WESTABBE HEALTHCARE CENTER
Facility I.D. Number: 0043687
2301 W. Monroe St.
Springfield, Illinois 62704
Survey Date: 8/23/1999
The facility has failed to follow the Imposed Plan of Correction for the survey of 4/17/1999 which states, in part, “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” and “The facility will ensure that there is adequate staff present to meet the needs of its residents”.
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 resident 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.
These requirements are not met as evidenced by:
Review of R14's clinical record revealed: admission 7/31/1999, diagnosis of Multi-infarct Dementia, history of recurrent TIA's and Benign Prostatic Hypertrophy. Review of the physician orders revealed resident to receive Coumadin 7.5mg. daily, Flomox 0.4mg. 2 every hour of sleep and Surfax 240mg. one daily. Physician's orders read up with assistance only with walker.
Review of the nurses' notes in R14's clinical record revealed he was admitted 7/31/1999 at 2:30 p.m., oriented x 3 to name, diagnosis of Multi-infarct Dementia; 8/11/1999 1715 "Res. has tried to leave building x 3 in past 3" hours. "Recommend RC placement."Wanderguard to be placed on resident for safety; 8/12/1999 0500 wandering in hallways x 3- confused. reoriented to time and place-alert to name- cooperative with care- will monitor; "08/13/1999 0500 wanders in hallway etc. Assisted back to bed" without incident"; 8/13/1999 "(6-2) Res feeds self, appetite gd- took 0800 meds" without "difficulty-Res incontinent of B&B; pulled down his pants and defecated in the hall way floor- Confused-Staff trying to reorientate Res to own Room & bath Rooms- voiced no c/o- staff observing"; "8/13/1999-(6-2) Writer called admission office to inform of difficulty" with "Res trying to leave the exit door on hall way 200- DON will check into the situation-- staff reported Res has opened exit door, some times just looks Out, other times he ventures out."; 8/14/1999 2230 resident pacing and wandering, oriented to first and last name only; 08/14/1999 "RSN up wandering 200 Hall" with "soiled bed linens. Inc. of B&B;. Assisted RSN to BR- 210B."; 8/15/1999 "0018 RSN wandering main dining RM. Fully clothed Clean & dry." No incontinency noted. "Assisted RSN to couch in unit Lounge. RSN does not want to return to bed @ this x. Confused wring Hands. Turned television set on for RSN."; 8/15/1999 "0105 Alarm to exit door @ end of 200 Hall going OFF. RSN Found holding 200 Hall exit door open" with "two female RSN's peering outside also. RSN Shut 200 Hall exit door loudly & RSN & two female RSN's followed writer to Unit Lounge. Writer assisted RSN & two female RSN's to sit on couch in unit lounge. Writer to Nurses station to Reset alarms."; 8/15/1999 0120 resident in chair at nurses' station eating a graham cracker & drinking water. Writer with resident.; "8/15/1999 0200 RSN followed writer to Rm. 106B to answer call lt. RSN in Hall outside Rm. 106B.- Writer explained briefly to RSN would be out" after "caring for RSN. Writer cared For Request OF RSN 106B. Upon entering Hallway" after "exiting Rm. 106B RSN not in sight. Writer Began to call & search for RSN."; 0210 after quick search for RSN in all rooms called center court staff to send back-up ASAP. All rooms and bathrooms, lounges, kitchen etc. searched thoroughly. "NO alarms sounding."; 0215 staff began searching immediate grounds located out all exit doors. All alarms sounding & activated. RSN not found.; 0220, E3 notified of the resident's elopement and to be at facility as soon as possible after notifying E2; 0225 notified nurse on call of resident's elopement; 0230 writer and staff continued room to room checks and outside around immediate vicinity; 0237 message left for E1. E2, E3 and staff searching facility and ground for resident; 0330 continue with extensive searches off facility grounds and grounds and all areas surrounding facility within a two mile radius. Calls placed to establishments open with bright lights with a description of resident