SUNSET MANOR NURSING HOME
Facility I.D. Number 0041996
129 S. First Ave.
Canton, Illinois 61520
Date of Survey 1/12/2000
First Health Revisit to Annual
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 the safety of residents at all times, such as but not limited to: nonslip wax on floors, safe equipment, assistive devices properly maintained, and proper use of physical restraints and adaptive equipment.
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.
Based on observations, record review and interview with facility staff it was determined the facility failed to provide adequate supervision to R11, and failed to utilize the existing door alarm effectively so as to prevent accidents.
This failure resulted in R11 leaving the facility without the knowledge of facility staff on 12/20/1999 from 11:10 p.m. to 11:50 p.m.
Examples of findings follow:
R11 has a diagnoses of chronic schizophrenia, dysphagia and a cataract on the right eye. Review of the physicians plan of care for December 1999 reveals that R11 has the diagnosis of "poor eyesight and impaired judgement."
The MDS (Minimum Data Set) dated 10/26/1999 reveals that R11 is independent with ambulation and transfers, has impaired short and long-term memory, is moderately impaired in daily decision making, and that R11 wanders 4 to 6 days per week, and is physically abusive and resists care 1 to 3 days in the last 7 days.
The annual physical exam dated 06/16/1999 states, "Alert and orientated x 1. He seems to have poor judgement skills and lack of insight." Facility staff assessed R11 as a high elopement risk on 10/15/1999 and 12/22/1999. The narrative portion of the elopement assessment states, "R11 is a high risk for elopement. He has a very short attention span-wanders-paces."
R11's physician orders on 12/13/1999 state, "Monitor patient as an elopement risk."
Interview with E10 on 01/11/2000 at 12:30 p.m. reveals that R11 is "very forgetful, if he got a block from the facility I do not believe he would find his way back. He might know enough to get away, but may not know enough to get back." Interview with E9 on 01/11/2000 reveals the following: "I would consider him confused, in my opinion if he got out I think he'd be lost, not able to find his way back."
R11's care plan dated 10/15/1999 identifies R11 with the problem behavior, "R11 is a potential to leave facility unattended." The short term goal is listed as: "not leave facility unattended." The approaches are listed as follows:
Nurses notes dated 12/20/1999 at 11:50 p.m. reflect the following:
"Successfully eloped at 2330; notified per police dept(Canton) of possible resident amb by local bar. Picked up by police officer and returned to facility at this entry. Notified D.O.N. of current status; no status changes noted after nursing assessment performed. Redirected to bed and given/covered with several blankets to re-warm resident. T 97.5 P-66 R-24 118/64. Day-shift staff to advise POA/M.D. of status."
Interview with E9 on 01/11/2000 at 12:55 p.m. reveals the following, "They did rounds about 11:00 p.m., between 11:10 to 11:15 p.m. I got a call from the police that one of our residents was seen walking a couple of blocks from the facility. I sent an aide to check. The police told me the person was wearing a gown. We started a room to room search and in the process discovered that the B-wing door alarm was disengaged. At that point the police brought R11 back."
Interview with E9 reveals that R11 was wearing a facility gown, shoes and socks when he was returned to the facility by the police. E9 stated, "Police found him a block from the facility. I did a full body assessment, he was obviously cold, no bruises, he was alert and communicating. By my best guess I would estimate he was gone 15 to 20 minutes. It was pretty cold that night."
The following information was received from the Illinois State Water Survey Weather Data regarding the temperature, wind chill and precipitation for December 20, 1999 between 11:00 p.m. and 1:00 a.m. at the Peoria Airport:
12/20/1999 at 11:00 p.m. the temperature was 8 degrees, with a 5 mile per hour wind and wind chill of 4 degrees.
12/21/1999 at 1:00 a.m. the temperature was 6 degrees with a wind of 7 miles per hour and wind chill of minus 5 degrees.
There was 0.01 inches of precipitation between those hours.
Interview with E2 on 01/12/2000 revealed that she instructed E9 on 12/20/1999 at approximately 12:00 a.m. to check all the door alarms in the facility to make sure they were active.
Interview with E1 and E2 on 01/11/2000 at 10:30 a.m. revealed that their investigation on 12/21/1999 revealed that they believed R11 left the facility through the the back door of the B-wing. E1 stated staff were turning off the door alarm of the B-wing back door to go out and smoke. E1 revealed that staff are only to go through the locked door to the basement exit to go out to smoke.
Interview with the Canton Police on 01/11/2000 at 11:00 a.m. reveals that a police report was not filled out on the incident.
Review of facility staffing reveal that there were 4 staff present in the facility at the time of the incident on 12/20/1999.
Observation in the facility reveals a 2 story facility with residents residing on both floors. The second floor doors leading to the stairwells are alarmed with battery operated alarms which have to be reset with a key manually when they alarm. On the first floor the exterior exit on the A-wing is equipped with battery operated alarms which have to be reset with a key manually when alarming. The B-wing (Alzheimer's unit) front and back exterior doors and 1 interior door are equipped with battery operated door alarms which have to be manually reset with a key when alarming. The B-wing also has an unalarmed door which leads to a small sitting room and then to the main dining room. The main dining room is located off of the front entrance of the building. The front entry door is equipped with a Wander Guard alarm and will not alarm unless the resident is wearing a Wander Guard bracelet.
Interview with E1 reveals that the front door is supervised during the day by office staff, but after 5:00 p.m. and on weekends, the front door does not receive constant supervision.
Interviews with E1, E2 and E9 reveal that the back B-wing(Alzheimer's unit) alarm was found to be "disengaged" on 12/20/1999, and it is believed to be the point that R11 exited the building.
Review of the log for checking of door alarms for December 1999 reveals that the entries are sporadic. On 12/16/1999 the "B-side" door alarm was checked and not rechecked again until 12/23 and 12/24/1999 according to the facility log.
Interview with E11 on 01/11/2000 at 3:30 p.m. reveals that he has been checking the door alarms in the facility daily but has not been keeping a log of the alarm checks. E11 reveals that he changes the batteries in the alarms routinely and does keep a log of the battery changes.
Review of the door alarm policy reveals that door alarms are to be used at all times to ensure resident safety and security, and that under "no circumstances can any door alarm be turned off."
Interview with E2 reveals that all residents are assessed for elopement risk and those identified as at risk for elopement are given Wander Guard bracelets. The facility has 6 residents currently using the Wander Guard system.
Interview with E2 and E12 on 01/12/2000 reveals that although staff have been checking the Wander Guard bracelets daily, there is no documentation prior to 01/12/2000. There has been no written policy addressing the need to check the function and verify the placement of the Wander Guard prior to 01/12/2000.
Review of the policy for Missing Person reveals that a report should be completed and a copy of the report sent to the Regional Public Health Office. Interview with E2 on 01/07/2000 revealed that IDPH was not notified of R11's elopement from the facility on 12/20/1999. E1 confirmed that IDPH was not notified.
Failure of the facility to adequately supervise R11, who had been identified as a high elopement risk by the facility, placed R11 at risk, allowing him to leave the facility on 12/20/1999 without staff knowledge. Failure of the facility to maintain an effective method to alert staff of a resident leaving the facility, places residents at risk for leaving the facility without staff knowledge.