ST. PAULS HOUSE & HEALTH CARE CENTER
Facility I.D. Number0005165
Date of Survey:07/15/02
Notice of Violation:09/18/02
Incident Report Investigation
The facility must provide the necessary care and services to attain or maintain the highest practical physical, mental, and psychological 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.
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 REQUIREMENTS are not met as evidenced by:
R3 is a 75 year old resident who was admitted to the facility in June 2001, with diagnoses including Cerebral Vascular Accident, Congestive Heart Failure and Dementia. According to the physician's order sheet dated July 2002, R3 has a physician's order for a "wandering bracelet at all times."
On review of the Resident Assessment dated 5/15/02, R3 has difficulties with long and short term memory; and has moderately impaired cognitive skills for decision making.
During an interview on 7/10/02, E2, the Director of Nursing, stated that R3 has been identified by the facility to have behaviors of wandering. E2 stated during an interview on 7/11/02, that R3 has had a physician's order for the "wandering bracelet" since December 2001.
On review of the clinical record, there was no plan of care implemented to address the resident's wandering behavior, even though the facility had applied the electronic monitoring device since December of 2001.
R3 resides on 2 East, which is a locked unit. During an interview on 7/10/02, E2 stated that most of the residents on 2 East are at risk of wandering and are placed on 2 East because the unit is locked and equipped with an alarm system.
The elevator on 2 East operates by use of a key pad entry code only. From the 2 East unit, there are a total of 4 exit doors that lead down to the main level to street access. These 4 exit doors are only equipped with a local alarm that will sound when the door is opened, not an adult electronic monitoring device alarm. Once on the main level, these doors are equipped with another audible alarm but these alarms do not signal at the nursing station. There is no staff assigned at the nursing station to monitor these alarms when they go off.
On the southeast end of 2 East, is a set of double doors that lead into other wings on the second floor. The set of double doors is equipped with a sensor to detect electronic monitoring devices. The double doors on 2 East are the only doors on the second floor that are equipped with these devices.
During observation on 7/10/02 and 7/15/02, R3 was wearing an electronic monitoring device on her right wrist. During an interview on 7/10/02, R3 stated that she is allowed to go outside of the facility alone, and that she enjoys spending time away from the facility and walks by the river. R3 was unaware and not cognizant of the physician order not allowing her to leave unaccompanied.
On 7/15/02 at approximately 11:30 A.M., R3 was asked by the Surveyor to open the employee entrance door, which is equipped with a sensor for the electronic monitoring devices. When R3 opened the door, the alarm was not activated. The employee entrance door is only equipped with a sensor to detect electronic monitoring devices, and has no other alarm device to alert staff of when the door is opened.
On review of the facility log for testing the door alarms for the months of May 2002, June 2002 and July 2002, the alarm system was working properly. However, on interview 7/15/02, E3 (director of environmental services) stated that he runs a test on the doors equipped with a monitoring sensor, by using a test bracelet which he holds in his hand. E3 further stated the actual devices that residents are wearing, are not tested to see if they are functioning.
There are a total of 7 residents in the facility that wear electronic monitoring devices. There are a total of 13 doors that lead directly to the street level. Out of the 13 doors on the main level, only 1 door (employee entrance) is equipped with a sensor to detect electronic monitoring devices.
On 6/28/02 at approximately 1:30 P.M., R3 was taken from the 2nd floor unit by a staff person, and brought down to the first floor auditorium, for a scheduled activity. During an interview on 7/10/02, E2 stated that when all of the other residents returned to the second floor (2 East) after the activity, approximately one half hour later, it was discovered that R3 had not returned. E2 stated that when R3 did not return to the unit, that facility staff were not certain of the resident's whereabouts. E2 stated that the facility was searched, and they were unable to locate R3. E2 further stated that it is not certain exactly how or when R3 left the facility. E2 stated that the assumption is that around 2:00 P.M., R3 used the exit doors in the auditorium to leave the facility. The facility activity was held in this auditorium. During a facility search for the resident, E2 stated that E6 (certified nurses assistant), who was on her way to work at 2:30 P.M., recognized R3 out in the community, and brought her back to the facility.
Both E7 (certified nurses assistant) and E8 (certified nurses assistant) stated that R3 is confused and frequently wanders. E7 and E8 also stated that R3 frequently tells staff that she is going home.
During a telephone interview on 7/11/02 at approximately 11:00 A.M., E6 stated that she saw R3 out in the community, walking towards the bus stop. E6 further stated that she asked R3 where she was going, and the resident replied that she was going home. E6 told R3 that her home (the facility) was in the other direction and she assisted her back to the facility.
On review of the Accident/Incident Report dated 6/28/02, R3 was observed "walking on side street by California and Roscoe Ave, trying to catch the bus." The vicinity in which R3 wandered to is approximately 6 blocks away from the facility, and is congested with heavy traffic and adjacent to railroad tracks. The temperature on 6/28/02 (per Chicago Tribune newspaper) was 86 degrees and high humidity.
R3 who wears an electronic monitoring device, was brought down to the 1st floor level where entry and exit doors were not equipped with sensors to detect electronic monitoring devices. While on the 1st floor, R3 was not monitored or supervised by staff and wandered approximately 6 blocks away from the facility, without facility staff being aware of leaving or her whereabouts. The failure of the facility to adequately supervise R3, check the working condition of her monitoring device, and develop an ongoing plan of care to deal with her consistent desire to leave the facility resulted in R3 being able to leave the facility unnoticed and to be at risk in the community due to her confused state.