given; 0415 E2 and E3 placed call to police department and spoke with officer with all details of resident's elopement. Facility search is ongoing; 0425 two uniformed police officers arrive and are updated. Shown picture of resident and clothing last seen in described. Full search of facility and grounds completed; 0525 Springfield police found resident matching description at 2411 Raleigh St. Resident at above address sitting on back porch with questionable injury per report from dispatch.; 0530 Officer from the police station called and ambulance en route to pick up resident for transport to emergency room. Requested physician's name and hospital choice etc. "Info provided"; 0540 resident's family notified and message left to call facility; 0545 Hospital emergency room called to notify of resident en route. Resident information given with report.;
0645 family returned call and updated on resident and whereabouts.; (6-2) resident returned to facility by ambulance at approximately 8:15 a.m.- taken to room- requested to take a nap- refused request to eat breakfast- noted skin tear to left forearm with abrasion to left elbow, abrasion to left knee. Resident wearing his eye glasses and refused to remove them while laying down in bed- clothes soiled- changed by staff with great deal of talking. Resident did not want any hands on care, eyes clear, react slowly to light- color pale pink, skin warm and dry to touch, when questioned, he denied any complaints, moved left arm without difficulty. Hospital x-rayed left elbow and will notify facility if there is a problem- Treatment of Neosporin to wounds daily times 7 days. Resident took his 0800 medication at 0830 also that he removes the blue sling at will; 1045 Alarm sounded and resident exited door 2 on 200 hall, staff assisted him back in the facility - staff observing resident as he walks hall ways. Sat resident down and gave him a sandwich and coffee.; 8/16/1999 0600 Resident agitated and refuses to move left arm but no complaints of pain. Remains nonverbal, agitated facial features. Refuses to allow staff to put sling on and examine left arm more closely.
Clinical record review revealed no hospital report or X-ray report on record. Surveyor requested E3 obtain these items from the hospital which she did.
Review of the emergency room record revealed 8/15/1999 0607 documentation Outside of Westabbe 3-3.5 hours - found in yard; complains of left elbow pain- abrasion; complains of left elbow-blood on shirt. Patient unable to move left arm except minimally. Patient alert. Skin tear to left forearm; abrasion to left knee. Left elbow and humerus X-ray. Left elbow contusion.
Review of the hospital discharge instruction revealed resident to have a wound check in 2 days, follow-up with own physician in 1-2 days, keep wounds clean and dry with Neosporin. Documents resident had tetanus injection also.
Review of X-ray reports revealed no fractures.
Review of the "ACCIDENT/INCIDENT REPORT" revealed: 8/15/1999, R14, eloped from facility and was located at 2411 Raleigh per police department; resident fell- found sitting at a address on back porch; sent to hospital per ambulance. R14 confused/disoriented; E3 notified 0220 and physician notified 5:30 a.m. Review of the nurse's documentation revealed: "No alarms sounded after 0105. RSN Had been" with " me most of time from 2230 to 0200 Oriented to name (1st & last) only. Pleasant.
Inc. BM x 2. RSN Had" 4 " total outfits between 2230 & 0200. @ 0105 set off alarm 200 Hall" with 2 "female RSN- Shut door loudly up sitting on couch for short x. To N.N. ate a graham cracker. Drank 60cc H20. Call lt. came on in 106B. RSN Followed writer to answer. RSN in 106B Inc. RSN" R14 "in Hallway outside Rm 106." Changed RSN 106B. RSN" R14 " no where in sight on my departure from Rm 106. searched for FAN. Called for Help to search. Notified" E1. Review of the KARDEX (INTERIM CARE PLAN) revealed no documentation R14 wandered or was a potential for eloping.
Surveyor requested to see R14's resident assessment and was told it was not done.
