Statement of Violation

ROSEWOOD CARE CENTER OF PEORIA

I.D. Number: 0035352
1500 W. NORTHMOOR ROAD
PEORIA, IL 61614

Survey Date:3/06/2000

Complaint Investigation 0020800, 0020816

"A" VIOLATION:

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.

Objective observations of changes in a resident's condition, including mental and emotional changes, as a means for analyzing and determining care required and the need for further medical evaluation and treatment shall be made by nursing staff and recorded in the resident's medical record.

Each facility shall:

Maintain all electrical, signaling, mechanical, water supply, heating, fire protection, and sewage disposal systems in safe, clean and functioning condition. This shall include regular inspections of these systems.

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 requirements are not met as evidenced by:

A. Based on observation, employee interviews, resident interview, incidents report review, policy review, hospital report review, and record review the facility failed to provide adequate supervision, monitoring of exit alarm systems and failed to ensure staff monitor the whereabouts of one of four sampled residents which allowed the resident to elope from the facility unnoticed by staff and resulted in the resident being injured and hospitalized for six days.

B. Based on record review, policy review, and interviews, it was determined the facility failed to provide necessary care to attain or maintain the highest practicable physical level for 1 for 4 sampled residents by not adequately monitoring and assessing a residents condition following a fall.

Findings include:

During an interview with the facility Administrator, and review of the facility incident report, and record review of R4, it was discovered on 1/25/2000 between 5:15 a.m. and 5:20 a.m., R4, an eighty-one year old female resident admitted to the facility on 1/03/2000 was discovered lying on the ground concrete driveway, in a pool of blood one-hundred-eighty (180) feet away from the facility by a first shift employee coming to work. R4 was conscious, responsive and wearing only pajamas and slippers when discovered. An employee, a certified nurse aide, discovered R4. She had another CNA with her remain with R4 while she went inside to get a nurse.
At 5:20 a.m. the employee and a third shift registered nurse came out with blankets to cover and attend to R4. The nurse called 911. The emergency medical transport arrived at 5:27 a.m. and took R4 to the hospital emergency department at St. Francis Medical Center.
A review of the hospital ER report, dated 1/25/2000, indicated R4 had a temperature of ninety-nine (99) degrees F. and documented the presence of a nasal fracture. Report reveals R4 returned to the facility the same a.m., then returned to the hospital at 12:10 p.m. the same day due to a deterioration in condition. The resident was admitted to the hospital and remained there for 6 days.
Contact with the National Weather Service in Lincoln revealed on 1/25/2000, the recorded outside temperature in Peoria was between plus twelve (12) degrees Fahrenheit and plus twenty-four (24) degrees F., and there was two (2) inches of snow on the ground and a trace of snowfall on that date.
Interview with the facility director on nursing and the third shift RN on the 300-400 wing and review of the employee reports concerning the incident revealed:

a) It was unknown by staff that R4 had exited the building.

b) It was not directly known how the resident exited the building.

It was further established through interviews that none of the staff involved during the incident heard any alarm signals during the time of this incident to indicate someone had exited or entered the facility.

6. Interview with the facility's RN on duty on the 300-400 wing, conducted in the a.m. of 3/02/2000, revealed it was believed R4 had exited the building through the employees entrance/exit door, located across the hall from the 300-400 Wing nurses station, and they knew for a fact the employees exit door alarm was turned off since they had arrived at the facility the evening before for their shift.

7. Further record review and interview with the third shift RN on the 300-400 wing indicated R4 was last observed at 5:10 a.m., seated in the assisted dining room on the 300-400 wing, watching television. This is located fifteen (15) feet from the employees exit door.

8. Review of the initial MDS, Dated 1/08/2000 for R4, indicated R4 has:

1) "short-term memory problem",

2) "modified independence in decision-making",

3) "is to require limited assistance with ambulation", and

4) "has history of previous falls."

9. Review of R4's care plan, dated 1/13/2000, indicated R4:

1) "wanders within the facility with potential to harm self and others as evidenced by attempts at elopement."

Care plan approaches include:

1) "photo posted at both nurses stations and front desk, to follow elopement policy and procedures",

2) "visual checks to redirect as needed."

Also cited in the care plan is "altered thought process as evidenced by forgetfulness to place and time", and that R4 "requires one (1) assist for ambulation, has poor balance, and mental function fluxuates."

10. Review of nurses notes, dated 1/16/2000 through 1/25/2000, indicated R4 was on occasion, "confused", "couldn't remember date, time, or facility name", and "couldn't remember date, day, or time of day." An entry in the nurses notes, dated 4:30 a.m. on 1/25/2000, indicated R4 ambulated out of room with shirt on only."

11. Observations during tour of the facility in the p.m. of 2/28/2000 revealed all of the exit alarm systems in the facility to include the employees exit door alarm were activated and functioning properly. It was also noted at that time the exit door and the inner hall door leading to the employees exit were functioning properly. It was further noted the exit door alarms have to be individually activated at a panel located at each of the nurses stations. After an alarmed exit door is opened, and the alarm begins to sound, the alarm must be

a) manually shut off at the nurses station,

b) manually reset at the nurses station.

12. Observation made during the a.m. of 2/28/2000 revealed there were photographs of R4 posted at both nurses stations and the front desk. Interviews with staff at all three locations revealed they were aware that the photos at the nurses stations and the front desk related to residents who were targeted as wanderers and who may be at risk for attempting to elope from the facility.

13. According to staff interviews, conducted in the a.m. of 2/29/2000 and a.m. of 3/02/2000, the exit door alarm for the employees exit was not turned on during the time R4 left the building in the a.m. of 1/25/2000. They also indicated the alarm was not activated because there was an inner door that had a keypad locking device attached to it which must have a code punched into the keypad in order to open the inner door leading from the inner hall through a short hall to the outer employee exit door which was alarmed. These interviews further indicated that at times this inner door did not latch properly which would allow someone to open the door without having to unlock the door with the keypad.

14. Two unsuccessful interviews were attempted with R4 by two different surveyors, on 2/28/2000 and 3/01/2000. R4 was unable to recall any specifics of the incident and sometimes gave answers unrelated to questions asked.

15. On 1/25/2000, at about 0520 hours, R4 wandered outside the facility and fell in the parking lot. R4 was sent to the hospital Emergency Room and diagnosed with a nasal fracture and facial abrasions and cuts. R4 returned to the facility at 0900 hours. A Nurses note at 0915 hours documents the presence of and description of the facial injuries, and that R4 was uncooperative. Further assessment was not done.

16. There is no further documentation of monitoring R4's condition until the development of projectile vomiting at 1125 hours. At that time, the only assessment of R4 consisted of taking vital signs.

17. 911 was called and R4 was sent back to the hospital ER for evaluation (the second ER visit that day).

18. There is no evidence of assessment or monitoring of R4's condition following the return to the facility for 2 hours and 25 minutes, when R4 developed projectile vomiting.

19. Per review of the second ER visit report and R4's record, R4 was admitted to the hospital and remained there for 6 days. The hospital report documents the additional diagnosis of a subdural hematoma.

20. Interviews done with E1 and E2 on 3/01/2000, confirm the lack of documented evidence of monitoring R4's condition upon return from the first ER visit on 1/25/2000.

21. Review of the facility's policy on "Neurological Checks" indicates when any incident which MAY have caused a head injury or trauma, the nurse will implement neurological checks and initiate the Neuro Check Form. The policy was not followed as there were no Neuro checks done on R4, and no Neuro Check Form initiated.