CONVALESCENT CARE CENTER - MATTOON
Facility I.D. Number 0036897
Date of Survey: 08/02/01
Notice of Violation:01/02/02
Incident Investigation of July 14, 2001
Personal care shall be provided on a 24-hour, seven-day-a-week basis to include, but not limited to, the following:
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 ABUSE OR NEGLECT A RESIDENT. (a, b) (Section 2-107 of the Act)
This requirement was NOT MET on July 14, 2001 as evidenced by:
Based on record review, observation and interview the facility failed to provide an adequate supervision system for R1 which resulted in R1 leaving the facility without staff knowledge. The facility was notified of R1's absence by a citizen. R1 was found by staff stuck on a railroad bridge approximately 100 yards west of the facility.
The findings include:
1. Per admission record review R1 was admitted to the facility on 11/02/01. R1 is 83 years old and resides on the Annex East Alzheimer's unit. R1's diagnoses on the current physician's order sheet are Multifocal dementia, Dependant Edema, Anxiety Disorder and Hypertension.
An incident report dated and transmitted to the IDPH Regional Office via fax on 7/15/01 at 2:30 p.m. and hotline information sheet dated 7/16/01 at 12:55 p.m. indicated that Director of Nurse's (E1) notified the Department that a local person from the community had informed staff on 7/14/01 (a Saturday) at approximately 1840 (6:40 p.m.) that a lady in a pink sweater was walking on the railroad tracks. The report stated that staff found R1 in a supine position with left leg caught between railroad ties. The report stated that R1 had sustained a dime sized abrasion to left lower extremity and had slight edema. The resident was transported to hospital emergency room and was returned to the facility with no fracture. The report stated that a full investigation was in process.
On 7/17/01 at 5:59 p.m. E1 sent a summary report of the incident to the department that stated R1 had "no fracture, soft tissue trauma (bruising) and approx. dime size abrasion to left knee." The report concluded "After thorough investigation and interview with staff members it was determined that the east exit door on the Alzheimer's Unit had a pin, which is part of the locking mechanism , which was catching on the threshold and allowing the door alarm to be reset without the door being 100 % closed."
2. On 7/30/01 at approximately 9:45 a.m. the Alzheimer's Unit (Annex East) was toured with E1. The unit is a locked twenty seven bed unit with a census of 14 residents. It was observed that the Annex East unit can be entered from the north foyer through a set of double fire doors that are located at the west end of the corridor. The unit is one hall. There are ten rooms on the north side and seven rooms on the south side. The lounge/dining room and nurses station is located approximately in the middle of the unit. There is a set of double doors to exit at the east end of the corridor that leads to a fenced in courtyard with a five foot high chain link fence with two north gates side by side. There is a dining room exit door on the west side that exits to a wooden patio and the fenced courtyard.
Per interview with E1 at 9:45 a.m. and E2 at 11:00 a.m. in order to leave the unit at the west end of the unit corridor into the north foyer, a code must be entered into a key pad to release the door. The door has a locking mechanism that otherwise releases after 15 seconds after the panic bar has been pushed. Once the code is entered the unit can be exited by pushing on the door (not the panic bar). An alarm is activated any time the panic bar is touched or the door is opened without a code. Per interview with E3 the alarm reactivates in 5 seconds and door relocks.
Administrator (E2) showed surveyor the east doors at 11:00 a.m. and stated that at the time of the incident on 7/14/01 the Annex East exit doors and the dining room door were equipped with a magnetic lock and locking pin mechanism with 15 second release and a turn key alarm reset located beside the door. The door alarm system was designed to alarm when the door is opened or the panic bar is pushed. E2 stated that when he checked the doors the night of the incident it was discovered that the right door was catching at the bottom so it wasn't closing completely. E2 stated this allowed the staff to reset the alarm with turn key, however if you pushed on the door glass above the panic bar the door would open without setting off the alarm as the pins had not engaged. E2 stated on 7/31/01 at 10:45 a.m. that he had discovered this on 7/14/01, following the incident. E2 stated that after he had been at the facility awhile one of the staff had told E2 about a possible door latching problem that one of the Certified Nurse's Aides (CNA) (E9) had told them about.
On 7/30/01 it was observed that the doors now had a keypad control and hardware had been installed that will not allow the door alarm to be reset unless the door was completely closed. The facility had also added an additional personal alarm which would also activate if the door was opened to the two exterior exit doors of the unit.
3. On 7/30/01 at approximately 10:00 a.m. surveyor walked with E1 from the fenced courtyard just outside the east exit to the railroad tracks that were approximately 30 yards north of the facility. Surveyor and E1 walked toward the west on the railroad tracks. It was observed that the wooden railroad ties were warped and cracked and that the gravel surface between rails was uneven. Approximately 100 yards down the track from the facility was the railroad bridge where R1 was found. The bridge was approximately eight feet wide and had no guardrails.