Interview of the nurse on duty the night R14 eloped revealed when she reported to work the evening nurse and she made rounds. She was informed R14 wandered and opened doors, but came back in and was not easily agitated. At 10:30 p.m., approximately, R14 was in the unit lounge by nurses' station and he was wet. Resident was taken to his room and in bathroom, got clothes off and sat him on toilet and then to bed. In bed approximately 1 hour wearing pajamas. After the hour noticed him coming out in hallway and incontinent of feces/changed him and cleaned him and his bed. Put him in another pair of pajamas and put him back to bed. R14 got up again, maybe one hour later if even in bed that long' wandered back down hallway and at this time had blue jeans on backwards. Nurse told him he needed to change pants and he stated the hell with you. Took him to television lounge, but he was up and down wandering in the dining room. At 1:05 a.m. alarm on 200 hall went off (she was doing bed check) and R14 was holding door open and 2 female residents were peeking out the door; R14 slammed the door all residents went back to the unit lounge (television lounge). R14 sat maybe 5 minutes and went up to nurses' station and ate a graham cracker and drank water. A call light came on and he followed the nurse down 100 hall (106B). She told R14 to stay there as she had to clean the resident up. Nurse pulled the privacy curtain, in 106B, and as she walked to the resident's bathroom to wet the washcloths, she saw R14 outside the room. Gave incontinent care to the resident in 106B and when done R14 was not in the hallway- he was gone. Nurse went to the television room and checked and checked building. No alarms were going off. Called over and asked for orderly. Orderly went over and checked whole building and they checked the census. The laundry person and another CNA came over from the main building and checked inside and out. The laundry person stated the gate to the fence was open. Notified management. Nurse stated R14 left with blue jeans still on backwards, but he was fully dressed when he eloped.
Interview of E1 revealed they do not know what happened or what door he actually went out. Interview revealed there was only one staff person on duty the night R14 eloped. Interview revealed the orderly (E7) was going between the 2 buildings to work. E1 stated it was 10 minutes max before he was noticed gone. E1 stated the orderly, she believed, was in the main building when R14 was discovered missing.
Interview of E2 revealed if he had known there was only one staff person over there he would " have come in to babysit". Interview of the CNA E7 who was working both buildings revealed he was not in the RC building at the time R14 was discovered missing, but in the Main building doing bed checks.
Review of the staffing schedule for the RC building, 8/15/1999 revealed there was only a nurse assigned.
Review of the facility documentation of residents at a risk for elopement in the RC building revealed 6 residents to be named (including R14 in the 6). Review of the "RESIDENT HOURLY CHECK" documentation revealed R14 was added to the list 08/13/1999 at 7 a.m. Nurses' notes document he had attempted to leave the building 3 times in 3 hours on 8/11/1999.
Observation of the door alarms in the RC building 6/17/1999 revealed them to be sounding. Surveyor went in room 106, closed the door, had the office manager open the 200 hall door, and surveyor could hear the alarm when the door was closed.
Interview of R14 revealed he was confused.
Review of the facility documentation of their door alarm monitoring, for August 1999, revealed them to be checked once daily in both buildings, on 8/2, 8/3, 8/4, 8/5, 8/6, 8/9, 8/10, 8/11, 8/12, 8/13, 8/16 and 8/17. Alarms not checked 8/1, 8/7, 8/8, 8/14 or 15.
Review of the facility's "MISSING RESIDENT" policy revealed: "POLICY: to ensure the health, safety and welfare of residents at all times, each unit Charge Nurse during their respective tour of duty will be aware and responsible for knowing the location of their residents at all times. When residents are participating in various programs such as physical therapy, recreational activities, dining, etc., the staff in these program areas will exercise sound judgment and be aware and responsible for the health, safety and welfare of their participants.
RESPONSIBILITY: At the beginning and end of each nursing tour of duty on each nursing unit the oncoming and leaving unit Charge Nurse will account for all residents on their respective unit.
PROCEDURE: 1) A search of the immediate area (building) will be initiated. 2) Within a fifteen (15) minute period, if the search of the immediate area (building) proves unsuccessful, the unit charge nurse will report the incident to the nursing shift supervisor or Charge Nurse on duty who will direct additional staff to search the premises outside of the center. 3) The nursing shift supervisor/Charge Nurse will notify the Director of Nursing and/or Administrator if immediate search fails to locate resident. 4) The Director of Nursing/Administrator will determine need to report incident to the local police department with a complete description of the resident and what he/she was wearing. If the local police are contacted, the family of the resident will also be notified. 5) Upon solving the disappearance, the nursing shift supervisor will terminate the missing persons' report with the local police and notify all other previously contacted parties. 6) Upon notification of the attending physician the nursing shift supervisor or Charge Nurse will take orders pertaining to the resident's condition and follow through as indicated. 7) The incident will then be documented by the unit charge nurse in the resident's chart, reflecting all "facts" including specific times, i.e. time discovered, time of notification, local police, administrator, etc. 8) An incident report will be completed by the unit charge nurse and the nursing shift supervisor. 9) The Administrator/Director of Nursing is to determine if the Department of Health is to be notified."
