Rosewood Care Center-Galesburg
Facility I.D. Number: 0032805
Date of Survey: 9/18/03
Incident Investigation of 9/12/03
Resident Care Policies
The facility shall have written policies and procedures, governing all services provided by the facility, which shall be formulated by a Resident Care Policy Committee consisting of at least the administrator, the advisory physician or the medical advisory committee and representatives of nursing, and other services in the facility. These policies shall be in compliance with the Act and all rules promulgated thereunder. These written policies shall be followed in operating the facility and shall be reviewed at least annually by this committee, as evidenced by written, signed and dated minutes of such a meeting.
General Requirements for Nursing and Personal Care
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 observations, interviews and record reviews, the facility failed to ensure supervision to prevent an accident by not following their policy of door alarm response and action, resulting in R1 falling outside the facility with a resultant hip fracture.
Record review reflects R1 to be an 81 year old resident readmitted to the nursing home 06/30/02. R1's diagnoses includes Alzheimer's and dementia. Current evaluations document R1 having wandering behavior and decreased cognition. R1 is an independent ambulator, but is unaware of self safety.
On 09/12/03, at approximately 1930 hours, an exit door alarm sounded. E9 announced over the intercom for staff to check the 200-300 halls, but failed to indicate the specific door. E10 checked the East Patio Door (located off the 200 hall), did not see any resident outside, and told E4 it was "all right." Then E10 shut the alarm off. Neither E4 or E10 initiated a head count of residents. A short time later, Z2 came to the nurse's desk on the 700-800 wing and reported a female walking outside. E3 immediately went to a West exit door off the 800 hall. R1 was found lying on cement about 6 feet from the door. It was dusk and a light rain was falling. Upon being assisted to stand, R1 indicated pain in the right leg. A wheelchair was gotten and R1 was transported inside and put to bed. R1 continued to indicate pain in the right leg. The physician was notified and order was obtained to send R1 to the hospital for evaluation. R1 was found to have a fracture of the right hip.
Interviews with E1, E2, E3, E4, E5, E6, E7, and E8, confirm R1 has exit seeking behavior and needs supervision to prevent unauthorized exits from the facility.
The results of an internal investigation conducted by E1, and E2 confirm facility policy was not followed. According to the policy, the receptionist on duty is to announce the specific door location after the alarm is activated. The policy further instructs staff to go the the designated door for a visual check for residents. If no resident is seen, staff are to initiate a head check, starting with identified wanderers. Then, if a resident is determined missing, a perimeter search of the premises is started to search until the resident is found.
Interviews with E4, E5, and E6 confirm they did not know what action to take following the exit alarm sounding.
Interview with Z1, on 09/18/03 confirms receiving a call from the facility the evening of 09/12/03 saying R1 had gotten outside and fallen.
R1 was observed at a local hospital at 0800, 09/18/03. Z1 was feeding R1 breakfast. R1 was determined non-interviewable by responding to questions by repeating or laughing. According to Z1, R1 had no other injury than the hip fracture.