Illinois Masonic Home
Facility I.D. Number: 0010249
Date of Survey: 03/12/2003
Incident Investigation of February 28, 2003
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 were not met by the following:
Based on observations, record review, and interviews, it was determined that the facility failed to ensure that staff utilized available resident monitoring systems so as to prevent one of one sampled residents (R1) from gaining access to an open stairwell and subsequently being found at the base of the stairs, with multiple injuries. Findings are as follows:
Review of a facility incident report transmitted to the State Licensing Agency Regional Office on 03-01-2003 indicated that R1 was found at the bottom of a stairwell located in the southwest wing of the Collin's Building on 02-28-03, at approximately 4:15 P.M.. The incident report stated that the resident was found at the bottom of the stairwell with her wheelchair still present at the top (of the stairwell). The report states that R1 sustained a laceration to the back of her head and was subsequently transported via ambulance to an area hospital for evaluation.
Review of R1's clinical record confirmed that R1 is an 88-year-old female admitted to the facility 02-01-1991. The record (March, 2003, physician order sheet) reflects that R1 has diagnoses that include organic brain syndrome, Alzheimer's Disease, renal failure, osteoarthritis, and chronic obstructive pulmonary disease. Most recent assessment data (Minimum Data Set- MDS) completed 12-03-2002 indicates that R1 has both long and short-term memory problems, is moderately impaired for cognitive/decision making ability, has behaviors that includes wandering and resistance to care. Assessment information indicates that R1 has some indicators of delirium and disordered thinking present which include being easily distracted, having periods of altered perception or awareness of surroundings, has periods of restlessness and having mental function that varies over the course of the day. Assessment data confirms that R1 is extensively to totally dependent on staff for activities of daily living (ADLs). Assessment data reflects that R1 has a history of falls.
Further review of assessment data for R1 reflects that R1 is a fall risk with a 03-05-2002, RAP (resident assessment protocol) which states "multiple falls, health & mentation declined, requires increased assistance and supervision with ADLs. Safety awareness impaired visually monitor, personal alarm to alert staff of attempt to transfer without assist". Current assessment information data reflects the following: 03-03-2003, mini mental state assessment score=seven out of 30; 03-04-2003, elopement assessment (i.e, risk for leaving unnoticed)=High Risk; 11-19-2002, and 02-28-2003, fall risk assessments=fall risk.
R1 was briefly interviewed on 03-11-2003, at 11:20 A.M. with R1 expressing no recall of the incident. R1 appeared to lack safety awareness and was unable to communicate with any sense of reality.
Review of R1's plan of care dated 12-03-2002 reflects self care deficits related to cognitive impairment, decreased attention to task-very easily distracted, cognitive loss-progressive dementia with short term memory; advancing dementia with increasing difficulty sequencing steps for daily care; at high risk for falls related to wandering; high risk for elopement related to advancing dementia-poor safety awareness; among other medically related problems or issues.
Included as an approach to R1's wandering and elopement risk problem for nursing staff to follow is "...staff visually monitor resident when in dining room, redirect when attempting exit, frequent visual checks, supervision on and off unit...do not allow to leave facility or unit unattended...utilize behavior monitoring log...personal alarm on resident when in bed and chair..."
Interview with E2, director of nursing on 03-11-2003, at 10 A.M. confirmed that R1 has a history of confusion and exit seeking behavior. E2 confirmed that R1 has a history of being able to self propel her wheelchair and does so often on the unit. E2 confirmed on 03-12-2003, at 9:30 A.M. that R1 is very quick while in her chair as she uses her feet on the floor and hands and arms to pull herself along the handrails on the unit. E2 confirmed in interview on 03-12-2003, at 9:30 A.M. that her expectation for R1's supervision prior to the event on 02-28-2003 was that of "frequent visual checks" as stated per R1's plan of care. E2 explained at this time that any and all staff persons are expected to redirect such a resident away from exit locations and maintain awareness of such resident's whereabouts.
Review of R1's clinical record (nurse's notes) reflect that R1 has a history of exit seeking behavior as documented by direct care staff on the unit. Attempts to exit the unit are documented in nurses notes for the following dates: 10-02-2002, 10-13-2002, 10- 21-2002 (times two), 10-27-2002 (times three), 11-10-2002,
11-13-2002, 11-27-2002, and 11-29-2002. Per interview with E2 on 03-12-2003, there have been no known incidents of R1 successfully leaving the unit.
