"A" VIOLATION(S):

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 needs of the resident.

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.

These requirements are not met as evidenced by:

Based on observation, interview, and record review, the facility failed to provide adequate supervision for one (R1) out of six residents at risk for elopement from the facility. R1 eloped from the facility 12/07/01.

The Findings Include:

1. On 1/7/02, during an investigation of the Incident of 12/07/01 involving R1, E1 was interviewed. E1 stated that on the morning of 12/7/01, R1 ate his breakfast; received his 9 a.m. medication; and then disappeared from the 3rd floor of the facility. The 3rd floor of the facility is a secured area because 3rd floor residents in general, have a diagnosis of dementia or Alzheimer's. A search of the building and surrounding area was performed and the resident was not found. The facility received a telephone call from the police at approximately 9:40 a.m., informing the home that R1 was found by the police at 71st and Parnell.

E1 further stated that the facility investigated the incident and came to the conclusion that R1 left the facility through the front door. All the exit doors of the facility are alarmed except the front door. No alarm went off and they were all in working order the day of the incident.

2. On 1/7/02, a tour of the 3rd floor and route R1 used to exit the facility was made. The 3rd floor elevator is located across from the nurses' station. The elevator is secured by a coded key pad. R1 had to wait in front of the nurse's station for someone to either key in the code or come up to the 3rd floor for the door to open and the resident to enter. The elevator again, on the 1st floor is located in front of the nurse's station. When R1 exited the elevator on the 1st floor, he had to walk past the 1st floor nurse's station to get to the door leading to the reception area and the front door of the building. The door leading to the reception area is not locked or labeled when going out of the building, only coming into the building. At the time of the tour, the door was propped open and the outside glass door clearly visible from the reception area door. To leave the building through the front door, R1 had to pass by the receptionist's window. Posted on the wall, next to the window, out of sight of the public, is a picture of R1 with five other residents who are known by the facility to be at risk for elopement. R1 passed four check points (elevator, 3rd & 1st nurses' station, receptionist) where he should have been stopped by staff.

3. Review of R1's record identified that R1 has diagnoses of Alzheimer's and dementia. The Quarterly MDS (Minimum Data Set) dated 11/29/01 states the resident's cognitive ability is moderately impaired. He is a wanderer that is not easily redirected. R1 has a care plan for elopement and wandering. During interview of the resident on 1/7/02, R1 only recognized his name when called. R1 could not answer any other questions. The resident only talked aimlessly.

4. According to the review of the record, R1 left the building with only a blue shirt and pants on.