The bridge crossed a ravine approximately 15 feet deep by thirty feet wide that had areas of standing water and chunks of cement at the bottom. The tracks themselves were five feet wide with wooden railroad ties spaced approximately 6 inches apart. The ditch bottom could be seen through the empty spaces between the ties. There were two areas on the bridge where the wooden ties were split and broken leaving a gap approximately twelve inches wide by four feet long. Per multiple staff interviews R1 had been found with leg lodged in one of the large gaps. The facility was not visible from the bridge only the treeline around the facility could be seen. There was a tall grassy field on the north side of the tracks. There was a road and houses on the west side of the bridge. There were a couple of brick water treatment buildings that were boarded up on the south side of the tracks between the bridge and the facility. Per interview with E2 trains do occasionally use these tracks.
4. R1 was observed on the Alzheimer's unit throughout the day on 7/30/01. R1 was observed to be seated in the dining room or walking on the unit visiting with other residents. On 7/30/01 at approximately 12:30 p.m. R1 was interviewed in her room. R1 had walked to her room with the surveyor and had a slow steady gate. R1 was wearing pants, no socks and tennis shoes. She pulled up pant legs so her lower legs could be viewed in response to a question about how her legs were. R1's ankles were slightly swollen and there were faint bruises along both shins. R1 was asked what happened to her legs. R1 responded "I had a big accident." R1 stated "I was helping a lady looking for some animals and the fence broke and the animals got out." When asked if she remembered being on the railroad tracks? R1 did not recall. When asked if R1 remembered being on a bridge ? R1 responded " It scared me!" "I think I lost my equilibrium".
R1's most recent Minimum Data Set (MDS) assessment dated 6/13/01, identified R1 to have short term memory problems. R1's cognitive skills for daily decision making were moderately impaired (decisions poor; cues /supervision required.) Behavior symptoms identified were wandering on a daily basis and behavior was not easily altered. Per interview with E1 during initial tour of the unit on 7/03/01, E1 stated that R1 frequently states that "she is going home."
R1's care plan of 6/28/01 identified "Potential for elopement from facility due to cognitive loss, due to vascular dementia and wandering." and "High risk for falls due to vascular dementia and unsteady gait at
5. On 7/30/01 at 11:00 a.m. staff nurse (E4) was interviewed . E4 stated that on the night of the incident it was his third night working in the facility. R1 was in the dining room for supper with the others during his med pass. E4 stated he went to lunch around 6:00 p.m. and returned to the unit about 15 to 20 minutes later. (per time card clocked out at 6:04 p.m. and clocked in at 6:23 p.m.)
E4 stated when he returned to the unit he went to the nurse's station at this time R1 wasn't in the dining room. E4 stated he was still at the nurse's station when E8 came to the unit around 6:45 p.m. and informed them that a "Mattoon resident" reported that he had seen an elderly woman walking on the railroad tracks. E4 stated that they did a head count and determined that R1 was missing. E4 stated that he, E8, and E5 went out to the tracks to look. E4 stated that after going down the tracks looking toward the east and not finding anything they went to the west. E4 thought he could see something on the tracks in the distance. They found R1 in the middle of the railroad bridge.
E4 stated that R1 was face forward on her hands and knees and that her left leg was through the opening between the ties up to her knee and the other foot was between the ties to the ankle. E4 stated he did a physical assessment and sent E8 to call ambulance. A neighbor came to the tracks and told them that he had already called. E4 said that R1 had stated that she "was going to the store for her mother and that she had fallen and couldn't get up." E4 stated that they did not feel they could safely get R1 off the bridge themselves so E4, E8 and E5 waited with R1 until the ambulance arrived for help.
6. Housekeeper (E8) was interviewed on 7/30/01 at 11:30 a.m. E8 said he had worked in the facility for a month. E8 stated he was in the first dining room in the front of the building when a man reported a lady in a pink sweater was on the tracks. E8 stated that he knew that R1 was wearing a pink sweater that day so he ran to the alzheimer's unit to tell them that E8 thought R1 was out on the tracks. E8 stated he was present when they found R1 on stomach on bridge with one leg caught in the bridge gap.
7. Utility Aide (E5) was interviewed on 7/30/01 at 2:15 p.m. on the unit and CNA (E6) was interviewed by telephone at 4:00 p.m. E5 stated it was her third night on the unit and E6 stated it was her first full night on the unit. Both staff persons were working on the unit during the time of R1's unnoticed absence from the facility.
E5 stated that R1 had finished with supper and was wandering around and had been to the doors. E5 stated that whenever the alarms went off she or E6 went to check they would find residents at the doors and both she and E6 had reset doors alarms.
