EAST PEORIA GARDENS HEALTHCARE CENTER Facility I.D. Number 0045492 Date of Survey: 12/20/01 Notice of Violation: 02/15/02 Complaint Investigation "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 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. These REQUIREMENTS are not met as evidenced by: Record review of R6's current physician's orders showed R6 to have diagnosis of Alzheimers Dementia. Resident is an 80 year old female resident. Per social services notes dated 10/8/01 and signed by E4 (social services director),"R6 has had a deterioration in cognition and mood. This is probably due to progression of her Dementia. She has long and short term memory problems and poor daily decision making skills. She has been wanting to leave the facility without her daughter." Psycho-social notes dated 10/2/01 and signed by E3 (psycho-social director) stated, "Resident has once again been tearful and wanting to leave facility. This has been increased over the past few days." The most recent minimum data set (MDS) dated 10/10/01 was completed for a significant change in resident's cognitive status. Review of the MDS dated 10/10/01 showed R6's cognition skills to be moderately impaired, a deterioration in status. R6 was also identified on the MDS as having short and long term memory impairment as well as unstable behaviors related to disease progression. Care plan dated 10/11/01 stated a short-term goal as, "Resident will not attempt to leave facility unaccompanied." R6 was interviewed on 11/21/01 at 12:50 pm and on 12/18/01 at 2:25 pm. Resident was able to state her first name only. She was unaware of the date or where she was. She stated it is "just a place to sit and we are here." Nurses notes dated 11/5/01 and signed by E20 (licensed practical nurse) stated, "Service Station called and stated a confused woman was there." The facility is located on a major road with a 40 mph speed limit posted. The gas station is located 0.1 miles from the facility. These same notes stated, "E1 (administrator) and E17 (medical records clerk) went to get R6 and brought back here." Interview with E23 (office clerk) was conducted at approximately 1:30 pm on 12/18/01. E23 stated she received the call from the gas station stating that there was a "confused looking elderly woman at the station." E23 stated she reported it to E1, who then left with E17 to pick up R6. During interview on 12/18/01 at 11:30 am, E17 stated she accompanied E1 on 11/5/01 when R6 was picked up and returned to the facility. "R6 was located on the curb between two houses on a side street across from the gas station." E17 also stated that she would question R6's ability to find her way back to the facility. During interview on 12/18/01 at 11:10 am, E20 stated, "R6 left the facility on 11/5/01 without staff knowledge and walked to the gas station .... I was the nurse assigned to R6 for this day. I do not feel that R6 would be aware of her safety. I feel R6 is more confused and would be unable to find her way back to the facility." Interview with Z1 (daughter) was conducted by phone on 12/18/01 at approximately 12:20 pm. Z1 stated she was informed that R6 had gone to the end of the driveway of the facility on 11/5/01. Z1 stated she feels that R6 would be unaware of how to return to the facility if she left the grounds. Z1 stated that R6 forgets where rooms are in her (Z1's) house when R6 comes to visit. Interviews were conducted with E1, E2 (director of nurses), Z1, E17, E20 and E23 on 12/18/01 between 11:10 am and 1:30 pm. All persons interviewed stated that R6's cognitive status had deteriorated since October of 2001 and that R6 is unreliable, is unaware of safety issues, and is at risk for getting lost in the community. The front door is alarmed. On 11/21/01 at approximately 1:15 pm, no staff were at the desk. The front door alarm sounded. After approximately a minute, E7 (certified nursing assistant/CNA) came to the desk and turned the alarm off. She was interviewed as to how staff knows what triggered the alarm. E7 stated that it was someone coming in that triggered it. E7 was asked how she knew this since she was not at the desk. E7 stated that no one was outside the door, so it was someone coming in. E7 was standing on the side of the desk where view of the outside is not possible. No announcement was made for staff to check the door, nor was a visual check performed by E7. Upon entrance to the facility on 12/18/01 at 9:20 am, no alarm sounded at the door or nurses station. A complete check of all exit doors was done on 12/18/01 with E2. The service entrance/exit door was opened. E2 stated that an alarm sounds at the nurses desk, the staff announces for someone to check the door and then an all clear is called with the alarm being shut off. Approximately two minutes passed, no announcement was made nor did staff come to check the door. At the nursing station, no alarm was sounding. E2 stated someone shut it off. When staff were questioned by E2, all staff at the desk (E1, E6 registered nurse/RN, and E15 RN) denied the alarm was sounding and stated that no one had turned it off. E6 was noted to come and flip a toggle switch for this door from a down position to an up position. An alarm immediately began sounding. The alarmed door in the TV room, leading to the outside parking lot was pushed. A faint alarm was heard at the nurses station from this position. A switch above the door was in an off position. E2 stated that it was not a significant part of the alarm. A CNA then turned the switch to the on position and a loud alarm sounded. The other facility doors alarmed when opened. Interview with E2 on 11/21/01 at 4:00 pm showed four residents in the facility to be at risk for elopement from the facility. On 12/18/01 at 3:50 pm, policies and procedures were requested of facility staff in relation to residents entering and exiting the facility. E1 and E2 were unable to locate any policies. |