HICKORY NURSING PAVILION Facility I.D. Number 0032029 Date of Survey:06/20/02 Notice of Violation:07/24/02 Licensure Incident of 06/18/02 "A" VIOLATION(S): Categories of Personnel 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 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. General Requirements for Nursing and Personal 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. General nursing care shall include at a minimum the following and shall be practiced on a 24- hour, seven day a week basis. 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. General Building Requirements 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 clinical record reviews, staff interviews, police incident reports, review of maintenance logs and facility policy and procedures, the facility failed to properly supervise 2 of 2 residents of the facility (R11, R12) identified as wandering/elopement risks and wearing electronic monitoring devices. The facility failed to check the door alarms and wandering devices daily as per their policy, failed to update care plan of R11 after a previous elopement attempt, failed to assure that the door alarms were in working order, and failed to provide the necessary supervision for these residents as in both incidents. The facility discovered the residents missing about the same time as the police or family member called to inform them that they had the resident. Examples include: R11, with a diagnosis if dementia, chronic renal failure, diabetes, on hospice care was admitted on 4/10/02. An electronic monitoring device was placed on R11 at admission. Review of incident report indicates that on 6/18/02 R11 left the building without supervision and was found by the police approximately 6 blocks away at 12:35 p.m. wandering and going through a garbage can without shoes on. Police took R11 to the emergency room and notified the facility at 12:45 p.m. Facility chart indicates the staff became aware of R11 missing at the same time the police called them. R11's record clearly indicates that R11 had a previous elopement attempt from nursing notes dated 6/16/02 and from a wandering assessment where the wife indicates that resident eloped twice from another facility. On 6/16/02 at 4:20 p.m. resident was found walking down the busy street in front of the facility which is a 4 lane road going north and sound heavy with traffic. R11's wandering continued 6/16/02 when at 7:00 p.m. he was found in another resident’s room. On the day of the incident, 6/18/02, nurse’s notes state that R11 was last seen at 11:45 a.m. There was no evidence that facility responded to R11's increased elopement risk by monitoring, checking his alarm device, or instituting any changes in his care plan. R12 has a diagnosis of dementia, hypertension, psychosis, altered mental status and admitted on 5/16/02. An electronic monitoring device was placed on this resident at admission due to history of wandering as identified on the admission note. R12 is also described as confused on admission. On 5/17/02 at 12 midnight, facility became aware that R12 was missing per review of nursing notes. At 12:05 a.m., 911 was called. At 12:15 a.m., the brother of R12 called the facility to tell them that R12 was brought to his home by police. Police report indicates they respond to a senior citizen walking westbound at 11:53 p.m. approximately 1 mile from the facility by a forest preserve and at a busy intersection. Facility was aware that R12 was a new resident and known wanderer and failed to supervise and monitor this resident as per their policy, and there was no evidence that monitoring device was checked or doors were checked. This incident was not reported per interview with E1 to Public Health. Surveyors entered facility on 6/19/02 and discovered facility had two residents identified as wanderers and had electronic devices applied (R11 and R12). A tour was made to check doors and devices. Facility has 5 exit doors. The north and South doors had keypads and were in working order. The front door was identified as having electronic device equipment and faces as a busy street. This door was not working and per E1 and E9 (maintenance) the tile was cracked underneath the carpet and was interfering with the circuit for the electronic monitoring device. The facility found this out after the 6/18/02 incident. The other door southwest is also identified as an electronic monitoring door and was not working when tested by surveyors. Switch was turned off at times per interview with R14. R14 stated that she has often observed R13 turning off this door alarm. The last facility door is the northwest door which leads to a fenced yard–although the surveyors noted that the fence was open and leading to the parking lot. This door not working. E8 (housekeeper) stated that door “not working last couple of months”. E8 attempted to flip the switch, upon prompting by surveyors that alarm was not working, E9 decided that it was a short. Since incident, facility has put supervision on the doors until repaired. Review of facility policy on electronic monitoring devices states that alarms are to be checked daily and devices are to be checked every shift. The elopement policy states that supervision will be done, care plans will be revised as needed and all staff will be made aware of the wandering residents. None of these approaches were done in above cases. Facility staff were interviewed and E4 stated she was unsure if R12 wore a device. E5 stated R11 is a wanderer but doesn’t wear a device to her knowledge because if he was wearing this device, it would go off. Maintenance logs show only weekly checks done of doors. For the incident of 6/18/02–door last checked per log on 6/14/02. For the incident of 5/17/02, checks done 5/13/02 and then not again until 5/20/02. Care plans were reviewed, and show that R11's care plan only lists device to left ankle with no dates, no other interventions, no plans for supervision and monitoring. On R12's care plan, there is nothing that addresses the application of the monitoring device, or the history of wandering. R12's care plan was also not updated after the incident of 5/17/02. |