ROYAL HEIGHTS NURSING & REHAB CENTER
Facility I.D. Number 0041228 900
Royal Heights Road
Belleville, IL 62226
Date of Survey: 01/12/01
Incident Report Investigation of 12/08/00
Notice of Violation: 03/19/01
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.
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.
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, resident interview, staff interview, and record review, and review of facility's investigation, the facility failed to adequately supervise one resident sampled who was at risk for elopement (R-1). On 12/8/00, at approximately 11:00 a.m., R-1 eloped from the facility and the facility was unaware that he was not in the building or was unaware how he eloped from the facility.
1. On 1/11/01, at 8:50 a.m., R-1's medical record was reviewed in the conference room. According to his physician's order sheet, dated January 1 thru January 31, 2001, he has the following diagnosis: Seizure Disorder, Anxiety, Schizophrenia, Arteriosclerosis, Osteoarthritis, Organic Delusional Disorder, COPD, History of Alcohol Abuse, Hypertension and Dementia. R1 was admitted to the facility on 05/04/89.
On 1/11/01, at 9:00 a.m., R-1 was observed in his room sitting in a chair at the foot of his bed. He was wearing two urine saturated adult diapers and was trying to put on men's underwear over the diapers. He had his shoes on the wrong feet. The certified nurses assistant attempted to have him stand but had difficulty. He was aware of his name but was not aware of time or place.
On 1/11/01, at 9:30 a.m., R-1 assessment was reviewed in the conference room. The assessment dated 9/25/00, noted the following: R-1 had short and long-term memory problems, moderately impaired decision making skills, periods of restlessness, episodes of disorganized speech, unsteady gait and had fallen in the past 31-180 days. On 1/11/01, at 9:40 a.m., R-1's care plan was reviewed in the conference room. His care plan dated 10/13/00, noted that he was at risk for elopement and wanders throughout the facility. His care plan interventions included the following: Wander guard on at all times and check each shift, redirect away from doors, monitor whereabouts at all times, follow facility protocol on elopement procedures, security to monitor whereabouts, encourage activities, and redirect as needed. His care plan also noted that he was at risk for falls and had an unsteady gait. His care plan interventions for this problem included the following: Encourage resident to stand up and face forwards to watch were he is going; tell him to slow down if he is running; monitor for changes in his gait; monitor floors and keep free of clutter; assist resident with ambulation as needed; ensure proper fitting footwear; review medications; toilet every two hours and as needed; and place call light within reach.
On 1/11/01, at 9:45 a.m. R-1's social service assessment note, dated 10/11/00, was reviewed in the conference room. The social service designees noted the following: Resident continues to wander throughout facility hallways.
On 1/11/01, at 9:50 a.m., R-1's nurses notes were reviewed in the conference room. His nurse's note, dated 12/8/00, 9:02 a.m., noted the following: "(R-1) observed wandering near front door wander guard alarm set off staff walked behind resident and returned him to his unit at 9:03 a.m."
On 1/11/01, at 10:00 a.m., an incident investigation report, dated 12/8/2000 was reviewed in the conference room. The incident report noted that at "10:55 a.m.", R -1 was observed in front of the nurses station by E-5. At "11:00 a.m"., R-1 was standing near the nurses station, observed by E-6. At "11:04 a.m.", E-2 was in front lobby when passer by requested receptionist to assist with getting R-1 out of her car. E-2 assisted R-1 out of woman's car back into the facility. He was wearing a sweat shirt and pants, white socks and brown shoes. The report noted that the temperature was "55 to 65 degrees Fahrenheit".
On 1/12/01, at 9:00a.m., the National Weather Bureau at St. Louis Lambert Airport was contacted by phone. According to the National Weather Bureau, the temperature on 12/08/00 at around 11:00 a. m. was approximately 33 degrees F.
