Facility I.D. Number 0011528
Date of Survey:08/09/02
Notice of Violation:10/11/02
Incident Investigation of 07/23/02
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.
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.
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.
These regulations are not met as evidenced by:
Based on observation, staff and resident interviews and record review the facility failed to provide supervision for one resident of eleven residents who have been assessed for wandering behaviors (R1) (a confused resident who eloped from the facility on 7/23/02).
R1 was admitted on 7/22/02 at 4:30 PM. R1 is 61 years old and has diagnoses of chronic alcoholism and ETOH dementia (alcohol abuse related dementia).
Staff interviews were conducted on 8/6/02, which included E1 (Administrator), E2 (Director of Nurses), E4 (Maintenance), E5 (Licensed Practical Nurse-LPN), and E6 (Registered Nurse-RN). The interviews confirmed that R1 was assessed behaviorally to be an elopement risk the same evening he was admitted (i.e., displayed pacing behaviors and verbally requested to be taken home). E1 indicated he made an attempt to put a wrist alarm device on R1 so staff would be alerted if R1 attempted to leave an exit door. R1 resisted and "was combative." Subsequently, E1 indicated, Z1 and Z2 volunteered to attempt to outfit the device onto R1's wrist, after they visited more with him and he settled down. The device was turned over to Z1 and Z2. The device did not get outfitted onto R1. Nor did staff check anytime later that night, or the next day, if the device had been outfitted to assure R1's safety.
Facility Incident Report of 7/23/02 indicates R1 eloped from the facility. Nurse notes of that date indicate, "Mental Health facility...called here to tell us he [R1] was down @ M.H. heading toward Driver facility." Facility Incident Investigation Report dated 7/24/02 (written by E1) indicates, "Resident returned to room after supper [approximately] 6:15....Approx 6:25 call received from Christian County Mental Health Workshop. They observed a man with a bracelet near their building. Quick head count could not locate resident [R1]. 2 Aides went to Mental Health and retrieved resident....by 6:30 p.m.. Resident must have pushed door alarm canceling button....all alarms functioned properly. Resident was outfitted with watch mate wandering alarm."
Nurse's notes indicate that resident was unharmed after the above incident.
Z3 (a Mental Health Center employee) was interviewed on 8/8/02. Z3 indicated that he and some fellow employees were eating their evening meal outside at a picnic table at the Mental Health Facility, which is approximately 0.2 miles from the Nursing Home and on the opposite side of McAdam Drive.
McAdam Drive is a two lane blacktopped road with no sidewalk and a speed limit of 45 miles per hour. Z3 indicated he noticed R1 walking in the road about 6:15 PM on 7/23/02. Z3 took closer note of R1 when he saw that R1 "didn't move out of the way when a truck came by." He said, "The truck had to veer to miss him [R1]." Z3 "kept an eye on him" and noticed he had "a plastic bracelet on" when he walked to the picnic table. Z3 suspected then that he might be a resident of the Nursing Home so he went inside to call the Nursing Home and asked his fellow employees to keep track of where R1 goes.
E6 took the call from Z3 and asked Z3 what the man in question was wearing. When E6 heard it was "a plaid shirt and blue jeans" E6 figured it was R1. That is when E8 and E9 were dispatched to find and retrieve R1 back to the Nursing Home.
Meanwhile, Z3 went back outside and was told R1 went between the buildings and cut across the railroad tracks that run parallel to the road. Z3 said "went at a pretty good clip." Z1 said R1 got about a block beyond the tracks. Z3 called out to R1 to get him to stop. Z3 indicated that when he caught up with R1 he asked him if he was from the Nursing Home. R1 said, "I think so." Z3 asked, "Are you lost?" Z3 indicated R1 said, "Yes, I think I am." Z3 indicated he could tell by talking to R1 that he was confused and not able to keep himself out of harms way by himself. Z3 convinced R1 to go with him back toward the tracks. Z3 asked R1 if he was OK and said R1 responded, "I'm kind of tired." On the way back Z3 said that they had to wait for a train to go by before getting back across the railroad tracks, around the buildings, and back to the picnic table. There they talked, rested and waited for Nursing Home staff to take him back. Z3 said R1 was easy to direct into the car that came to pick him up by saying it was air- conditioned. Z3 said the whole time period of events was about a half hour or so.
The temperature reported on 7/23/02 in the Taylorville paper was 85 degrees.
R1 was interviewed on 8/8/02. He was asked if he remembered going out of the building by himself a few weeks ago. He said, "No." He said, "My memory is just now coming back to me. I just now realize where I am. I thought I was back in my bedroom upstairs." He was asked if he knew where he lived previously and he said, "Edinburg." Edinburg is 10 miles from Taylorville. He was asked if he knew how to get to Edinburg from here. He said, "I don't know, are we in Springfield?"
R1's assessment completed on 08/02/02 identified R1 to have a cognitive level "1" with short term and long term memory problems. R1 was unable to name any of the items on the "recall" area.
The facility did the following in response to the incident:
a) Alarm device bracelet applied to R1's wrist upon return from elopement incident on 7/23/02.
b) Elopement policy inservice conducted for all staff on 8/1/02.