EUNICE C. SMITH NURSING HOME
Facility I.D. Number0008409
Date of Survey:02/14/02
Notice of Violation:03/22/02
All necessary precautions shall be taken to assure that the residents' environment remains as free of accident hazards as possible. All nursing personnel shall evaluate residents to see that each resident receives adequate supervision and assistance to prevent accidents.
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 evidence by:
Based on observation, resident, staff and physician interview and record review, the facility failed to provide adequate supervision for one resident (R1) who eloped on 1/17/02.
On 2/8/02, the facility's incident report regarding R1's elopement on 1/17/02 was reviewed. The Facility Self-Report Form noted that R1 put on his coat and exited the facility via the front door. It also noted the following: "The (personal) alarm did not sound because he cut off the bracelet. He was seen on College Ave, walking slowly with aid of his walker. The person who saw him works at Alton Memorial Hospital and is familiar with our facility so she came into the facility and told the Office Manger...that she had seen a gentleman walking on college avenue." According to the report form the office manager and a CNA (certified nurses' assistant) found R1 walking on the road east of the facility. He was returned to the facility.
On 2/8/02, at 9:50 a.m., E1(the Administrator) and E2 (the Director of Nurses) were interviewed. E1 said that the facility has been discussing alternative placement for R1with R1's family. E1 said R1 had no safety awareness and is always talking about leaving the facility. E2 said that R1 talks about leaving and cuts his personal monitoring device off. E2 said that the staff have attempted to put the personal monitoring device on the back of suspenders and on his walker but he has taken them off. E2 also said that R1 had called several cab companies to pick him up.
On 2/8/02, at 11:00 a.m., an interview was conducted with R1 in his room. He questioned the surveyor how to leave the facility. He said "I want to get out of here. I want to go home". The surveyor questioned R1 if he ever left the facility without letting the staff know. He said that he tries to leave but someone always gets him.
On 2/8/02, R1's record was reviewed. His physician's order sheet, dated February 2002, noted he had the following diagnoses: Pneumonia, Congestive Heart Failure, Diabetes, Dementia, Colitis, Anxiety, Agitation and Depression.
On 2/8/02, his nurses' notes were reviewed. His nurse's note, dated 1/14/01, noted the following: "(10 a.m.) States he is leaving to go home get his meds ready. Walking down hall. (10:45 a.m.) ask if his meds were ready he was leaving and would call a cab." His nurse's note, dated 115/02 at 5:30 a.m., noted the following: "New (personal) alarm applied to walker not to res due to res uncooperative with that in the past." His nurse's note, dated 1/15/02 at 8:30 a.m., noted the following : "Res. ambulating in hallway with walker stating he needed his medications and he's going home soon this AM. Noted res had removed (personal) alarm from walker." His nurse's note, dated 1/15/02, at 2:00 p.m., noted the following: "Res ambulated down hall with coat on stated he was going home. Called cab and waiting in lobby then exited at front door, walking down sidewalk. Returned without diff with redirection."
His nurse's note, dated 1/17/02, at 1:45 p.m., noted that R1 was talking on the phone with someone about going home. The nurse then received a telephone call from R1's physician's office. The representative from R1's physician's office told the nurse that R1 had called to go home and asked if he was a threat to himself or others. At 1:55 p.m., the nurse documented that R1 had eloped from the facility out the front door and the alarm did not sound due to R1 had taken his personal monitoring device off. The nurse documented that R1 had walked with his walker down the street "quite a ways." This nurse documented that he was returned without injury.
His nurse's note, dated 2/7/02, was reviewed. The nurse documented that R1 exited front door and left walker inside with personal alarm attached to it. R1 had called a cab. He was returned to the facility by two staff member.
On 2/8/02, at 12:35 p.m., E3, the office coordinator, was interviewed. She said that the incident occurred on 1/17/02 between 1:00 p.m and 3:00 p.m. She said that she and E4 were sitting in her office when a woman came and said there was a gentleman with a walker walking on College Avenue down the hill. She said that she and E4 (a CNA) ran out and ran East on College Avenue. She said that they initially did not see R1 but as they went over the hill they saw him at the bottom of the hill. She said that R1 was on the side of the road and cars were slowing down and going around him. She said that there was no sidewalk and R1 was ambulating with his walker on the road. She said that with the help of the woman who reported R1 missing they convinced R1 to get into her car. She said that R1 was returned to the facility. She said that she believes he got out the front door based on the direction he went away from the facility. She said that it was cold and R1 wore a light windbreaker jacket. She said that College Avenue is a very busy street and that is why she and E4 "took-off as fast as we did" after the woman reported the incident. She said that R1 had a habit of taking off his personal monitoring device.
On 2/8/02, at 1:20 p.m., E4, a certified nurses' aide, was interviewed via telephone. She said that she was picking up her pay check on 1/17/02. She could not recall the time. She said that it was "sometime in the afternoon." She said that a lady came and knocked on E3's office window. She said that the lady said there was a resident walking down the road. E4 said the lady described the resident. E4 said that they ran out of the facility after R1. She said that R1 was one third down the hill on College Avenue. She said that he was "trying to thumb a ride". She said that both she and E3 were concerned that they would not be able to convince R1 to come back to the facility. At that time, the lady who reported the incident pulled up alongside R1 and asked him if he needed a ride. E4 said that R1 and she got into the woman's car and returned to the facility. She said that College Avenue was very busy street. She said that R1 had a hat and a jacket on. She said that R1 has a history of taking his personal monitoring device off and frequently tells staff he is going home.
On 2/8/02, at 1:52 p.m., E6 and the surveyor tested the seven exit doors in the facility. The only type of door alarm use to notify staff that residents were leaving the building through the doors was the personal monitoring device system (an alarm system attached to a door which is activated by a resident wearing a bracelet). R1 had a history of taking off his personal monitoring device and did not have the device on the day he eloped from the facility. At 2:00 p.m., E2 said that all of the exit doors have door alarms that are not activated by the personal monitoring devices; however, these alarms are not turned on until evening shift.
On 2/8/02, at 1:40 p.m., an interview was conducted with E5. She said that R1 is constantly talking about going home. She said that he is confused and takes his personal monitoring device off. She was not sure how he removed his personal monitoring device.
On 2/8/02, at 3:15 p.m., an interview was conducted with Z1, Z2's registered nurse. The surveyor provided Z1 with several questions regarding R1's safety awareness to ask Z2 (R1's physician). Z2 relayed her answers to Z1 who responded to the surveyor via a telephone conference. Z1 said that Z2 noted that R1 did not have safety awareness to negotiate traffic, environmental hazards such as hills, ditches, or lakes. Z2 said that R1 would not have safety awareness with regards to inclement weather. Z2 said that R1 has a guardian because he is not competent.
On 2/8/02, at 4:20 p.m., this surveyor drove to the approximately location R1 was found on 1/17/02. It was approximately .2 miles away from the facility.
On 2/13/02, at 9:30 a.m., an interview was conducted with E8. She said that she saw R1 on 1/17/02 at approximately 1:45 p.m. She said that R1 was making a telephone call. She said that immediately after he got off the telephone, R1's physician's office called. They told E8 that R1 had just called about going home and asked if he could harm himself or others. She said that he eloped at approximately 1:55 p.m. She said that he has a history of taking off his personal monitoring device. She said that he does not have safety awareness and said "that is a scary thought" when questioned about his ability to negotiate traffic.