF.
   
   During a confidential interview with two previous employees of this facility, it was stated by both employees that R6 had eloped from the facility earlier in 1999. No exact date could be given, however it was stated that "between the last week of April and the 10th of May 1999". R6 had left the facility some time between 7:00 a.m. and 9:00 a.m., and was found by the facility staff up on the interstate trying to "walk to the Jefferson Barracks Bridge". R6 was approximately 2-miles from the facility, and was talked into coming back to the facility, by the former staff reporting this incident.
   
   Per a second confidential interview with former staff, it was reported that this incident was investigated and a report given to the acting administrator in May 1999.
   
   Per confidential interview with current housekeeping staff it was stated that; she and the former staff person did go out and retrieve R6 from Hwy 255 and Mousette Road earlier this spring after he had walked away from the facility, and that R6 was brought back to the facility by herself and another staff (former employee). Current staff stated a Code Yellow had been called for this resident.
   
   Per interview with the Administrator, DON, and Facility Consultant, it was revealed that they had no knowledge of this elopement. There was no documentation of this incident in the resident's chart. No documentation that a report had been filed with IDPH for this period of time in 1999.
   
   During discussion of R6's 1999 elopement incident, the Facility consultant, and social worker stated that although they had no knowledge of the 1999 incident, they did know about and were involved in a elopement of this same resident in August 1998. Social services worker stated she saw the resident walking along the side of Interstate 255, while she was driving in to work that a.m. Social Services stated she went to the facility to inform them she saw the resident, and was accompanied by a (now ex-employee) staff to retrieve R6. Social Services stated that the police were called to assist as the resident was refusing to return, how ever they could not help because resident was responsible for himself. Social Services states that the resident did eventually return with her to the facility, and signed out AMA.
   
   However, there again is no documentation of this incident in the resident record in 1998, there is no copy of a signed and dated AMA for 1998, and there is no documentation that IDPH was notified of the above incident in either 1988 or 1999.
   
   
3. Based on record review, staff interview, the facility failed to adequately implement procedure to prevent further incidents from occurring.
   
   R15 with diagnosis in part dehydration, sepsis, sacral decubitus. Review of clinical record, and incident report revealed on 01/12/2000 at 1:30 p.m. R15 was found on the floor beside the bed with half side rail up. R15 sustained two lacerations to forehead measuring 2.3x0.4 and 2.0x0.2. R15 care plan was updated on 01/22/2000 and fall was not addressed on plan of care.
   
   Interview of staff, told Surveyor R15 bed rails was changed to full bed rails. No assessment found to reflect R15 was assessed for full bed rails.
   
   
4. Based on record review, staff interviews and observations, it was noted that the facility does not always provide adequate supervision of one additional resident with a history of wandering out of the facility.
   
   R23 has a history of wandering out of the facility. On 11/14/1999 at 2:15 p.m. R23 was "discovered" by nurses aides to be outside lying on the ground under the bushes. (Per the incident report completed by the attending nurse).
   
   R23 was assessed as being very confused, lethargic and has a shuffling gait. A partial investigation was done by the DON, which revealed that the door alarms were not answered in a timely manner to prevent the resident from falling once outside the facility.
   
   On 02/04/2000 interview of the nurse in charge at the time of the incident revealed that "no door alarms sounded when R23 left the facility."
   
   On 01/28/2000 R23 again got out of the building and traveled approximately 50 yards to the rear of the building across an ice/snow pile, icy pavement, and snow covered yardage. Only one staff responded to the resident exiting the building and after the resident became combative, this staff left the resident unattended outside as she returned to the building for assist in getting R23 to return.
   
   R23 has diagnoses of glaucoma with highly impaired vision, hypertension, Alzheimer's, diabetes, psychosis, aggressive behavior, seizure disorder and is at risk for falls. Per interview of charge nurse, R23 can become combative and may need two or three staff to get him to return to the building.