Morton Terrace Care Center
Facility I.D. Number: 0045500
Date of Survey: 7/31/02
Investigation of the Incident of 07/19/02
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 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 observation, record review, and interview the facility failed to monitor resident R1, when R1 was exhibiting exit seeking behavior. R1 left the facility without staff knowledge, wandering away from facility property.
R1 is an eighty year old female admitted to the facility on 03/21/02. The incident report dated 07/19/02 indicated that R1 exited the facility on 07/19/02. Interview with the facility's administrator (E2) at 11:00 A.M. on 07/29/02 and written statement by certified nurse aide (E6) indicated that R1 was last seen by E6 at 6:50 P.M. on 07/19/02 when E6 redirected R1 away from the Gateway exit door which exits to the out side of the facility. Interviews with CNA (E5) and unit nurse (E11) in the P.M. of 07/29/02 and written statements by E6 and CNA (E9) dated 07/19/02, verified that R1 was not monitored by staff, as outlined in her care plan, after being discovered by E6 attempting to exit the building. Interview with CNA (E5) at 2:50 P.M. on 07/29/02 verified that she had seen R1 at 6:15 P.M.
on 07/19/02 walking and carrying a bundle of clothes to include sweater, shirt, pants and a purse and R1 said she was going home. According to the incident report dated 07/19/02 the facility was contacted at 7:17 P.M. on 07/19/02 by telephone from the local police department stating that a resident of the facility was in their custody. This was the first time that the facility staff were aware that R1 was not in the facility. From the above interviews and written statements it was verified that R1 was not observed in the facility by staff from 6:50 P.M. until 7:20 P.M. on 07/19/02.
Telephone call to the police department at 11:05 A.M. on 07/29/02 indicated that R1 had been seen by unidentified persons approximately four blocks from the facility. These unidentified persons called the police who picked up R1 and returned R1 to the facility.
The facility is located in a residential area. The building has a city road in front which has a moderate traffic flow and a sidewalk. The speed limit is thirty-five miles per hour. There is an apartment complex with a communal garage on the south side and a residence on the north side of the facility. There is an eight foot tall fence between this property and the facility's property. The street where R1 was discovered is located behind the facility in a subdivision that has no speed limit signs.
During telephone contact with the National Weather Service at 3:05 P.M. on 07/29/02 it was verified that at 7:00 P.M. on 07/19/02 the outside temperature was eighty-four degrees Fahrenheit and the humidity was seventy percent making a heat index of ninety-three degrees Fahrenheit.
R1's current physician's order sheet (POS) verified that R1 has a diagnosis of Dementia with Suicide Ideation and Organic Brain Syndrome with Agitation.
R1's current Care Plan dated 07/03/02 indicated under Cognition/Activity that R1 has poor short term memory and often spends most of her day packing her belongings and looking for the way home. R1 attempts to elope several times a day. R1's care plan dated 07/03/02 for Mood/Behavior indicated that R1 is restless daily and says she wants to go home daily. Documentation in the same care plan further indicated that R1 is considered an elopement risk, eloped 7/19/02, has a history of making suicidal statements and has attempted suicide.
Approaches on R1's care plan dated 07/03/02 include to place R1's picture in wanderers book, alarms will be checked routinely, and monitor R1's whereabouts if R1 is seen near exits. Care Plan for Falls dated 07/03/02 indicated that R1 is at risk for falling due to history of falling, decreased cognition, resulting in poor safety awareness. A check of the wanderers book at 9:00 A.M. on 07/29/02 indicated that R1's picture was in the book.
Nurses notes dated between 03/22/02 and 07/25/02 in R1's chart indicated that R1 has had twenty-seven elopement attempts and six falls. Nurses notes dated 05/29/02 at 7:20 A.M. indicated the following: "Resident pacing halls, attempt to elope, resident went out exit door, act personal with her, resident was walking with staff member around the building, when she was walking along road side on the sidewalk resident attempted to jump in front of moving car, stating she wanted to die, resident kept repeating this."
Interviews on 07/29/02 with employees E2 at 11:00 A.M., E4 at 2:40 P.M., E7 at 2:45 P.M., E5 at 2:50 P.M and staff nurse (E11) at 10:50 A.M on 07/30/02 indicated that R1 would not be aware of her own safety in any situation.
An interview attempted with R1 at 10:15 A.M. on 07/29/02 verified that R1 is not oriented and could not answer simple questions appropriately. R1 knew her name but was confused concerning the time, date, place and did not know where her room was when she was across the hall from it. R1 showed no knowledge of safety awareness. R1 also did not remember the 07/19/02 elopement. 4