Care Centre of Champaign
Facility I.D. Number: 0041889
Date of Survey: 03/07/03
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.
Personal care shall be provided on a 24-hour, seven-day-week basis.
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.
This REQUIREMENT is not met as evidenced by:
Based on interviews, observations, and record review, it was determined that the facility failed to provide supervision for one of five residents (R11) wearing electronic monitoring bracelets resulting in R11 exiting the facility on 02/12/03 without alerting staff. R11 sustained scratches to the face and forehead. The facility failed to ensure that the electronic monitoring system on the inner front door was functioning at the correct sensitivity, and failed to ensure that the secondary constant alarm on the outer front door was activated to alert staff of someone exiting the facility. The facility failed to have policies and procedures on the door alarm system.
1. According to R11's medical record, R11 has a diagnoses of Alzheimers disease, Dementia, and Atypical Psychosis. R11's resident assessment instrument (RAI), dated 12/25/02 shows that R11 wanders, is cognitively impaired requiring supervision, and ambulates independently. His fall risk assessment, dated 12/23/02, shows him to be at high risk.
His elopement (risk for leaving unnoticed) assessment, dated 12/23/02, shows R11 to be at moderate risk even though, according to nursing notes, he has had a history of an attempted elopement on 03/15/02, and subsequent attempts on 01/13/03 and 01/15/03. On 02/13/03, after the elopement, R11 was assessed to be at high risk. During interview with E13, care plan coordinator, on 02/26/03, at 2:25 p.m., E13 stated, "(R11) has worn an (electronic monitoring device) since his admission (05/25/01)."
R11's care plan, dated 01/06/03, identifies R11 as an elopement risk with approaches of location monitoring every 15 minutes, and to ensuring (electronic monitoring device) is on (R11) and functional. The resident location monitoring log confirms that staff were documenting every 15 minute checks up to 02/12/03 at 10:00 p.m.
According to the facility accident/incident report, dated 02/12/03, and, from staff written statements, R11 was not in his room or the facility at the 10:15 p.m. check. E25's, Licensed Practical Nurse (LPN), statement, dated 02/12/03, shows that at 10:15 p.m. E25 went to R11's room to check on R11's roommate and noticed that R11 was not in his room or bathroom. E25 went to the nurses station and R11 was not there. E25 then, called the certified nurse aides (CNA) together and a room by room search was initiated without success. At 10:25 p.m., the staff went outside and searched. E22 and E26, CNAs, found R11 between 10:30 and 10:35 p.m. E23's, CNA, written statement, dated 02/12/03, documents that R11 was found just north of the church next door. During interview on 02/19/03 at 2:50 p.m., E22, CNA, stated, "We went room to room and then went outside and split up. I saw (R11) walking north of the church. When we got to him he was at the street corner north of the church at Mattis avenue. He was in the snow. He was wearing a long sleeve pajama shirt and long pajama pants, a pair of socks, and footies." (The area where R11 was found is approximately one and one half blocks from the facility.)
During interview on 02/19/03 at 2:33 p.m., E23, CNA, stated, "I did a bed check on (R11) at 10:00 p.m. At 10:10 p.m. we were dressing (R7). At 10:15 p.m. R11 was not in bed. We searched the facility every hall and every room, bathroom, linen and laundry rooms, employee bathroom , except the kitchen. The door alarm did not sound. We assumed he got out 'A' hall door because he was found by the church. He was very cold. He was wearing men's pajamas and socks. He was shivering. There was an icicle of blood where he hit himself. One of his hands was scraped, the left hand. His feet were like ice."
During interview on 02/20/03 at 3:29 p.m., E25,LPN, stated, "On 02/12/03, I was in the medication room putting medications away. At 10:10 p.m. I went into (R11's) room. He was not there. Nor was he in the circle area by the nurses station. I told the CNAs to do a room by room search, then we went outside the building.
E22 and E26 (CNAs) found him. He had lacerations to his face and he was cold. I heard no door alarm. I checked his eyes and level of consciousness. His response was normal and his (hand) grips were equal. I did not do a neurological check sheet. I checked his bottom because there was snow on the butt of his pants. There was no bruising. I checked his legs, arm, face and head. His vital signs were: temperature- 97.1 degrees fahrenheit, pulse-22 , respirations 20. He refused to let me take his blood pressure. There was snow on the ground and it was cold outside. I did not check his (electronic monitoring device) when he came back into the facility. When he left for the hospital, I did not hear the (electronic monitoring system) go off (as he went through the front door). R11 attempted to go out 'A' hall door earlier between 3:30 p.m. and 4:00 p.m. on 02/12/03. I saw him and brought him back and sat him in front of the television. I forgot to document that."
