ANNA HENRY NURSING & REHAB CENTER
Facility I.D. Number0041483
Date of Survey02/05/02
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 residents 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 care needs of the resident.
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.
AN OWNER, LICENSEE, ADMINISTRATOR, EMPLOYEE OR AGENT OF A FACILITY SHALL NOT ABUSE OR NEGLECT A RESIDENT.
These requirements are not met as evidenced by:
1) Record review reveals R13 to be an 84-year-old having a diagnoses of Psychosis, Depression, Senile Dementia with agitation, and Delusions/Hallucinations.
During interview of R13 on 1/29/02, R13 stated her name but would not answer questions such as, where she lives or the season of the year.
The Minimum Data Set (MDS) of 12/26/01 has R13 marked as having short and long term memory problems. R13 is ambulatory and is assessed as having a wandering behavior. R13's care plan identifies her as a risk for attempting to leave the building. R13's evaluation for unsupervised pass outside of the facility was marked that she was not appropriate for an unsupervised pass. R13 has an order for a Electronic Monitoring Device (EMD) which alerts staff when R13 leaves or attempts to leave through the front door. Interview with Z1, ( R13's attending physician), stated during interview on 1/29/02 that it was "Probably not safe for her to be out unsupervised."
Interviews with Z2 and Z3, (concerned citizens) revealed that on 12/28/01 at approximately 7:15 PM they were driving on route 143, Marine Road, into Edwardsville, Illinois. They were rounding some curves and were surprised to see an elderly lady (R13) in their headlights walking along the road. Z2 said he turned around and went back and asked her if she needed assistance. Z3 said that R13 said "oh my yes". R13 said she lived through the woods but that she was missing her little girl. R13 would not tell them her name or names of family. Z3 said she was cool to the touch but not cold. Z3 said that R13 was wearing a shirt, slacks , sweater, socks and slip on flat shoes. Z3 said she was carrying a paper bag with a new night gown and some slippers. Z2 and Z3 talked R13 into their car and drove her to the Edwardsville Police Department.
Review of the Edwardsville Police report revealed that Z2 reported the assist to a citizen at 7:26 PM on 12/28/01. Z3 was the responding officer. Interview with Z3 on 1/25/02 revealed that after talking with R13 he was able to determine her name. Z3 said that R13 could not give him any other information about where she lived or about family. Z3 felt R13 was in a dangerous stretch of road after dark and was inappropriately dressed for the weather. Z3 relayed the information to Z4, supervising Police Officer.
Z3 then started calling nursing homes in the area. Z3 contacted Anna Henry Nursing and Rehab Center and talked to E1(Registered Nurse). E1 told Z3 that she had last seen R13 at approximately 6:30 PM. E1 said that R13 wears a EMD bracelet and that if she exits the building an alarm is triggered. E1 did not know how R13 exited the building without the alarm sounding. Z3 did not think that E1 knew R13 was missing when he called. Z3 returned R13 to Anna Henry Nursing & Rehab Center at approximately 7:45 PM - 8:00 PM. Z3 said the EMD alarm sounded when he entered the facility with R13.
The area R13 was found is in the 6900 block of Marine Road (HWY 143), approximately .6 mile from the facility. There are no sidewalks along the street in this area and is not well lit at night. The road has hills and curves in the area. The speed limit changes in this area from 30 mph to 35 mph. Across the street from the auto body center is a wooded stretch with heavy underbrush. This is where R13 was found walking along the road by Z1 and Z2.
The National Weather Service was contacted. They said the temperature in St. Louis, MO at 7:00 PM on 12/28/01 was 34 F.
Interviews with the licensed nursing staff E1, E2, and E3 revealed that they were not aware that R13 had left the facility until the Police had called and informed them. They all said the exit doors were checked and all alarms were working properly. The front door has a EDM alarm but did not have a door alarm that would alert staff if a resident left the building that did not have a EDM bracelet on.