Review of the facility's investigative report dated 03-01-2003 reflects in part, that "At 1615 (4:15 P.M.) staff heard the door alarm for the southwest stairwell of the Collin's Building engage. Multiple staff responded to the alarm, which was disengaged following the discovery of (R1). The total time the alarm was engaged was 69 seconds. When the staff found her she was at the bottom of the first floor stairwell and her wheelchair was at the top of the stairs with the front wheels on the first step. It appears that the resident was attempting to go down the stairs in the wheelchair, however, this was unwitnessed by staff. The resident sustained a laceration to the back of her head....R1 was transported by (ambulance to an area hospital). She returned from the ER (emergency room)...Upon her return to the facility bruising and edema were noted and monitored. (R1) began to verbalize increasing pain and she was also assessed to have decreased range of motion....(R1) was again sent to the ER on 3-1- 03 for further evaluation and x-ray. The results showed a pelvic fracture..."
Review of the radiology report dated 03-01-2003 confirms that R1 sustained "Two fractures involving the inferior pubic ramus on the left--one in the inferior acetabular region and the second distally in the pubic region". Review of the orthopedic surgeon consult dated 03-01-2003 reflects that R1 sustained a "contusion to the knee" as well. Documentation on the facility incident report (additional follow ups 02-28-2003, and
03-01-2003) reflects that R1 received sutures to the back of her head, sustained some bruising and edema to the left lower leg, edema of the left hip/thigh area, bruising and swelling to the left knee, and an abrasion to the chin with bruising to this area.
Observations made on 03-11-2003, at approximately 9:30 A.M. in the Collin's Building first and second floors reflected that living units were equipped with closed doors that lead to an interior stairwell in three separate locations on both floors. According to interview with E3, maintenance director, each door was equipped with a signal device prior to and at the time of the incident which was installed to alert staff if a resident were to open the doors to the stairwells. E3 confirmed that these alarms are constantly on and active, and can only be deactivated with a keypad at the door location to permit a brief passage. All doors on both floors were inspected and found to be functional following the incident on 03-11-2003. E3 and E2 confirmed that signals register at three separate locations, the nurse's station panel, nurse's station TV monitor, and on strobe lights in the corridors adjacent to each stairwell door. All locations were examined and found to be functioning.
Review of written statements completed by the four staff persons (E4, E5, E6, E9) who were present on the unit at the time of the incident and results of interviews with those four staff persons (conducted 03-11-2003, and 03-12-2003) reflected that the responses to the door alarm signals resulted in a delay of staff arriving at the southwest stairwell door that was opened at exactly "16:13:54" (4:13.54 P.M.) according to facility computerized records.
E6, activity aide, in interview on 03-12-2003, at 10 A.M. confirmed that when she heard the alarm she was in the north wing corridor and immediately went to the dining room double doors (which is in the opposite direction to the door that was opened). She stated that she quickly realized that she had checked the wrong door and by identifying the flashing strobe light at the end of the southwest wing ran to the exit and was ultimately the first to arrive at the scene to find R1 at the bottom of the stairwell. E6 indicated in interview at this time that she was not aware of the need to check the wall panels until an inservice was held following the incident involving R1.
E4, CNA, in interview on 03-11-2003, at 2:45 P.M. confirmed that when she heard the alarm she was seated at the nurses station, got up and immediately went to the dining room (which is in the opposite direction to the door that was opened). She stated once she was inside of the dining room, she realized that she was in the wrong area and returned to the nurses station where she saw the flashing strobe light at the end of the southwest wing. She entered the stairwell where she was the second staff person to arrive at the scene of the incident involving R1.
E5, CNA, in interview on 03-11-2003, at 2:30 P.M. confirmed that when she heard the alarm she was standing near the nurses station and immediately went to the dining room (which is in the opposite direction to the door that was opened). She stated when in the dining room she realized she was in the wrong area after checking the dining room door alarm panel which indicated that the southwest door had been opened.
E9, activity aide, in interview on 03-11-2003, at 4:20 P.M. confirmed that when she heard the alarm she was at the end of the Southwest wing adjacent to the nurses station (this location places her closest to the southwest door of all staff on the unit at the time the door was opened). She stated she checked the nurses station wall panel which indicated that the southwest door had been opened. She stated she then proceeded to the southwest exit where she was the third staff person to arrive at the scene of the incident.
Interview with E2 on 03-12-2003 confirmed that there are other residents residing in the Collin's Building who are considered at risk for leaving the unit. According to information provided by E2 there are residents living on both floors that are assessed as cognitively impaired and mobile (via wheelchair or walking). There are 11 such residents on Collin's Building 1st floor and nine such residents on Collin's second floor.
According to information provided by E1, E2, and E3 on 03-11-2003, and observations made on 03-11-2003, it was determined that the facility took measures to maintain direct supervision of all stairwell doors on both floors (six total locations) 24 hours a day following the incident. This continued until the stairwell entrance doors were equipped with Illinois Department of Public Health approved magnetic closure devices on
03-07-2003. These devices were observed to be in place and functioning on 03-11-2003.