ROBINGS MANOR NURSING HOME
Facility ID Number: 0026716
502 North Main
Brighton, Illinois 62012
Survey Date: 9/13/99
Annual licensure and incident investigation
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.
This requirement was not met as evidenced by:
Review of the "INCIDENT REPORT FORM-IDPH NOTIFICATION" revealed R33 on 8/24/99 at 9:45 p.m. eloped, as was found outside the facility.
Review of the "INVESTIGATIVE GUIDELINES FOR ELOPEMENT/MISSING RESIDENTS" revealed the following regarding R33: diagnoses of Dementia and Arteriosclerotic Heart Disease, ambulatory speed walker, identified as an elopement risk, usually exits door #1 into fenced-in back yard, wears a safety alarm device, care plan addressed elopement plan, out of facility approximately 25 minutes, occurred at 9:50 p.m.-shift change, was found at 10:15 p.m. by a previous CNA 3/4 of a mile up the road with no injuries, safety alarm on resident working properly, unknown how he left the facility, all staff inserviced 8/25/99 at 2:00 p.m., and is to have 30 minute visual checks.
Review of the documentation letter sent to IDPH revealed the following. A resident was found outside of the building 3/4 of a mile up the road. He was out of the facility approximately 20 minutes. He was returned to the facility completely unharmed and safe. On 8/25/99 at 2 p.m. an inservice for all staff was conducted on door alarms and the importance of getting to them quickly. Staff were informed that they need to go out the door and double check the grounds and point of exit. Physician and family were notified. As part of the in house approach facility will do visual counts of their assessed elopement risk resident every 30 minutes.
Review of R33's clinical record revealed the following: admitted 9/10/99, date of birth 3/6/10, and diagnoses of CVA, Dementia, Arteriosclerotic Heart Disease and Atrial Fibrillation. R33 takes Plavix 75mg daily, Risperdal 1mg twice daily and Trazodone 50mg ½ tablet four times daily. Review of the annual assessment dated 8/13/99 revealed R33 to have a long and short term memory problem; is severely impaired cognitively; mental function varies over course of the day; usually is understood and understands; wanders daily and behavior is not easily altered; physically abusive behavior occurred 1 to 3 days in the last 7 days and behavior is not easily altered; resisted care 1 to 3 days in the last 7 and behavior is not easily altered; independent in ambulation; dependent on one staff for dressing, toilet use, personal hygiene and bathing; sitting and standing balance -partial physical support during test or stands (sits) but does not follow directions for test; and frequently incontinent of bowel and totally incontinent of bladder, no change since last year's annual.
Review of the nurses notes from 5/14/99 to 9/7/99 revealed the following documentation:
5/19/99 12:10 p.m. - resident continues to pace to and from doors setting off alarms-difficult to redirect-becoming agitated at times-resident walking with fast gait-unable to slow resident down, 1:00 p.m. - physician notified of increase in behavior;
5/20/99 1:05 p.m. - Resident continues to wander to doors setting off alarms- redirection with explanation unsuccessful; 5/22/99 10:30 p.m. - resident continues to set off door alarms earlier in shift. Became agitated when trying to redirect;
6/11/99 - "Monthly Goal Documentation" Resident feeds self regular diet in dining room eating almost 100% of meals. Ambulates throughout facility without assist. Often opens doors and sets off alarms. Has to be coached back inside. Needs assist with daily activities of daily living, dressing etc. Has short and long term memory loss. Resident is incontinent;
8/3/99 - "Monthly Goal Documentation" continues to have long and short term memory loss-needs redirection by staff. Resident paces frequently and tries to exit facility, setting door alarms off. Returns to facility with staff assist without difficulty;
8/11/99, 9 p.m. - Resident has been agitated this evening. Resident has ran out 200 hall getting as far as fence. Resident "balls fist & shakes at staff when brought back in. Res. has went out door x 7 on this shift".;
8/24/99 10:30 p.m. - resident found walking north on sidewalk on highway 67. Resident returned to facility per CNA. DON notified. Physician notified. 10:48 p.m. - "VS 95.4, 80, 24, 206/98. No injuries noted.;
8/25/99 - Notified family after complete investigation of incident. "I told her that I needed to investigate completely. I called the ex-cna who returned him to the facility unharmed." Family member very understanding & stated, "I know what you all are going through he boggied by `butt' many of nights.";
8/25/99 2 p.m. - VS 97.1, 78, 20, 138/72 "out 200 exit door x1. returned inside per staff, ambulating independently, good appetite on both meals, incontinent of bladder, peri care per staff.";
8/26/99 1 p.m. - Resident has been out of facility x 4 this shift. Has become very agitated upon coming back into facility.; and
8/27/99 2:00 p.m. - setting off door alarms on 200 hall-returned to hall 200.