On 1/11/01, at 11:20 a.m., an interview was conducted with E-7 in the Medical Director's office. He said on 12/8/00, at around 11:00 a.m., he was supervising the residents who smoke outside the facility. He said he was paged. As he made his way towards the front lobby he saw nursing staff going towards the lobby. He saw R-1 coming back into the building. He said no alarms went off alerting the staff that R-1 was out of the building and the alarm pad did not show that anyone had left the building. He said all door alarms were checked and were operating correctly. He said he was not sure where or how R-1 got out of the facility.
On 1/11/01, at 11:45 a.m., an interview was conducted with E-1 and E-2 in the conference room. E-1 and E-2 said they were not sure how R-1 got out of the facility on 12/8/00. E-1 noted the alarm system may have been in the "cycle down mode" when R-1 left the facility. E-1 explained the "cycle down mode" was a mode on the alarm system that could be activated by entering a specific code onto the alarm system keypad. She said this code deactivates the alarm for approximately four minutes. E-1 said the facility identified the alarm system had the capacity to go into the "cycle down mode" shortly after the incident occurred. She said the alarm system was reprogrammed and the "cycle down mode" was removed from the alarm system shortly after the incident occurred.
On 1/11/01, at 11:45 a.m., an interview was conducted with E-2 in the conference room. She said that on 12/8/00, at around 11:00 a.m., she was sitting at the 100-hall nurses' station. She said a staff person asked her what the "Cycle down mode" meant and then showed her the keypad for the alarm system. E-2 said the keypad screen noted "Cycle down mode" but she was not sure what this was. She said she then walked to the lobby. At this time, she saw a woman talking to E-3 and telling E-3 she had found R-1. This woman said she put R-1 into her car and brought him back to the facility. E-2 said that no alarms went off during this time to identify that R-1 had left the building.
On 1/11/01, at 12:00 p.m., an interview was conducted with E-3 in the conference room. She said on 12/8/00, she worked as the receptionist from 8:00 a.m. until 12:00 p.m.. She said she did not leave the lobby area during this time. She said she did not see R-1 leave the facility at 11:00 a.m. and that no alarms went off during this time. E-3 said that sometime after 11:00 a.m., a woman came into the facility and told her that she had picked up a male and placed him in her car and questioned if this male was a resident at this facility. E-3 said that male was R-1.
On 1/11/01, at 1:20 p.m., an interview was conducted in an office across from the 100- nurses' station with E-5. She said that on 12/8/00, at approximately 11:00 a.m., she was sitting at the nurses station. She said that she was having another conversation with a female resident and this female resident kept talking to R-1. She said at no time did the alarm system go off noting that R-1 had left the building. She said that she had heard something about a "cycle down mode" but was not sure what that meant. E-5 stated "she believed staff brought (R-1) back into the building around 11:15-11:30 a.m., and (R-1) does ambulate with an unsteady gait throughout the building".
On 1/11/01, at 2:00 p.m., an interview was conducted with E-8 in the conference room. E-8 said he saw R-1 on 12/8/00 at about 11:00 a.m.. E-8 said R-1 was standing at the nurses station at this time. E-8 said "at about 11:07 a.m. he was walking up to the lobby and noticed that staff were bringing R-1 back into the building". E-8 said " he had been working at the facility for about one week when the incident occurred". E-8 said " he was unaware that R-1 was an elopement risk".
On 1/12/01, at 10:45 a.m., an interview was conducted with E-6. She said that she was working on 12/08/00 when R-1 eloped. She said that she was not aware that R-1 had left the building. She said that she had called security several times regarding the "cycle down mode" on the keypad of the alarm system and was told not to worry about it. She said that R-1 does walk slumped over.
On 1/11/01, at 4:45 p.m., the area around the facility was surveyed for possible hazards. There is a two lane road directly in front of the facility that is frequently traveled by automobiles. There is a school directly south of the facility. There is a large drainage ditch approximately 6 to 7 feet deep with a large culvert at the sidewalk that runs between the nursing home property, and the school property. Facility staff believe that R-1 was found by the unidentified passer by near the driveway of the school closest to the drainage ditch. There is a large four lane highway 2 blocks north of the facility.