ALDEN POPLAR CREEK REHAB & HCC
Facility I.D. Number 0032896
Date of Survey: 01/24/02
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 and personal care shall be provided to each resident to meet the total nursing and personal care needs of the resident.
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.
AN OWNER, LICENSEE, ADMINISTRATOR, EMPLOYEE OR AGENT OF A FACILITY SHALL NOT NEGLECT A RESIDENT.
Based on observations, staff and family interviews, and record reviews, the facility failed to supervise R1, who is a known wanderer as evidenced by facility's care plan, to prevent R1 from leaving the facility unaccompanied and from leaving the 2nd floor unsupervised.
R1 was found in the side parking lot, on the ground, calling for help, about 3:00am, on 12/04/01. The area around the facility includes a 4 lane, busy highway. The entrance roads are shared by a hospital, an assisted living facility, three facility parking lots, and a golf course with open water, behind the facility. Per call to the Chicago Library on 1/9/02, the temperature 12/04/01 was; "Low 54 Degrees Fahrenheit."
R1 was dressed in a shirt, pants and shoes, per E8's interview of 1/08/02. Per the nurse's notes of 12/04/01, R1 was last seen about 1:30a.m., after falling in his room. R1 is 80 years old and his diagnoses include: Congestive heart failure, Pacemaker insertion, Anxiety Disorder, Depression, Dementia other than Alzheimer's, Hypertension, Gastritis, and Renal failure receiving Dialysis 3 times a week. R8 has a left arm A-V fistula from 11/19/01, with sutures due to be removed 12/04/01 by Z2. Z1's orders include, "11/22/01: Therapeutic Pass w/meds & instructions w/accompaniment prn." R1 was not allowed out alone.
Per 1/08/02 interview of E8, E8 heard someone calling at different times. R2 told E8 that someone was calling for help. E8 thought it was someone in another room. Later, about 3:00a.m., R2 called E8 to her room. She said it sounded like the calling was from outside. E8 then looked out the window and saw R1 on the ground, lying in a parking space, and went out to get him with E9. E8 said R1's wheelchair was still at the nursing station on 2nd floor and R1 had gone out the door next to the nurse's station, down the stairs, and out the side door. R1 was ambulatory, sometimes in his wheelchair, and was a resident on the 2nd floor.
Z1's progress notes/exam of 12/06/01; " Resident found outside facility few days ago-bruises. Exam ... Nasal septum in midline with mild tenderness in upper part with small ecchymosis (L) Supra-orbital area. ...Extremities with 2++ edema, (L) arm with ecchymosis, ulceration with a clean base.
A. 1) Multiple bruises and contusions. No fx.
2) Confusion, Dementia.
P.) Close observation. Daughter advised to move patient to Closed - up unit."
R1's record review revealed that R1 was non-compliant with his diet of no salt and fluid restriction and would be found, eating salted popcorn in the lower level from the open popcorn cart. Staff would tell him not to go down, but he "would forget an hour later," per nurse's notes of 11/30/01. Record review nurse's notes had documentation of R1 trying to leave the floor on 11/23/01; 9:30pm "attempted to leave the floor several times...", 11/24, "attempted to leave unit to lower level," and on 11/24/01, 4p.m., "Unable to locate resident. Was in lower level eating popcorn. Returned to 2nd floor. Area on Left hand bleeding."
Record review revealed that R1 had gotten out of the facility before. Nurse's notes of 6/12/01, "7:30p.m.. Attempted to leave the facility 3 times." No incident report. The next day, 6/13/01, notes document that "(R1) was found walking outside the facility. M.D. and family made aware. New orders noted." No incident report made and no investigation to determine how he got out of the facility.
Observation of the first floor side exit door and the hall door leading to it , was noted to be unlocked and unalarmed about 1p.m. on 1/08/2002. The doors are marked "Alarmed." E9 was coming down the stairs and leaving. Surveyor asked E9 to go out and then try to open the door from the outside. E9 stated that, "This door is never locked or alarmed." E9 left and then came back in. This is the door to the parking lot where R1 was found by E8 and E9.
Subsequent tour of the facility with E1 and E3 revealed; 6 exit doors from the 1st and 2nd floor had alarms that were so soft, one could barely hear them. The alarms on the two doors by the nursing stations were barely audible. The other stair exits were at the end of the hall and by the other end of the hall. No alarms could be heard if staff was in a room. None of these exits are monitored.
At this time, E1 told surveyor that R1 had gotten out by the lower level "Dock door" leading to the back parking lot. Inspection of the "Dock door" revealed a right broken lock. E1 stated that the evening supervisor sets an alarm at 8p.m. and it's unset at 5:30a.m. when kitchen staff come in. E1 stated that E5 apparently forgot to set the alarm. E1 stated that R1 was found in the back parking lot and was seen when a resident went out on the enclosed patio to smoke. There are no documented interviews of floor staff indicating R1 was found in the back parking lot. If this occurred, there is no incident report and investigation.
Review of the schedule of 12/03/01 and 12/04/01 and staff interviews of E8 and E3, and nurse's notes of 12/04/01, revealed that R1 was found in the side parking lot on 12/04/01. The resident that heard him calling, resided next to the nursing station exit door to the stairs. The alarm/ light panel at the nursing station had no alarm for the outside doors.