VERMILION MANOR NURSING HOME
Facility I.D. Number 0000786
Date of Survey: 09/26/01
Incident Report Investigation of 09/16/01
A Violation (s):
The facility shall provide a Resident Services Director who is assigned responsibility for the coordination and monitoring of the residents overall plan of care. The Director of Nurses or an individual on the professional staff of the facility may fill this assignments to assure that residents plans of care are individualized, written in terms of short and long range goals, understandable and utilized; their needs are met through appropriate staff interventions and community resources; and residents are involved, whenever possible in the preparation of their plan of care.
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 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 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.
Record review of R1's most recent physician's order sheet dated September, 2001, reveal R1 is an 86 year old resident with sixteen separate diagnoses that include: dementia, type II diabetes, ulcers right leg, peripheral vascular disease, and history of ethyl alcohol abuse. R1 has 9 different medications ordered including Insulin Human NPH(U-100)/ml, 8 units subcutaneous (SQ) every AM and Insulin Human Regular (100U/ml), to be given on a sliding scale QID (four times a day).
Record review of an incident report dated 9/16/01 titled, Vermilion Manor Nursing Home- Danville Report of Incident to IDPH states R1 is on 30 minute checks and was last seen at 2:00PM on 9/16/01. The report states at 2:20 PM facility staff looked for and was not able to locate R1. The report indicates after a thorough search of the building and grounds the facility staff notified law enforcement. The report states R1 was returned to the facility about an hour after he was missed. The report states R1 was returned by local law enforcement who found R1 walking an undetermined distance from the facility.
Record review of Nurse's Notes dated 9/16/01, at 3:30 PM reveal R1 was returned by "two policeman, they stated they found him walking. Resident stated 'That was a long walk, I didn't think I would make it'."
Review of nurses notes dated 9/16/01at 3:30 PM reveal R1 was returned to the facility without injury. Review of incident/accident report dated 9/16/01 reveal R1 had a personal exit warning device in place on his right wrist when returned by law enforcement and this set off the front door alarm when R1 walked back through the door.
Interview with E7, certified nursing assistant (CNA) on 9/20/01 at approximately 12:00PM, confirmed that R1 had left the facility unnoticed by staff on Sunday, September 16, 2001. E7 states, "I was aware (R1) was an elopement risk. We were doing one-half hour 'Wander Sheet' (checks). I saw him and did a 'Wander' (check) on him at 2:00PM. I was about to go to break at 2:25(PM). I told (E6), another CNA on "D" Section where R1 was at, and that he needed to be charted on at 2:30PM. E6 came to me at 2:45(PM) and stated she could not find Mr.(R1), that she had walked the whole building. We did a whole building check and couldn't find him. At that time we saw the PM charge nurse (E15) and told her.... The supervisor then announced over the intercom for all staff to do a room to room, face to face search, of the whole building. There were people looking at the same time outside....We couldn't find him".
Interview with E4 on 9/20/01 at approximately 1:00PM confirmed that R1 was missing from the facility on Sunday, 9/16/01and unable to be located in the facility or on the facility property. E4 states, "I was working Sunday 9/16/01 3-11 shift. I got here at 2:45PM on Sunday and the search was underway when I got here. He was very fast. I think he 'piggybacked' out of here, probably out the front door. They (staff) probably saw another resident with an alarm, in the area, thought they set it off, and didn't look any further."
Record review of R1's "Prerestraining Assessment" dated 8/23/01, the date R1 was admitted to the facility, reveal a recommendation for a personal exit warning device. Under the heading Assessment Nurse Recommendations: the writer states, "No restraint needed. (personal exit warning device) in place D/T (due to) resident trying to leave out front door his first night here."
Record review of R1's initial assessment dated 8/30/01, reveal R1's short and long term memory to be impaired, and his cognitive skills for daily decision making to be moderately impaired. The assessment reveals R1 has periods of altered perception or awareness of surroundings, and his mental function varies over the course of the day. The assessment reveals R1 had exhibited wandering behaviors 1-3 days in the last 7 days. The assessment under section "J" reveals R1 has an unsteady gait.
R1's most recent care plan dated 8/31/01 under the problem heading, "Alteration In Psychosocial/Behavior, (R1) Wanders, R/T Cognitive Loss From Dementia-Wears (personal exit warning device). Approach #1 is (personal exit warning device)/Ankle sensor on at all times-Place On Wander Sheet., Approach #6 is Check every 1-2 hours or more often if needed to ensure safety.
Interview with Z1, on 9/21/01, at a local hospital, at approximately 9:30 AM confirmed R1 to have difficulty with personal safety awareness. Z1 states, "he has dementia...I don't feel he would be able to navigate outside with a sense of safety. If he came to a red light he probably wouldn't know that means stop. If he was feeling ill he would not have the presence of mind to seek help".
Interview with R1 on 9/21/01, at a local hospital, at approximately 9:45 AM confirms R1 to be disoriented as to place, to have a long-term memory problem, and not aware of safety issues. When asked his name and where he was, R1 stated "My name is....(R1), and I am in jail in Chicago". When asked what happened on Sunday when he left the facility, R1 stated "Most of the time when I walk it's on a Sunday, cause I work during the week. It was nice and warm so I took a little walk down the street. I walked down the middle of the road-there wasn't traffic much". When asked what he would do if he came to a busy road that he wanted to cross, R1 stated, "I would wait till the cars kind of cleared up a little bit-If I saw a chance I might make it, I would take off across".
Observation, by the surveyor, on 9/21/01 at approximately 2:30 PM, of the terrain within a one mile radius of the facility reveals the following: a busy two-lane city street that runs in front of and to the west of the facility with a posted speed limit of 35 miles per hour. A sidewalk on the
east side of that street was observed that extends for approximately fifty yards and then ends abruptly; after which there is a wide gully or ditch on the east side of that road. A black-top and gravel road lined on both sides by corn fields, (with corn stalks approximately 5-6 feet high) intersects that city street, runs east approximately 1/2 mile and then jogs sharply back north. Behind and to the east of the facility are bean and corn fields, groves of trees and wooded areas, a ditch that contains water, and a railroad track. Interview with E1, the administrator, confirms the resident was found behind and to the east of the facility on the gravel road that jogs back north.
Observation, by the surveyor, inside the facility confirm all exterior doors to be audibly alarmed except one. This door is the service door to the laundry. Per staff interview, this door should not be accessible to residents, because a set of double doors leading to the laundry are kept locked when laundry staff are not in direct visual contact with the door. Per staff interview these alarms are used to augment staff supervision by alerting staff if a resident leaves the building. When tested all alarms were found to be functional and staff responded appropriately.