Review of the Behavior Resident Assessment Protocol (RAP) revealed, "WILL PROCEED TO CARE PLAN AND ADDRESS BEHAVIORS THROUGH EPISODIC AREA OF CARE PLAN, RESIDENT WANDERS TO DOORS AND OPENS THEM, AT TIMES WILL SHUT DOOR BUT HAS BEEN KNOWN TO LEAVE BUILDING, WEARS WANDER GUARD AT ALL TIMES, WILL USUALLY STOP IF STAFF CALLS TO HIM AND ASKS HIM TO STOP, DOES NOT RECOGNIZE DANGERS TO SELF." Review of the Falls RAP revealed, "WILL PROCEED TO CARE PLAN FOR PREVENTION OF FALLS, RESIDENT AT PRESENT TIME HAS STEADY GAIT, NO SIDE EFFECTS FROM MED. USE TO INCREASE RISK FOR FALLS AT THIS TIME, RESIDENT DOES WALK AT A FAST RATE WHEN HE IS WANDERING HALLS AND HAS HAD FALLS IN THE PAST."
Review of the PSYCHIATRY PROGRESS NOTES dated 7/17/99 revealed the following documentation. Patient tried to get out of the exit door today but was redirectable. He was on his way to the other door but was able to call him and get his attention. He's able to engage in 1 on 1 conversation. He said that he is doing fine. He is able to respond to few questions but for the most part has significant delay in responding. Diagnosis of Dementia with delusions with depressed mood with psychotic features. Diagnoses of Depressive Disease, Schizoaffective Disorder and Bipolar Disease with Psychotic features. Risperdal 1mg twice daily and Desyrel 25mg four times daily.
Review of the "Elopement Risk Assessment" revealed 7/29/99 resident has poor decision making skills; has a history of elopement, wandering/history of wandering; has inability to identify safety needs; has altered perception; has increased agitation at times; and has a diagnosis which may lead to elopement high risk for elopement.
Review of R33's care plan revealed he elopes, sets off door alarms-does not always attempt to leave, worse during nice weather, does not recognize dangers to self, and is easily redirected but repeats behavior due to short term memory losses. Goal to decrease number of times resident tries to elope from the facility to one time weekly by 10/28/99. Approaches are to redirect to activity or escort to inner courtyard weather permitting, wander guard at all times, offer snack, ask if he needs bathroom and escort him there as usually does not know where it is, and staff to make visual checks of all residents of known elopement risk approximately every 30 minutes and prn if door alarm sounds.
Review of the facility's wandering list revealed R30, R33, R36, R4, R3 and R52 are a high risk for eloping; wear a wanderguard; are on 30 minute visual checks and prn if door alarm sounds; and they have elopement risk assessment in care plan area.
Review of the staffing schedule for 8/24/99 revealed 6 staff on the evening R33 eloped from the facility. Staffing revealed 3 nurses and 3 aides were working with 3 of those staff still employed at the facility.
Interview of 2 nurses working the evening of 8/24/99 revealed staff responded immediately to the door alarm but could not see anyone outside. Staff then started to do a head count and before they were finished an ex employee brought R33 back to the facility.
Interview of the Administrator revealed the resident wears a code alert bracelet but the code alert alarm is only on the front door. The Administrator stated this resident walks very fast and it was dark out then he exited #5 door so he was not seen when the staff answered alarm and looked outside and ex CNA saw the resident and brought him back to the facility. Administrator believed resident went across Main Street and then north on Route 67 and did not believe he crossed the highway. It all happened in 15-20 minutes. Administrator stated the resident has a tendency to go out door #1, which is enclosed, or door #5. This resident lives on the 100 hall. Door #5 is on the other side of the building at the end of the hallway which goes along the dining area, door to kitchen and by the beauty shop.
Review of the facility "ELOPEMENT/MISSING RESIDENT POLICY AND PROCEDURE" revealed it is the policy of the facility that reasonable precautions are taken to prevent resident elopement. Reasonable precautions include, but are not limited to, door alarms, wrist alarms and staff interventions. All staff shall be trained and in-serviced on an annual basis in how to operate and respond to alarms, proper resident intervention, and search techniques. Any staff member, regardless of department, who becomes aware of an activated exit or wrist alarm is required to respond immediately. Any person employed in the facility may be required to participate in locating an eloped or missing resident. In the event that a resident is found to be missing the following procedures must be initiated: staff will immediately notify the charge nurse; report to the charge nurse for assignment; conduct a search of the facility including under beds, in closets, bathrooms, storage areas, laundry and maintenance areas, outside buildings, inside parked cars and the entire grounds; search neighborhood streets and yards within 4 blocks of facility if resident not located on facility premises; continue and expand the search until the resident is located and returned to the facility.
Observation from the facility to where the resident was found 8/24/99 revealed it to be approximately 3/4 mile. Approximately ½ mile has a sidewalk and the rest of the distance is grass with fairly deep ditch before the highway edge, if the resident did cross Main Street and then go north as per interview of the Administrator.
Observation throughout the days of the survey revealed the resident to walk very rapidly about the facility. Resident would go into the conference room and walk rapidly around the table 4 or more times before going out the door and would never say a word to people sitting at the table.
Interview of the resident periodically throughout the survey revealed him to say ok when asked how he was feeling but would not carry on any form of conversation and gave no answer when asked if he ever went outside.
Staff did not fully search grounds of facility when door alarm sounded but just looked out and by the door, thereby could not have seen resident. Staff were aware this resident frequently tried to leave the facility by this exit.