Review, in-part, of the RESIDENT SECURITY POLICY AND PROCEDURES" revealed nursing staff will evaluate each resident upon admission for potential to wander and/or elope; The MDS coordinator will note any tendency to wander with potential to elope on the MDS; risk for elopement will be documented in the care plan for any resident meeting the criteria listed under identifying residents at risk for wandering and/or elopement (consideration when evaluating the potential for an individual resident to wander and/or elope: the resident is mobile, diagnosis of dementia or cognitive impairment, the resident has a history of wandering and/or attempted elopements, the resident is a new admission).
"WHEN A DOOR ALARM SOUNDS", in-part, If any missing resident search lasts for more than 30 minutes either the Administrator or Director of Nurses are to notify the resident's family/guarantor. In addition, all resident elopements that result in a resident exiting the facility require follow-up notification to the resident's family/guarantor that provides date/time of the elopement, any negative resident outcome, medical actions/notifications that were performed in response to the elopement.
Interview of E2, in regards to why the police were not notified until R14 was gone 2 hours, revealed he thought they could find the resident. Surveyor asked E2 if he would have been looking on porches and he stated no.
Review of the facility's investigation report, of R14's elopement, revealed: "On 8/15/1999 at 2 a.m. resident noted by nurse to not be in sight. A search was immediately started. The following investigation is based upon interview of staff and resident, alarm checks, and fence checks. Licensed nurse noted resident pacing and wandering at 10:30 p.m.. He was given ADL care and assisted to bed. At 11:16 p.m., ADL care was given again. At 12:18 a.m. resident was up, dressed and walking in the dining room. Licensed nurse made attempts to reassure resident and had him watch television. At 1:05 a.m. licensed nurse noted alarm on 200 hall. Nurse found this resident and two female residents looking out door. Nurse brought all three down hall to sit in sitting area. At 1:20 a.m. resident was given a snack at nurse's station. No further agitation noted at this time. At 2 a.m. resident was following licensed nurse as she was doing bed checks. Nurse answered a call light and had resident in visual sight prior to entering room. When nurse returned to hallway resident was not in sight. Nurse began searching halls at 2:10 a.m. When immediate scan resulted in not finding resident, convalescent center's staff was called to assist in search. At 2:30 a.m." Director of Nurses was notified and she then notified the administrator and she then notified the assistant administrator; above staff immediately went to the facility; E2 notified residents power of attorney at 2:40 a.m. and left message on answering machine; DON called again at 5:40 a.m. and another message was left; family returned call at 6:15 a.m.. "Staff did a thorough search of building and then went to area surrounding the building. Staff then began attempt to retrace steps of resident. Resident had noted not in building for only a few minutes and staff believed resident could be found soon.
Staff used cars to search and walked area using flashlights. The police were notified and officers were dispatched to search. Two officers came to facility to conduct search of the building again. At 5:15 police received a call from neighbors reporting a man sitting on their back porch. Police confirmed it was" R14. "Resident was taken to ER for evaluation and returned to facility at *:15 with an abrasion on left knee and left elbow and skin tear to right forearm. Resident was interviewed upon return from hospital and was asked why he left and where he was going. Residents reply was confused and mumbled about a farm. Resident was reinterviewed later that day and resident stated he was going for a walk but couldn't say where his destination was to be. Resident reinterviewed on 8/16 and his response was that he went out door by microwave. There is no microwave by any exit." "All alarms were checked twice by different individuals in the early morning and all were functioning appropriately. The nurse states that the alarm was heard prior to resident noted missing. All fence gates were checked and southwest gate was found standing open. Based upon investigation it cannot be determined exactly which exit the resident left or why an alarm did not sound. Alarms all work and can be heard at end of halls and while staff is in room."
Interview of Z1 revealed, 08/15/1999 she was awakened, approximately 4:30 to 4:45a.m., and she heard someone talking and then heard "help me, help me" so she called 911. Z1 stated there was a police officer in the area so her call was answered quickly. Z1 stated R14 was found between 2 houses; more on the other side but knew person who lived there was away. Z1 stated R14 had apparently tried to get up some steps.
Facility failed to ensure R14 was adequately supervised: