ELMWOOD NURSING & REHAB CENTER
Facility I.D. Number 0041210
Date of Survey: 12/20/01
Incident Investigation of 12/06/01
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 andpersonal 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.
Maintain all electrical, signaling, mechanical, water supply, heating, fire protection, and sewage disposal systems in safe, clean and functioning condition. This shall include regular inspections of these systems.
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 regulations are not met as evidenced by:
Based on interviews of staff and others, and review of facility records, the facility failed to supervise one of 19 residents who have been identified as potential wanderers. On 12/6/01, R1 left the facility without supervision or knowledge of facility staff.
Review of facility form entitled "Review of Elopement", reveals that the facility notified the Illinois Department of Public Health on 12/6/01 of the following occurrence:
"On 12/6/01 at 5:45 AM, Staff was getting residents up for the day and noted that (R1) was not at nurses station as he usually was, head count started at this time. (R1) was found in parking lot at St. John Newman School. No potential danger noted along the way. (R1) complained of pain in knees at this time and upon assessment, knees were red in color and had several small scratches on both. Behavior was normal, Res. could have been looking for a B.R. No past attempts to elope. The current care plan approach for this resident to prevent elopements is wander guard, check wander guard placement every shift, check function weekly, re-direct res, charge nurse to insure presence of res at beginning of each shift, each medication pass, meal times and end of shift. All door alarms are checked every other day and this door was checked on 12/5/01. Facility is in process of updating door alarm system."
Interview of E4, nurse who was coming on duty the morning of 12/6/01, reveals that she arrived at the facility at approximately 5:30 AM on 12/6/01. At that time she noted that the north exit door at the end of the 100 wing, near resident rooms 125 and 123, was slightly ajar. E4 stated that door was open "several inches" and as she approached the door, she could hear a faint buzzing. E4 stated that the sound emitting from the door was that of the normal door alarm only much fainter. When the door was pulled shut, staff checked it and found the door and door alarm to be working and sounding properly. When E4 came back to the nurses desk she did not see R1 sitting at the nurses station as was his normal routine. At that time, E4 had staff begin a head count on the 100 wing. When staff could not find R1 in his room, a head count was also started facility wide. This occurred at approximately 5:45 AM. At approximately 5:55 AM, staff began to search outside of the building for R1.
At approximately 6:10 AM, E5 was searching behind the building along with several other staff members, and saw R1 sitting in the parking lot on a concrete curb behind the school. He was wearing shoes, socks, sweat pants and sweat shirt. E4 stated that it wasn't real cold outside, probably the upper 40's. Staff brought R1 back into the facility and did a thorough body-check. E4 stated that R1 did not appear to be upset. R1's knees were a bit red and had a few scratches. Staff asked R1 where he was going and he stated, "Looking for you guys." E4 then notified R1's physician and family member. E4 stated that she did not believe that R1 intended to leave the facility as he had never attempted to do so until this time. E4 stated that she thinks R1 was simply looking for a bathroom as R1 often walks down that hall when he needs to use a bathroom.
Interview of E6, facility Maintenance Director, reveals that he checks all of the exit doors within the facility every other day. E6 stated that all of the exit doors on the 100 wing had been checked on 12/5/01 and were found in normal operating order. E6 reported that there had been a very bad storm with high winds and rains during the night of 12/5-6/01. E6 stated that he's not sure what happened to allow the door to come open and the alarm not to sound fully. E6 stated that he wondered if the winds and rain were at such an angle and velocity that it allowed a small amount of moisture to get into the 15 second delay alarm device and cause the door to open. E6 also stated that he also wondered if perhaps an electrical charge due to the storm may have allowed the door to disengage. E6 came on duty at the facility shortly after R1 was brought back to the facility. When E6
became aware of what happened, he immediately took the alarm device on this door apart and cleaned and dried the device. E6 tested the device and found it to be in normal operating condition. E6 has continued checking each door in the facility at least every other day and has found them to be in normal operating condition.
Interview of E1, facility administrator, reveals that the facility staff believe that the door coming open due to the storm was a "fluke" and that all conditions which led up to it occurring were unusual and had to have been "just right". R1 must have been in the area and coincidentally decided to exit the door. R1 had never tried to leave the building prior to this incident but had been identified by the facility as a potential wanderer due to his behavior of walking about the facility. E1 showed the surveyor a book which contains a list of potential wanderers, their pictures and a physical description. E1 stated that a copy of this book is kept at each nurses station and in the front office. E1 stated that all staff have been inserviced concerning potential wanderers and know where the identification book is located.
Record review reveals that R1 has diagnoses, in part, of Alzheimer's Dementia and Degenerative Joint Disease and was originally admitted to the facility on 2/13/01. R1 ambulates independently. R1 receives the following medications: Seroquel, Lasix and Potassium Chloride. Throughout all days of the survey, R1 was observed walking about the facility or sitting in a chair by the 100 wing nurses station. Staff frequently were observed interacting with R1 and redirecting him if he began to walk down one of the hallways in the facility. On 12/18/01 at 11:00 AM the surveyor attempted to interview R1. The surveyor asked R1 if he remembered walking outside the facility the other morning. R1 stated no, then began talking about his glasses. The surveyor attempted to redirect R1 and ask again about him being outside of the facility. R1 continued to talk about his glasses.
Record review further reveals that R1's plan of care identified the potential problem of wandering. The plan of care reveals: "2/26/01, Res has Dx of Alzheimer's and Dementia. Has poor short term memory. Requires some assistance with decision making. Res is independent with ambulation and transfers. Wanders about facility. Speaks to staff about leaving and going home. 5/24/01, Res cont to wear wander guard and attempt for elopement. Cont. to ambulate about facility adjusting well to facility and with staff. Cont. with plan of care. 8/23/01, Res. cont. to ambulate about facility, no attempt for elopement cont with plan of care. 11/22/01, Res cont to wear wander guard. no elopement attempts made. Cont. with plan of care." The following approaches are listed: "1. Wander guard 2. check wander guard placement each shift 3. check function weekly 4. Redirect res 5. Tell res this is his home when asked 6. Charge nurse to ensure presence of res at beginning of shift, at meals times, at med pass and at end of each shift".
On 12/18/01, the surveyor spoke with Z1, R1's physician. Z1 stated that due to R1's dementia he is confused most of the time, therefore he would not be aware of dangers in his environment. Z1 further stated that R1 should not be outside of the facility unsupervised.
On 12/18/01 at approximately 10:30 AM, E4 walked the route they suspect R1 took outside of the building with the surveyor. The door which the staff suspects R1 exited the building is one the northeast side of the building at the north end of the hallway which runs north and south. R1 would have had to walk around the building, to the south side of the building, walk through a parking lot and up a grass covered incline, across another parking lot which is located behind a church, then across a grass covered playground between the church and an office building and onto the parking lot behind the office building. R1 was found sitting on a cement parking block on the south side of the parking lot. The parking lot where R1 was found sitting is located behind an office building and between church grounds and school grounds. The parking lot is oil and chip. The area where R1 was located is approximately 3/10 of a mile from the facility. There is a chip and oil road located approximately 25 feet from the east side of the facility, which leads from State Highway 159 past the school located to the south of the facility. The speed limit on this road is not posted near the facility however, the speed limit is posted as 20 miles per hour near the school. There is a fence located on the east side of the road, between State Highway 159 and the road, approximately 4-5 feet in height. There is an open field to the west of the facility in which there are weeds approximately four feet in height. There is an open field to the north of the facility with no brush or growth and an uneven soil surface.