WHEATON CARE CENTER
Facility I.D. Number: 0039115
1325 MANCHESTER ROAD
WHEATON, ILLINOIS 60187
Survey Date: 6/21/99
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.
General nursing care shall include at a minimum the following and shall be practiced on a 24-hour, seven day a week basis:
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.
These regulations are not met as evidence by:
Based on record review, document review and staff interview, the facility failed to provide supervision to prevent one of 10 designated wandering residents from leaving the facility unescorted and sustaining facial injuries.
According to resident record, incident report and interview with E1, a motorist observed R1 one block from the facility at the corner of Woodlawn and Manchester Road and notified village authorities. A nurse documented that the Fire Department called at 12:00 noon to advise the facility of R1's whereabouts. According to nurse's note and interview with E3, R1 was last seen in the facility around 11:45 a.m. when E3 escorted R1 to the dining room for lunch.
Village officials transported R1 directly to Central DuPage Hospital for treatment. The emergency department documented R1's arrival at 12:20 p.m.. The emergency room report indicated R1 was alert and confused upon arrival. R1 complained of headache and neck pain. R1 had reportedly fallen on the pavement on her face, sustaining abrasions of the nose and left elbow and a bruise of the left eyebrow. R1 was admitted to the hospital with diagnoses including blunt head trauma, nasal fracture, multiple abrasions and cervical strain.
According to the investigation conducted by E1, E6 stated that a group of residents left the facility via the main entrance door at conclusion of lower level lunch, which is scheduled to begin around 11:30 a.m. These residents customarily leave the building after meals to smoke cigarettes on the front porch. A resident in the group who wore a Wanderguard bracelet activated the Wanderguard door alarm. E6 saw and retrieved R10, "not knowing that (R1) had left at the same time." The facility conducted no head count of residents at that time.
The Wheaton Police Department incident report stated that an officer was dispatched to 115 North Woodlawn on 06/06/99 at 11:42 a.m. The report stated that R1 asked, "'Can you help me?'" R1 then fell forward onto the pavement from a standing position.
R1 was an 85 year old, admitted 04/07/99 with diagnoses including dementia with delusions, cerebral vascular accident and osteoporosis. Assessments revealed that R1 was disoriented and severely cognitively impaired with hearing, memory and communication deficits. R1 was "not aware of safety needs..., unable to make needs known... (and unable) to follow simple commands." Staff notations included such observations as R1's "constantly trying to get out of the door...leave the building" on repeated occassions.
R1's elopement risk was identified at admission and an electronic wanderguard bracelet applied at that time. The record revealed that R1 required assistance with all activities of daily living. Staff documented that R1 needed assist, "redirection at all times as well as monitor her whereabouts every fifteen minutes." According to E1, it was the facility's practice to implement 15 minute monitoring whenever R1 became acutely distressed, exhibiting wandering or restless behavior. This undocumented procedure was performed frequently for R1.
R1's gait was unsteady, according to the comprehensive assessment. R1 complained of head pain and suffered a forearm abrasion after an unobserved fall in her toilet room on 05/13/99. R1 was found on the floor at her bedside on 04/13/99 without apparent injury.
The facility in located on Manchester Road, a residential street with a 35 mile per hour speed limit. Woodlawn Street where R1 was found is located one block west of the facility. Adjacent to facility property on the north is a Chicago and Northwestern Railway track which carries freight and commuter trains throughout the day.
In summary the facility failed to: