LINCOLN MANOR

Facility I.D. Number 0021501
2650 North Monroe Street
Decatur, IL 62526

Date of Survey: 10/05/01

Notice of Violation: 12/03/01

Incident Survey

"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.

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 interview, observation, and record review, the facility failed to ensure that one resident, R1, was prevented from eloping from the facility. R1 is assessed by the facility as an elopement risk (leaving the facility without the facility's knowledge). This failure resulted in an immediate jeopardy situation for R1 when she sustained a fall during the elopement that resulted in a fractured right hip and contusions to the right cheek.

Findings include:

Record review of R1's most recent physician's order sheet dated September, 2001 reveal R1 is an 89 year old resident with diagnoses that include senile dementia with agitation, hypothyroidism, and arthritis. Review of R1's September’s physicians's order sheet reveal R1 to be on 3 medications including Prozac, potassium, and Vitamin E.

Record review of R1's most recent minimum data set (MDS) dated 9/19/01, reveal R1 is severely impaired cognitively, and under section E of the MDS (Mood and Behavior Patterns) wandering behavior occurred 4 to 6 days out of the previous 7; and the behavior is coded as "not easily altered".

Interview with R1 on 10/04/01 at approximately 8:00 AM, at a local hospital, confirm R1 to not be oriented as to her own name or what happened to her on 9/29/01. When asked her name R1 replied, "I don't know", when asked what happened to her last Saturday (9/29/01), R1 replied, "I don't know".

Record review of R1's most recent Care Plan dated 9/28/01 under the heading Problem reveal, '(1) Wandering and Egression Attempts...' Under the heading Short-Term Goal, ' (1) R1 will have no incidents of egression by next review.' Under the heading Approach, 'Check R1 daily for presence of her (personal exit warning device) bracelet'

Interview with the administrator on 10/3/01 at approximately 8:30 AM, in the administrators office confirms R1 to be an elopement risk, E1 states "yes, she is an elopement risk, she eloped in April (2001), that is why we have a bracelet (personal exit warning device)on her."

Record review of nurses notes dated 4/26/01 reveal a successful elopement by R1 previously. The notes state, "Director received a call from Oxford House (a neighborhood elderly highrise apartment), that R1 was there. E5 went to walk resident back. No apparent injuries."

Review of an Accident/Injury Investigation Form dated 9/29/01 reveal R1 received a fractured hip when she eloped from the facility. The report states, "Res (resident) apparently eloped from building/ staff indicates no alarm activated. Res found in driveway in laying position."

Review of a nurses note titled, " Followup Report From Occurrence on 9/29/01 with (R1)", reveals a passer-by found R1 and knocked on the door of the facility to alert staff. The report states, "Was told a gentleman was heard knocking on door #3 @ 7:30 PM and told staff, (E3), that an elderly woman had just fallen at the end of driveway and she (R1) couldn't say where she was from."

Interview with E3 (R1's nurse on the day of elopement) on 10/3/01, at approximately 12:00 PM confirm R1 was found outside, injured. E3 states, "A man came to the door and said there is an elderly woman out here who fell and is lost, and wanted to know if she was one of ours. Then I followed him out the door-she was sitting in the approachway (where the sidewalk, driveway, and the yard meet) at the end of the drive. She was almost to the street... it was dark out. We brought her back in a wheelchair (to the facility), assessed her, and found out she had pain in her hip. When we brought her back inside her bracelet (personal exit warning device) set off the alarm, so we know it was working. We called the doctor and sent her to the hospital. Also, when the ambulance took her out of the facility her bracelet (personal exit warning device) set the alarm off again. But I don't remember hearing any alarm go off earlier, we did not know she was out"

Record review of a local hospital Progress Record dated 9/30/01, reveals R1 sustained a fractured hip when she eloped from the facility. The physician states, "wandered out of N.H. (nursing home), found on ground, fx (fracture) R (right) hip, contusions R (right) cheek."

Record review of a local hospital radiology report dated 10/01/01 regarding R1, states, "INDICATION: SUBCAPITAL FRACTURE RIGHT FEMUR."

Observations made on 10/03/01 at approximately 4:00 pm in the company of E1,the administrator, and E3, the nurse who responded to R1's elopement, revealed the area where R1 was found on 9/29/01 at approximately 7:30 PM. Interview with E3 confirmed the resident was found approximately 150 yards from the facility's main entrance, at the end of a blacktop driveway, sloping down and away from the facility and ending at a city sidewalk that connects to an approachway adjacent to North Monroe Street. E3 indicated the resident was found where the sidewalk, the driveway, and the yard join together, less than six feet from North Monroe Street. Observation at this time reveals North Monroe Street to be a heavily traveled, four lane city street with a posted speed limit of 35 miles per hour. Interview with E3 during this observation, confirms that it was dark and that R1 would not have been visible from the facility at the time of the elopement.

Observation by the surveyor, inside the facility, on 10/04/01 at approximately 10:30 AM, confirm all exterior doors to be audibly alarmed. Interview with administrator on 10/3/01 at approximately 8:00 AM, confirm these alarms are used to augment staff supervision by alerting staff if a resident leaves the building. When tested by the surveyor on 10/04/01 at approximately 10:30 AM, all alarms were found to be functional and staff responded appropriately.

Interview with E1 on 10/4/01, at approximately 5:00 PM in the administrators office, confirm that some family members and visitors have the code to silence the alarm system in the building. E1 states, "yes staff have told me that certain people who do not work here are able to silence the alarm."

Record review of the facility's personal exit alarm log sheet dated 10/01/01 reveal there were 13 residents at high risk for elopement present in the facility and wear the (personal exit warning device.)