During interview on 02/20/03, at 3:45 p.m., E27,CNA, stated, "That night (02-12-03) before supper (R11) attempted to go out 'C' hall door. He did not get out. " Surveyor questioned E25 further on 02/20/03 if she had been notified of this issue and she did not remember if E27 had told her about his attempt to exit C hall door that night. E27 had left the facility at 9:42 p.m. prior to the incident.
During interview on 02/27/03 at 11:10 a.m., E26, CNA, stated, "I heard no door alarms go off except when staff were taking the garbage out 'B' hall door. We were doing the 15 minute checks at 10:15 p.m. when we noted (R11) was not in his bed or in the lobby. We did a room to room check then went outside. As I was returning from searching outside, I saw a man walking by a house north of the church. I caught up to him in front of the house almost at the corner of Cypress street and Mattis avenue. He was wearing mens maroon pajamas and socks. He clearly had fallen on his rear. There was snow on it. His face was cut up. There was snow on his socks. He was returned to the facility where we sat him in a gerichair and the nurse looked at him. We changed his clothes. His feet were white and a little pink like he had been out in the cold. When he left the facility for the hospital, I heard no alarm go off when he went through the front door."
During interview on 02/19/03, at 3:35 p.m., E28, LPN, stated, "I heard no door alarms go off. About 10:15 p.m., someone said they could not find (R11). When they returned him to the facility, his socks had snow balls on them. His feet were reddish, pinky red. Cold feet. (E25,LPN) assessed him. He was wearing mens pajamas and socks."
On 02/19/03, at 11:26 a.m. during an interview with R11, he was unable to remember going outside on 02/12/03 or what caused the scratches on his face. During a second interview with R11, on 02/21/03, at 2:45 p.m., R11 was unable to describe how to cross the street or what to do when he sees a stop sign.
On 02/19/03, at 11:26 a.m., R11 was observed to have scratches on the bridge of his nose, four scratches over the right eye, three scratches under his right eye and cheek and, five small scratches on the palm of his right hand.
According to the Midwestern Regional Climate Center, contacted 02/20/03, at 2:47 p.m., the weather condition for 02/12/03, between 10:00 p.m. and 10:30 p.m. was 14 degrees fahrenheit and 13 degrees fahrenheit, respectively.
During interview on 02/20/03, at 9:40 a.m., E24, maintenance director, stated, "I check the resident's (electronic monitoring bracelets) and the exit door alarms weekly." Surveyor accompanied E24 on 02/20/03 as he tested each resident's bracelet using a portable hand held electronic monitoring device called a "signaling device tester". As he held it close to the bracelet, the small light on the tester would light up signaling that the bracelet was functioning. All five bracelets lit up the tester.
On 02/21/03, at 10:05 a.m., surveyor checked the electronic monitoring system on the inner set of double doors at the front exit. E24 supplied surveyor with an electronic monitoring device which was on top of the surveyor's hand as she exited through the inner front door. The electronic monitoring device failed to activate the electronic monitoring system to illicit an alarm until the device was moved within one and one half feet of the electronic monitoring system (two gray boxes) one attached on each side of the inner doors. Then, an alarm was heard. This was attempted several times using two different devices with the same results. The administrator and director of nursing were called to witness the demonstration. At 10:25 a.m., E24 adjusted the sensitivity of the system boxes on the side of the doors. This time, when the surveyor walked through the doors with the device, the alarm sounded. The outer set of double doors at the front exit was observed to have a door chime which when the doors were opened sounded with a "ding-dong-ding-dong". At this same time, surveyor asked E1, administrator and E24, if there was any other alarm attached to the outer front door. E1 stated that she was only aware of the door chimes and was not aware of a third alarm on the front door. At 12:30 p.m., E24 showed surveyor a toggle switch on the alarm panel in the beauty salon marked "front door". E24 stated that he had forgotten about it. It was noted to be shut off. Leaving the door chime as the only signal on the front door. During interview on 02/21/03, at 12:40 p.m., E2, director of nursing, stated, "I was inserviced on the door panel, but I did not know about the front door switch for the alarm. We should turn it on when the manager leaves at 6:00 p.m." At 2:03 p.m. on 02/21/03, E1, administrator was shown the alarm panel in the beauty salon and how it worked. E1 appeared surprised saying, "We have a third alarm?"
During a second interview with E25, LPN, on 02/21/03, at 3:30 p.m., E25 stated, "I am not aware of a third alarm or toggle switch on the alarm panel for the front door. No one showed me this. It was not turned on 02/12/03. I did not know about it." As of 02/21/03, at 3:55 p.m., after making repeated requests for the facility's door alarm policy, there was no evidence of a door alarm policy.