ILLINOIS MASONIC HOME
Facility I.D. Number 0010249
One Masonic Way
Sullivan, IL 61951
Date of Survey:06/07/01
Notice of Violation: 08/06/01
Incident Report Investigation of May 19, 2001
The number and categories of personnel to be provided shall be based on the following: Amount and kind of personal care, nursing care, supervision, and program needed to meet the particular needs of the resident at all times.
General nursing care shall include at a minimum the following and shall be practiced on a 24- hour, 7-day a week basis: 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.
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.
Every existing facility shall have each exterior door equipped with a signal that will alert personnel in the area if a resident leaves the building. Any exterior door that is supervised during certain periods during the day or night 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 the following:
Based on observation, record review and staff and resident interview, the facility failed to supervise the dining room on 5-19-01 and failed to maintain the auditory paging system connected to the door alarm system for Collins 1 resulting in one resident (R1) leaving the unit unknown to staff and sustaining a fractured humerus.
Record review reveals that R1 was admitted to the facility on 10-26-91 and is 83 years old. R1's diagnoses include Alzheimers Disease, History of Circulation Disease, Depressive Disorder, Anxiety state, Coronary Artery Disorder, and Type 2 Diabetes. The assessment for R1 dated 2-27-01 identifies problems of judgement, impairment of expression and understanding, impaired problems with memory and decision making, restlessness, mental function varies, resists care, wandering behavior, tries to exit facility, needs no assistance with ambulation, but does need assistance with dressing, eating, bathing, bowel and bladder.
Care Plan of 2-27-01 identifies concerns of self care deficit, wandering, and cognitive impairment.
Observation of R1 in the dining room on 5-31-01 reveals that there is a yellow and reddish bruising on the left forehead and also on the left forearm. Upon attempting to talk to R1, she is unable to answer appropriately.
The facility accident/incident report of 5-19-01 at 4:55 p.m. reveals that R1 "got outside through dining room doors and fell. [Electronic signaling device] on left ankle intact. Patient found lying on right side per staff.. Complains of right shoulder, right knee pain. Small abrasion noted to forehead. Paramedics present and performed first aid. Investigation of incident initiated. Resident sent to ER via ambulance for evaluation."
Interview with E3 on 5-31-01 at 10:45 a.m. revealed that R1 was noted leaving the dining room by R2 on Collins 1 between 4:48 p.m. and 4:52 p.m. on 5-19-01 and was not found by staff until 6:08 p.m.--1 hour and 20 minutes later.
Facility investigation report and interview with E3 on 5-31-01 at 10:45 a.m. reveals that the dining room on Collins 1 was unsupervised from 4:48 p.m. to 4:52 p.m. on 5-19-01 while staff was assisting a resident from her room to the dining room. Interviews with E1, E2, E3 on 5-31-01 at 4:15 p.m. and interviews with E7 and E8 at 2:00 p.m. confirms this information. Interview with E7 on 6-4-01 at 2:15 p.m. reveals that she did leave the dining room unsupervised for a few minutes to help another resident. When returning to the dining room R2 told E7 that R1 had exited out the alarmed dining room door. This leads to an unoccupied and unalarmed part of the building. Interview with E6 on 5-31-01 at 3:45 p.m. revealed that when she was walking through the dining room on the way to her own supper break, she noted that there was no staff present in the dining room on 5-19-01 at approximately 4:40 p.m. but E6 failed to intervene or report this. E6 also stated that the alarm was not sounding at that time. Interview with E8 on 6-4-01 at 2:30 p.m. reveals that her responsibilities on 5-31-01 was to pass medication, administer treatments, and assign the 3 aides and 1 RA(bed maker) to their supper breaks. E8 states the supper breaks should have been done differently to make sure resident needs could be met.
Review of the Incident report reveals that R1 left the dining room on 5-19-01 between 4:48 and 4:52 p.m. and the door alarm did sound when R1 opened the door. The secondary system that failed is a computerized auditory paging system that announces the specific door that is opened, it's location, and this auditory page is heard throughout the building. Interview with E1 on 6-4- 01 at 11:00 a.m. reveals that this system has not been working since 5-14-01. The facility is working to find a specific part that this system needs to fix it. When R1 got beyond the Collins Building, she was in an unoccupied part of the building that has no alarmed external doors, as these are waivered.
There are two ponds on the grounds. There is a pond on the east side of the building where the Collins building is located. This pond is #1 pond and is 78 feet wide and 750 feet long and is 3 feet deep. The #2 pond is 240 feet wide and 660 feet long and 5 feet deep. R1 was found beyond these 2 ponds, approximately .2 of a mile from the Collins Building on a gravel road that is east of the big barn on the property. Tour of the grounds with E3 on 5-31-01 verified these locations.
The injury that R1 sustained per xray report of 5-19-01 reveals "There is an impacted comminuted fracture through the anatomic neck of the humerus." R1 did return to the facility with a sling in place, an order for oxygen at 2 liters, pain med as needed.