GREENWOOD TERRACE NURSING & REHAB Facility I.D. Number 0045070 Date of Survey: 10/17/01 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. Objective observations of changes in a resident's condition, including mental and emotional changes, as a means for analyzing and determining care required and the need for further medical evaluation and treatment shall be made by nursing staff and recorded in the resident's medical record. 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: Based on record review, staff, resident and physician interviews the facility failed to prevent an elopement of a cognitively impaired resident (R3) from the facility without staff's knowledge. Findings include: On 10/04/01, a review of the incident reports revealed that R3 had eloped from the facility at 6:25 AM on 08/09/01. The report identified that R3 wandered about a block from the facility. R3 had an electronic monitoring device on his right ankle, and was returned to the facility at 6:40 AM. Nurses notes dated 08/09/01 revealed R3 was found at 2:15 AM rapidly ambulating past the 200 hall, and again at 3:00 AM when R3 was returned to his room. The notes indicate that at 4:30 AM that R3 is resting in bed. The notes further state that at 6:25 AM a Code Yellow was called, and when R3 was returned to the facility that his electronic monitoring device did activate the alarm signal. Staff interviews revealed that the Code Yellow was not called until the visitor came to the facility to report that they may have a resident missing. Record review for R3 revealed R3 was admitted to the facility on 7/13/01, with diagnoses in part of Alzheimer's disease, with Acute Mental Status Change. An evaluation by Z2 (Psychiatrist) dated 7/24/01 revealed R3 was alert to person only with decreased memory and poor insight. Review of the Minimum Data Set (MDS) dated 7/20/01 revealed R3's short term memory was impaired, cognitive skills were moderately impaired - decisions poor; cues and supervision required. R3 was not identified as having wandering behavior. R3's ambulation was identified as independent. Review of the nurses notes revealed R3 was admitted to the 300 hall on 7/13/01. R3 attempted to leave the facility on 7/14/01 several times. The nurses notes identified that R3 was moved to the 100 hall on 8/10/01. The nurses notes of 8/11/01 identified that R3 went to the exit doors 2 times and was brought back. The electronic monitoring device was working. Review of the Wandering Resident Monitor form revealed the start date for monitoring R3's elopement behavior was not started until 10/5/01 at 4:30 PM. Interview of E13 on 10/12/01 revealed R3 was initially admitted to the 300 hall because the family did not want R3 on the Alzheimer's unit. R3 was transferred off the 100 hall at the family's request and after R3 eloped he was moved back to the 100 hall. Interview of E5 (LPN) on 10/4/01 at 12:20 PM revealed she was in charge of R3 on 8/9/01 when he eloped from the facility. E5 stated she did not know R3 had left the building, and she did not hear the door alarm sound. E6 (CNA) told E5 a resident was out of the building. E5 stated she was informed that it was R3. E5 identified R3 was returned to the facility about 6:40 AM, and he did not have any injuries. R3 was confused, tired and seemed happy to be back in familiar surroundings. R3 was dressed in a shirt, pants and shoes. E5 stated R3 would not be capable of being out of the facility without supervision because he could not recognize safety hazards or know where he was going or how to return to the facility. E5 identified on 8/9/01 at 2:15 AM, and 3:00 AM, R3 was wandering off the 300 hall. R3 was returned to his room and was put on every 15 to 20 minute checks; however, neither E8 (CNA) or E5 documented any visual checks. E5 said she recalled the last time she checked on R3 was at 4:30 AM. E5 stated E8 (CNA) was the direct care staff in charge of R3 on 8/9/01. E5 stated she reported to E1 (ADM) on 8/9/01, that E7 (LPN) did not follow the proper procedure for responding to a door alarm when R3 had eloped from the facility. E5 identified that she started the investigation regarding R3's elopement immediately. E5 stated she interviewed E7 and determined that E7 did not call "Code Yellow " until after R3 was reported missing by the visitor. E5 stated a "Code Yellow" was to be called when a door alarm sounds and no one can be seen going out the door. E5 said that E7 told her she looked out the front door; however, she did not look around the outside of the facility. E5 stated she completed the incident report; however, she did not call the Illinois Department of Public Health. E5 stated she asked staff on duty to write statements, but she did not receive any from the on duty staff. Interview of E7 on 10/5/01 at 10:10 AM revealed on 8/9/01 she heard the front door to the facility sound around 6:00 AM. E7 stated she looked out the front door and did not see anyone. E7 stated she did not go out the door and look around the building. E7 stated she thought it was an employee coming into work. E7 stated she returned to the 100 hall where she was working. E7 stated she did not call a "Code Yellow" but she knew she should have called one. E7 stated she received a call from the kitchen staff stating a visitor was in the kitchen, and found a person who he thought might be a resident walking down the road. E7 stated she went outside and saw that it was R3 down the road standing with 2 women. E7 stated she took her car, and returned R3 to the facility. E7 identified that R3 was confused and stated he was on his way to work. Interview of E12 (CNA) on 10/4/01 at 1:30 PM revealed she was on duty at 5:30 AM or 6:00 AM on 8/9/01 when the front door alarm sounded. E12 stated she and E7 went to the front door and looked out, but did not go outside the door. E12 stated they did not see any one and returned to the 100 hall. E12 stated she did a head count of the residents on the 100 hall and they were all there. E12 stated a visitor came in and said a resident was outside. E12 stated she called a "Code Yellow" to alert the staff someone was out of the building. E12 stated R3 was returned to the facility. Interview of E10 (CNA) on 10/4/01 at 10:50 AM revealed she came on duty at 6:00 AM on 8/9/01. She reported hearing a knock on the door about 6:30 AM, and a visitor came in. E10 stated the visitor stated a resident got out. E10 stated E7 and E12 went outside and the visitor pointed down the street. R3 was about a block away. Interview of Z4 (R3's Power of Attorney) on 10/4/01 at 2:20 PM revealed R3 had a history of being confused at home. Z4 stated that R3 would call her and tell her he was lost; however R3 was sitting on his own front porch. Z4 stated R3 was not capable of being outside by himself because of his confusion. Interview of Z1 (R3's Physician) on 10/5/01 at 10:00 AM in the conference room of the facility, revealed R3 confused, cognitively impaired and was not capable of being out of the facility without supervision. Z1 identified that R3's judgment was poor and he had limited insight. Interview of R3 on 10/4/01 at 1:30 PM revealed R3 was alert to his name but not place or time. R3 stated he was in Arkansas and headed to Granite City. R3 was not aware he was in a nursing home. Interview of E1 (ADM) on 10/4/01 at 9:30 AM revealed she was not aware of R3 eloping from the facility on 8/9/01. Interview of E1 on 10/5/01 at 2:30PM revealed she was aware of R3's attempt of elopement. E1 stated she assigned the investigation to E9 (DON at the time of the elopement). E9 told E1 when R3 left the building on 8/9/01, he was within the staff's sight, and returned in 5 minutes to the facility. E1 stated she was not aware that E7 failed to make a head count of all residents, and failed to sufficiently respond to the door alarms to prevent R3's elopement until this surveyor brought it to her attention of 10/5/01. The facility is located in a residential area, upon a steep incline from the road. There was residential building construction immediately to the south of the building and parking lot. R3 was found south and east of the facility 0.1 miles from the front door of the facility. The temperature average for 8/9/01 from 6:00 AM to 8:00 PM was 63 degrees F to 87 degrees F and sunrise was at 6:08 AM as identified on the weather.com Internet site. |