Based on interview and review of their written statements they had last seen R1 around 6:20 p.m. E5 and E6 had then gone together into a resident room to assist a resident to bed. Neither staff had heard an alarm or were aware that R1 had left the facility until they had been notified by E8.
E5 stated that she hit the panic bar at the east door and went outside. E5 stated at that time the alarm went off. E5 stated that the gate was closed with a bungee cord and the other gate was closed but stake was not in ground so it would open.
8. E6's written statement from 7/14/01 was reviewed and revealed that E9 had come to the unit and told staff about a "door trick" to always pull the door back in after shutting alarm off with keys. That the door doesn't always shut completely and after turning key for alarm they (residents)can go out without alarm going off.
At 4:00 p.m. E6 was interviewed per phone. E6 stated that she had stayed on the unit while the other staff searched for R1. E6 indicated that E9 had come to the unit from another hall and told her about the door and E6 also stated that another staff had made a statement to her a few days after the incident about having a similar problem with the door that had been reported along time ago.
9. CNA (E9) was interviewed by phone on 7/31/01 at 7:30 a.m. and stated that he had discovered the first time he had worked in the facility on the unit approximately eight or nine months ago that the east door did not always close all the way and when he pushed on the door that it opened and the alarm did not go off. E9 stated that he had reported the problem with the east door failing to completely close to the unit nurse and that he had completed a work order at that time. E9 currently works weekends only and stated that he rarely works on the Alzheimer's unit.
10. CNA (E10) was interviewed on 7/31/00 by telephone at 11:20 a.m. E10 stated that the very back door facing the fence on the Annex East didn't always latch after it had been open and had slammed shut. E10 states that she always pulls the door to make sure it is closed because you can't tell by looking at it. E10 stated that she had last reported the problem to the former administrator and director of nurses approximately 6 months ago. E10 stated she floats and works on the unit approximately once per week. E10 did not know if the door was not latching recently because she automatically pulls the doors toward her when she resets the alarm.
11. The Facility Elopement Risk book identified residents with exit seeking behaviors. Photographs of the residents were included. Per review of this book, R1 was assessed as an elopement risk. Per review of updated elopement risk list dated 7/16/01, there are twelve residents on the unit that have been identified as an elopement risk. R1 is currently on 15-minute visual checks.
Interview with E1 on 7/30/01 at 1:00 p.m. reveals that staff document observations of residents on a visual check sheet. This documentation is sent to medical records after completion.
The Visual Check Sheet for 7/14/01 was reviewed for R1 with E1 on 7/30/01 at 1:00 p.m. in the medical records office. It had times listed in half hour intervals for each day from 12:00 a.m. until 11:30 p.m. Staff had documented that R1 was on the unit continually for that (7/14/01) day. E1 was asked about the discrepancy. E1 stated that when she had looked at the sheet after the incident occurred, the 6:00 and 6:30 p.m. block had not been filled in. R1 had also been in the hospital until after 8:00 p.m. per review of nurse's notes.
E12 had been working in medical records since 7/09/01. E12 stated that "If the visual check sheets have blanks on them I give them back to the CNA's to fill in." E1 was present during this conversation and was unaware that this was happening and informed E12 not to sent them back to the units. Previous medical records staff E11 also stated in interview on 7/30/01 that she also took visual check sheets back to the CNA's to fill in if there were blanks and she did not report those individuals.
12. Maintenance Director (E3) was interviewed on 7/30/01 at approximately 11:45 a.m. while E3 and E13 were on the Annex East changing the codes for the exit key pads. Per interview with E3 the codes to the door alarm pads are changed each week. E3 stated that all doors are checked on a daily basis Monday-Friday to insure that the door alarms work and that doors close properly. Review of the July 2001 facility preventative maintenance log and interview with E3 confirmed that the exterior doors were not being routinely checked for proper function on weekends prior to this incident. E3 stated that they had been checking doors on a daily (M-F) basis for sometime including prior to R1's incident. E3 stated that on the night of the incident he had been called in to work on the left exit door as the weatherstripping was causing the door not to shut completely and there was a striker that needed adjustment. Surveyor stated that E2 had said that it was the right door that wasn't working properly. E3 insisted that he had worked on the left door. E2 later clarified that due to a misunderstanding E3 had worked on the wrong side of the double doors on 7/14/01. The next day, the left door was repaired by grinding off the pin that had come down at the bottom of the door to allow the door to completely close.
E3 stated that no one had reported any problems with the door not closing. E3 became maintenance director in January of 2001. E3 stated he had no work orders for these doors. E3 stated that if door problems are found during daily checks that adjustments are made and it is not documented. E3 stated that he also works on doors from verbal comments and does not fill out work orders.