BLOOMINGDALE PAVILION Facility I.D. Number 0044347 Date of Survey:01/31/02 Notice of Violation:03/19/02 Annual Survey "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 met the total nursing and personal care needs of the resident. All necessary precautions shall be taken to assure that the resident’s 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. A. Based on observation, record review and interview, the facility failed to adequately supervise 1 of 30 sampled residents (R13) to prevent elopement from the facility without staff knowledge by failing to visibly check R13 as careplanned, and failure to ensure proper functioning of R13's electronic monitoring device. Findings include: 1. According to the current physician's order sheet (POS), R13 has diagnoses including senile dementia, coronary artery disease, pacemaker and depression, and is on antipsychotic and antidepressant medications. The quarterly assessment of 11/14/01 assesses R13 as moderately cognitively impaired, has behaviors of wandering, has unsteady gait and history of falls in the last 30 days. Care plan problem entries dated 10/8/01 and 11/14/01 respectively state that R13 is a "wander risk - has verbalized intent to leave building..." and "has cognitive deficits and poor decision-making." Approaches include to "visibly check resident q (every) 1 hour; q AM/PM, q ½ hour 11-7 + check {electronic monitoring device} q shift." Review of accident/incident report and 72 hour follow-up charting reveals that on 1/22/02 R13 "went out of facility. It was discovered when nurse {E 31} went to give 5 p.m. meds and realized that {R13} was not in his room. The police returned {R13} to the facility at 6:00 p.m. . . " The incident report and investigation report revealed that when R13 was returned, R13's electronic monitoring bracelet did not activate the alarm system at the front entrance. The incident report and statement by E31 did not indicate that Illinois Department of Public Health (IDPH) Regional Office had been notified. IDPH staff stated per phone on 1/30/02 that no report was at the office. Interview with special projects nurse (E14 ) 1/30/02 approximately 10:30 a.m. confirmed information on incident report and investigation. Written statements by E2 and E36 (Human Resource Staff) provided by the facility state that R13's bracelet did not set off the door alarm. E14 stated that staff do not routinely checking the electronic bracelet for functioning. E14 also stated that she assumed that the incident report was faxed to IDPH, but did not have paper confirmation. E2 stated on interview on 1/30/02 at 12:10 p.m. that bracelets were being checked but not daily, and checks were not being documented. Interview with R13 on 1/30/02 at 11:50 a.m. revealed that R13 did remember that the police brought him back one day, but did not recall when or where he went. R13 stated he went outside because it was "hot in here", and said he did put his coat on. R13 stated he did not cross any streets, but if he would have, he would "stop at the corner and go with the light." R13 did not remember the name of this facility. According to the written statement by E31, confirmed by interview with E31 on 1/30/02 at 1:15 p.m. in the front office, R13 had been visiting with his wife on the first floor, but was last seen on the second floor about 3:45 p.m. When E31 could not find R13 in his room, she asked the aide to look for him. When they could not locate him, they initiated a head count. While the head count was in progress, the co-administrator (E2) came to the unit and asked E31 where R13 was, stating that the police called the facility asking for R13. E31 stated that about that time, about 6:00 p.m., they were called down to the first floor where the police had returned R13. E31 stated that at that time it was noted that R13's bracelet did not activate the alarm. E31 stated that R13's bracelet was promptly changed. E31 stated that R13 did not say anything about why or where he had gone, and the police did not state where they had found him. E31 confirmed that they were not doing hourly checks on R13. According to phone interview with city police (Z1) on 1/30/02 at 3:00 p.m., R13 was seen about 5:00 p.m. on 1/22/02 at a gas station at the corner of Bloomingdale and Lake Streets, approximately 1 ½ to 2 miles from the facility. Z1 stated he was just sitting at the station, alert and friendly, but it soon became apparent that he was disoriented. Z1 stated he was wearing sweat pants, shirt and coat, but was wearing what looked like slippers. Z1 stated they first made phone calls based on where R13 said he was from and identification he was carrying. But then the police noted R13's identification band that indicated the facility's address and phone number. Z1 stated they called the facility then returned R13. Z1 stated that when returned, R13's electronic bracelet did not activate the door alarm system. According to the undated facility policy for Elopement Risk in effect at the time of the incident, the front entrance has the electronic monitoring system, and is monitored by the receptionist during primary business. The policy also states that alarms are checked daily by maintenance and by the weekend administrators. Policy also states residents are assessed on admission using the "Nursing Assessment/Reassessment Form" for a potential elopement risk. Then upon a change in status an elopement risk assessment is completed. R13 was first assessed on 8/7/01 as not being an elopement risk. Then monthly summary charting dated 10/01, "wanders" was checked under the section for behaviors. E2 stated on 1/31/02 at 9:15 a.m. that she believed it was at that time that R13 was transferred to the second floor. |