SHAWNEE CHRISTIAN NURSING CENTER
I.D. Number: 0025619
1901 13TH ST.
HERRIN, IL 62948
Survey Date: 1/26/2000
Incident Report Investigation
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 resident's 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 were not met on 1/18/2000, as evidenced by:
Based on record review and staff and resident interview the facility failed to prevent the elopement of one confused resident from the facility.
R1 is an 84-year-old female, with a diagnosis of Dementia with Alzheimer's type with Agitation, Major Depressive Disorder, Psychosis, and Gait Disorder.
R1's most recent assessment, dated 1/17/2000 indicated her cognitive status as moderately impaired (decisions poor, cues/supervision required). R1 was coded with a behavior of wandering (occurring daily) and not easily altered.
R1 was assessed as being independent in transfer and ambulation.
Per review of incident report of 1/18/2000, record review and staff interviews, R1 did elope from the facility grounds on 1/18/2000. The facility was not aware of R1's elopement on 1/18/2000, until E5 returned R1 to the facility at 7:15 p.m.
E5 was interviewed and also provided, a written statement, that described the incident of elopement of R1 on 1/18/2000. It is as follows:
R1 was found to be walking south on North 13th Street, at approximately 7:15 p.m. on the 1800 block by E5 who was currently off duty. R1 was approximately 100 to 125 feet from the facility property line. R1 was only wearing a sweat suit and a sweater.
The street of North 13th, is a moderately traveled road, which can become fairly hazardous in regard to being a well-traveled street.
Per telephone interview with SIU Weather Center for 1/18/2000, at 7 p.m. was as follows: TEMPERATURE: 35 degrees. WIND: Out of the Northwest at 10 miles per hour. Per interview with E12, who was the 3-11 LPN on Side 1, when R1 eloped from the facility on 1/18/2000. E12, last saw R1 at 6:30 p.m. E12 was unaware that R1 had eloped from the facility, until E5 brought her to Side 1, at approximately 7:15 p.m., and E5 related to E12 that R1 had been found one and a half blocks from the facility.
R1 stated to E12 that she was starting to get cold. R1 also stated, "It's cold out there". Vital signs were: Temp - 99.7, P - 72, Resp. - 20 and B/P 140/68. There were no injuries to R1 at that time.
Per E12's verbal interview and written statement, it was ascertained that R1 had eloped out of the facility from Side 1 South door.
It was determined by E12 that E10 had not re-alarmed this door as per policy/procedure, for the employment of the Sentry door alarm system, earlier in the evening.
E12 interviewed E10 regarding the re-alarming of Sentry door alarm system and discovered that Side 1 South Door had not been properly activated to sound the alarm.
E12 inserviced E10 regarding policy/procedure for setting the Sentry door alarm and E10 gave a return demonstration on 1/18/2000.
Per written statement from E10, confirming the fact that she had not re-alarmed the Sentry door alarm system on Side 1 South Door as per protocol.
Per interview with R1, surveyor was unable to determine that she was capable of being safe and free from harm in an unsupervised situation. R1 was unable to comprehend the safety issues relating to traffic and crossing a road.
R1 did have a Wander Guard on her right ankle.
Per interview on 1/25/2000, R1 did not have any planned destination when she eloped on 1/18/2000. Side 1 South Door only has a Sentry Door Alarm, not alarmed for Wander Guard.
Therefore, on 1/18/2000 at approximately 6:45 p.m. R1 eloped from the facility thru Side 1 South Door. No one in the facility was aware that R1 was not in the facility, until an off-duty staff person, brought R1 into the facility at 7:15 p.m.
Per observations on 1/25/2000, the facility was properly following their elopement policy and all door alarms were functioning properly at that time.