HEARTLAND HEALTH CARE CENTER-GALESBURG Facility I.D. Number 0041806 Date of Survey:07/26/02 Notice of Violation:09/13/02 Incident Investigation of 07/12/02 "A" VIOLATION(S): The facility shall provide a Resident Services Director who is assigned responsibility for the coordination and monitoring of the resident’s overall plan of care. The Director of Nurses or an individual on the professional staff of the facility may fill this assignment to assure that resident’s 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 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. 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. Based on observation, record review, and interviews, the facility failed to respond to a verbal cue of elopement by R1, thus enabling R1 to leave the facility unattended, and the facility failed to do a exterior perimeter search of the building after the door alarm was activated. Findings include: R1 was admitted to the facility on 04/13/01. Among her diagnoses listed on the current physician's order sheet (POS) is senile dementia, anxiety, chronic obstructive pulmonary disease (COPD), emphysema, and hypertension. The current POS also has an order for oxygen 2 liters by nasal cannula whenever necessary (PRN). R1's current Assessment dated 04/22/02, identifies R1 as being confused, disoriented, and moderately impaired at making decisions. The MDS also indicates that R1 has a behavior of wandering and is independently ambulatory, requiring only supervision from facility staff. R1's current care plan dated 05/08/02 identifies that R1 is a "Potential exit seeker, is confused, and is mobile". R1 was observed on 07/19/02 at 10:15 AM walking independently in hallway pushing a wheelchair in front of her. R1 was using oxygen per nasal cannula with the oxygen tank fastened to the wheelchair. During interviews with E10 (staff nurse) on 07/19/02 at 1:50 PM, E8 CNA (certified nurse aide) on 07/19/02 at 2:10 PM, and E7 (CNA) on 07/19/02 at 2 PM, all stated that R1 is a confused resident and that she becomes short of breath when walking around without her oxygen. All stated that R1 likes to go out to the enclosed courtyard to smoke and that if R1 decided to go outside, R1 would not know the difference between the door that leads to the courtyard, and a door that exits to the outside of the building. E10 also stated that R1 is too confused to realize if she needs oxygen, or that the oxygen will help her breathe better. E10 also stated that R1 becomes more confused when she is not using her oxygen. An interview attempted with R1 on 07/19/02 at 1:40 PM verifies that R1 is not oriented and could not answer simple questions appropriately. R1 stated that she likes to go outside and that she uses oxygen, but she doesn't know when or why. R1 showed no knowledge of safety awareness. In the interview with E7, on 07/19/02 at 2 PM, E7 stated that on 07/12/02 around 6:15 PM, R1 left the dining room, independently ambulating. E7 heard R1 say "I'm going home now," as she left the room. E7 stated that she remained in the dining room, and that the alarm on the northwest door that exits to the west side of the building sounded a few minutes after R1 had left the dining room. E5 (staff nurse), interviewed on 07/23/02 at 8:45 AM, stated that she responded to the door alarm by going to the door, opening it, and looking down the west side of the building. When she did not see anyone she walked around the corner to the front of the building and then back inside. E6 (ADON), Assistant Director of Nurses, interviewed on 07/23/02 at 1:20 PM, stated that she also responded to the door alarm by walking outside the front door. According to E6, she saw E5 and went back into the facility. Neither employee circled the perimeter of the building before going back inside. Both stated that their main concern was the busy traffic on the street in front of the building. According to E5 and E6, once inside, E7 informed them that R1 had left the dining room. A search of the inside of the facility was done by E5 and E6. When R1 still was not found a second "sweep" of the building was started, and E8 and E9 (CNA's) were told to search outside. According to E5 she decided to recheck the back of the building as there is a large hole in the lot behind the facility from the basement of a house that had burned down. It was at this time that E5 saw a man driving a car toward the facility, and R1 was sitting in the back seat. According to E5, the man and woman in the car stated that they had found R1 walking a "couple of blocks" down the street, knew she belonged in the nursing home, and were bringing her back. E5 interviewed on 07/23/02 at 8:45 AM and E6 interviewed on 07/23/02 at 1:20 PM stated that it was between 30 to 45 minutes from the time the door alarm sounded and R1 was brought back to the facility. E5 and E6 were the staff who responded to the door alarm and conducted the search. During an interview with E8 at 2:10 PM on 07/19/02, E8 stated that he observed R1 outside as she was brought back into the facility and that R1 was breathing hard. E5, however, felt that R1 was anxious and upset upon return to the facility as she did not want to get out of the car. Per the Climate Control Service at the University of Illinois, at 6 PM on 07/12/02, the temperature was 72 degrees, with a relative humidity of 47 %, and winds at 7 miles per hour. E5 stated during interview on 07/23/02 at 8:45 AM, that R1 was dressed appropriately, in shoes, slacks, blouse and sweater. E1(administrator) stated in an interview on 07/19/02 at 3 PM, that she returned to the facility the night of the incident and began her investigation. It was at this time that she interviewed E5 and corrected her, informing E5 that she should have circled the perimeter of the building immediately when she did not see anyone outside the northwest door. E5 was also counseled on completing a thorough assessment on a resident upon their return to the facility. This is verified by E5 in interview on 07/23/02 at 8:45 PM. According to E1, interviewed at 9:15 AM on 07/23/02, the facility's policy regarding "exit seeking residents" is that any resident who exhibits one of the four following triggers would be considered at risk for elopement and placed in their exit seekers program:
E1 also stated that when R1 said that she was going home, E7 should have followed R1, or alerted other staff to supervise her. E1 also stated that when the door alarm sounded staff responding should search the exterior perimeter of the of the building if they do not see the person who set off the alarm. Per observation, the facility is located in a residential area. The building has city streets on two sides. R1 exited from the door on the northwest corner of the building. The street outside the front, north side of the building has a constant flow of traffic, with a speed limit of 30 miles per hour. The side street on the east side of the building has no speed limit posted. There is a cement parking area outside the facility on the east side that is on a steep incline. Just behind the facility on the south side is an empty lot where a house burned down. There is a large hole approximately two feet deep and the length and width of the house basement. The house southwest of the facility has an above ground swimming pool surrounded by a chain link fence that did not have a lock on the gate at the time of observation on 07/23/02 at 11:AM. E1 stated during an interview on 07/19/02 at 3 PM, that the "Missing Resident Locator Form"is the facility's policy that the staff would use as guidance when a resident is missing from the facility. It is not stated clearly that the exterior perimeter search should be conducted as a first step to locating the resident that is thought to have left the building. The policy states, "1. Whenever a staff member discovers a resident missing, or hears an alarm that may indicate a resident has left the center, the staff member immediately conducts an initial internal or simultaneous external search of the immediate area to locate the resident." Per interview on 07/23/02 at 8:45 AM E5 was not aware of the form, or where it was located. |