FAIR OAKS HEALTH CARE CENTER
Facility I.D. Number: 0043422
1515 Blackhawk
South Beloit, Illinois 61080
Survey Date: 10/01/99
Complaint 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.
Personal care shall be provided on a 24-hour, seven day a week basis.
The DON shall oversee the nursing services of the facility including:
Planning an up-to-date resident care plan for each resident based on the resident’s comprehensive assessment, individual needs and goals to be accomplished, physician’s orders, and personal care and nursing needs.
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 regulations are not met as evidenced by:
Based on observation, record review and interview the facility failed to:
a) have all exterior doors alarmed or provide visual control at all times;
b) supervise a resident with a Wandergard;
c) revise resident's care plan to address wandering/Wandergard;
d) assure that all staff is aware of a resident's use of a Wandergard;
e) follow its own policy and procedures on Missing Residents and Elopements.
The findings include:
R1 has diagnoses to include Compression Fracture, HTN, Dementia, and Parkinson's Disease. On 9/30/99 at 10:15a.m. R1 was observed to be wearing a Wandergard around the ankle.
On 9/30/99 at 10:35a.m. a visitor informed facility staff that R1 was across the street at the flower shop.
Visitor indicated that she visits her relative at the facility every day and that is why she knows R1's name.
R1 was returned to facility by staff after being notified by visitor at approximately 10:40 a.m.
R1 had to cross a busy 4-lane highway with a grassy median between the lanes. The temperature was 48 degrees at 9a.m. according to a lighted sign at the bank down the street. The highway is about 100 feet from the facility.
E3 was asked to check door alarms with surveyor. The back outer right door did not alarm when opened by E3. E3 thought that the door did not alarm due to a hearse parked by the back door.
E3 indicated that the front and back doors have motion sensors (outside) on them that disarm the door alarms for 5 seconds to allow entrance from the outside without triggering the door alarms. The motion sensor picks up motion up to 10 feet from the door. E3 also indicated that the inner front and inner back door have Wandergard system on them but the back door Wandergard system was in need of repair since 9/22/99 and was not functioning on 9/30/99.A part that was needed had not arrived as of 9/30/99.
E2 indicated that all departments- administration, nursing, activities, social services- had been notified of the non-functioning Wandergard system on 9/22/99.
E1 was asked when did she become aware of the broken Wandergard system on the back door and E1 indicated on 9/22/99 or 9/23/99. E1 was asked what procedure was put in place to assure the safety of the wandering residents due to the broken Wandergard system. E1 indicated none.
R1's room is located 4 rooms down from the door staff believed she exited from and is 2 rooms away from another exit door.
R1's physician orders are;'Can leave facility for MD appointments only-Can not leave facility for home visits with family.'
Review of R1's physician progress notes regarding her mental status are as follows:
7/20/99 (R1) is confused.
7/21/99 (Neurologist) There are times (R1) is considerably better oriented, not the case now, but usually (R1) is quite demented as is the case at the present time.
Neurological examination shows that she is quite demented, in fact unable to provide me with any history, unable to answer any questions pertaining to degree of orientation, language... (R1's) mental status can best be stated as saying that (R1) is alert and demented. Her diagnosis at the present time is Alzheimer's disease.'
8/26/99 (R1's) mental status same.'
Review of R1's medical record reveals no documentation of R1's Wandergard or when it was applied. E1 verified this and other staff also did not know when R1's Wandergard was applied.
R1's care plan does not address a wandering problem, confusion or the Wandergard. E1 verified that R1 is confused.
E4 indicated that R1's care planning was held on 9/24/99 by E5 as E4 was out on medical leave. E4 indicated that when E4 contacted E5 as to why Wandergard was not addressed on care plan, E5 indicated she was not aware of R1's Wandergard.
R1's nursing assessment of 9/23/99 for cognitive skill for daily decision-making reveals that R1 is moderately impaired; decision making poor; cues/supervision needed.
Attempts to interview R1 revealed that R1 is confused and at times R1 would ramble when asked if family visits.
Z1 and Z2 indicated that R1's mental status is confused and her judgement skills are poor, impaired and were surprised that R1 got out. R1 is there because of impaired judgement. R1 needs supervision and has to go out with someone. Z2 indicated,( "R1) could have been killed."
The facility did not follow its own policy and procedures which states: