Facility I.D. Number 0044743
No. 1 Poplar Drive
Sumner, IL 62466
Date of Survey: 07/24/01
Notice of Violation: 08/27/01
Incident Investigation of July 3, 2001
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.
An owner, licensee, administrator, employee or agent of a facility shall not neglect a resident.
These requirements are not met as evidenced by:
Based on record review, interviews and observation, the facility failed to provide adequate supervision by not monitoring a resident (R1) as indicated in the resident's assessment and care plan to prevent an elopement that resulted in injury, and by failing to make a complete assessment of R1's condition following the elopement and by not making a complete report of R1's condition to the physician.
R1 is a 75 year-old resident with diagnoses including Dementia, Insulin Dependent Diabetes Mellitus (IDDM), Transient Ischemic Attacks and Cerebral Vascular Accident. R1 is assessed as independent with transfer and ambulation. Cognitive status is moderately impaired requiring cues and supervision. On 7/3/01, R1 eloped without staff's knowledge between the hours of approximately, 6 p.m. and 8:05 p.m. R1 had been on a picnic outing earlier that day without incident. Per interviews, R1 received his evening Insulin injection around 5:30 p.m. It was after that, that staff stated they tried approximately 4 times to encourage R1 to get up from his bed and go out to the dining room for supper, the last attempt being around 6 p.m. At 8:05 p.m. staff out in the patio area cleaning up after an evening activity were notified by a neighbor of the facility on the Southeast side that there was a man seen coming out of the wooded area by the trailers. E2 (Certificated Nursing Assistant, CNA) and E5 (Activity Director, A.D.) noted it was R1. The wooded area is approximately 80 yards from the East entrance to the facility and 470 yards from the wooded area to the creek located Southeast of the facility. (This was measured by E6, the Maintenance person, on 7/24/01). E6 stated there were run-off areas where it was muddy in the wooded area. The street behind the facility near where R1 was found, is not a heavily traveled street. Staff further stated they saw R1 sit down on the ground, before they got to him. E2 and E5 escorted R1 back to the facility and seated him at one of the dining room tables. R1 was exhausted, disheveled, with mud on his person and clothing, and had some bruising under his right eye. E4, (Register Nurse, R.N.) in charge, was notified. E4 did not come and assess R1. R1 was then taken to the shower room and showered. Preparing R1 for the shower, E2 (CNA) and E3 (CNA) found that R1 was incontinent of bowel and bladder, had light bruising to his left shoulder, and had mosquito bites to his back, shoulder and arms. E2 stated he removed a tick from R1's scalp while washing his hair. Per the facility's investigation report, dated 7/5/01, R1 was attired in a knit polo type shirt, sweat pants, shoes, socks, briefs and a hat. The temperature was approximately 73 degrees. There had been rain in the area prior to this date (during the weekend per E6). R1 was on a 15 minute check which was not done from 6 p.m.-8 p.m. per staff interviews and record reviewed. According to interviews, all door alarms were working that day. Staff were unable to determine how or when R1 left the facility. Per the facility's Investigation Report, R1 was given his Insulin shot at 5:30 p.m. by E4. R1's blood sugar was 262 at that time. R1's blood sugar was taken after his return and was found to be 85. R1 had not eaten the evening meal. E3 stated she gave R1 a regular soda and a brownie. R1's next blood sugar taken 7/4/01 at 6 a.m. was 165. E4's (RN) nurse's note following the incident states "no signs of trauma." The Incident Report completed by E4, is dated 7/3/01, time, 6 p.m., physician notified at 8 p.m. (facility staff were not aware R1 was gone until 8:05 p.m.), body part involved was marked the "eye" and under treatment on the form, is written, "none required."
Interview with the physician, indicated he was aware of the elopement, but not aware of R1's blood sugar, bruising, the tick on his scalp and the mosquito bites. This was confirmed by E7 (Acting Administrator) on 7/24/01.