Alden Morrow Rehab & Health Care Center
Facility I.D. Number: 0019596
Date of Survey: July 8, 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.
Personal care shall be provided on a 24-hour, seven-day-a-week basis.
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.
AN OWNER, LICENSEE, ADMINISTRATOR EMPLOYEE OR AGENT OF A FACILITY SHALL NOT ABUSE OR NEGLECT A RESIDENT. (Section 2-07 of the Act)
This REQUIREMENT is not met as evidence by:
Based on observation, record review, and staff interviews, the facility failed to provide adequate supervision to one resident (R5) with diagnoses including Dementia and Alzheimer's Disease. R5 has made frequent attempts to get on the elevator and leave the unit. R5 has been identified by the facility as a wanderer, and was discovered missing from the skilled unit on 06/14/03 at 5:00A.M., however, the 11:00P.M.-7:00A.M. staff acknowledged not knowing the whereabouts's of R5 since 3:00A.M. on 06/14/03. The resident was missing from the unit for 6 hours, and was located 06/14/03 at 9:00A.M. in the basement, in the locked mechanical/boiler room.
R5 is a 71 year old female with diagnoses including Alzheimer's Disease, Dementia, Hypertension, and Diabetes Mellitus.
Per 01/04/03 history and physical, R5 is identified as having poor memory, being disoriented, and being a wanderer.
The facility identified the problem of R5 wandering into the rooms of others and one of the approaches is to monitor resident for safety concerns while wandering.
The surveyor requested an elopement risk assessment for R5 but none was presented.
R5 was housed on the unlocked skilled unit (4th floor) where there is a standard elevator door with up/down buttons to open it. The exit doors of the floor have functioning alarms.
A review of the 06/14/03, 5:00A.M. nurses' notes and the 6:00A.M. incident report of the same date states: "went to patient room for accucheck, the patient was not in the bed or in the bathroom. All rooms and floors including the immediate surroundings were searched with staff."
According to the nurses' notes that begin on 06/14/03 at 5:30A.M., as written in part, by E9 (LPN-4th floor, 11:00 P.M. shift). R5 was not in bed or the washroom. The nurses' aid (CNA) stated, R5 have not been seen since the last rounds were done. 7:00A.M. the search for the resident continues 7:45A.M. the search continues, 8:00A.M., the administrator was called and informed of the R5 not being found in the room, the search continues. At 9:00A.M., R5 was found in one of the rooms in the basement by E1 (administrator).
The staff did an entire facility check, and R5 was found in the locked mechanical/boiler room which is located in the basement.
Surveyor interviewed E4 (LPN-4th floor) on 07/02/03 at 1:55P.M. regarding R5's frequent attempts to enter the elevator. E4 stated, "Prior to this, it was just recently, about a couple of days she (R5) would try to get on the elevator. I am not 100% sure of the time span in which she attempted to get on the elevator."
On 07/02/03 at 2:36P.M., E1(administrator) was asked about R5 attempting to get on the elevator. E1 stated, "I think I may have heard that she (R5) tried to get on the elevator before, but she was redirected; she often gets on the elevator with staff to go to activities."
On 07/02/03 at 1:55P.M. in the inservice room, E4 was questioned about R5's elopement from the 4th floor unit. E4 stated, "No one knows how she got off the floor. The alarms were working on the exit doors, so the only other means of getting off the floor were the means of the elevators. The shift told me (from the nurse in the report) that she (R5) is missing, we can't find her , nobody knows where she is at."
Surveyor ask E4 where R5 was found? E4 stated, "E1 (administrator) found her (R5), she (E1) said she (R5) was in the basement in one of the rooms." Surveyor ask, did E1 tell you what room R5 was found in? E4 stated, "Yes, I prefer not to say where she (E1) found her (R5), I just don't want to, no given reason. She (R5)
was inside of a room with the door closed."
E7 (CNA) was interviewed at 2:28P.M. on 07/02/03 about R5's elopement from the skilled unit. E7 stated, "Nobody knew how she (R5) got away. I think she got on the elevator, she had too. I searched the 4th floor, and did not find her. I was here when they found her. I think it was E1 (administrator) who found her. E10
(CNA) was with her (E1), she (E10) is on vacation. It was said to me, we found her, but I don't remember where they said they found her."
At 2:36P.M. on 07/02/03 in the inservice room, E1 was interviewed about finding R5 in a basement room. E1 stated, "I had a laundry aid that was with me when I found her. I think her name is E11 (laundry aid), I can't think of her last name. I found her in the mechanical/boiler room. The resident was seated on the floor next to the air handling unit in the mechanical room.
The only logical conclusion is she (R5) got on the elevator and got off of the unit." Surveyor ask E1, should the mechanical/boiler room be locked at all times? E1 stated, "Yes."
Surveyor then ask, was the room locked the night the resident entered it? E1 stated, "I would think that it was left open in order for her (R5) to have gotten into the room. I used a key to go into the door to check the room, and found the resident in there. It was not accessible from approximately 10:30P.M. until I actually arrived on site. No, I do not know who left the boiler room open, I can't say definitely how long it was left open."
On 07/02/03 at 2:05P.M., surveyor interviewed E4 (LPN) as to how the 6 hour time line was established for R5 being missing from the 4th floor. E4 stated, "My determination on R5 being missing for 6 hours was based on the fact that E9 (LPN), the 11- 7P.M. nurse had stated verbally to me (E4) that the CNA working with R5 had stated to her (E9) that she (CNA) had last saw R5 around 3:00A.M. on the night in question. R5 was returned to the 4th floor at 9:00A.M. The time between 3:00A.M. - 9:00A.M. is a total of 6 hours. I worked the 3-11P.M. shift on 06/13/03. R5 was medicated by me (E4) at 9:30P.M. She (R5) was in bed in her room at that time. She (R5) remained on the unit the entire 3-11P.M. shift."
Surveyor then interviewed E8, (CNA, 11-7A.M. shift), via telephone from the 4th floor nurses' station on 07/03/03 at 2:15P.M. E8 who was assigned to R5 the night of the incident was asked what happened? E8 stated, "R5 was a wanderer, she (R5) walks around all of the time. She (R5) was a little confused and a little forgetful. I was making rounds between 2:00A.M. and 3:00A.M., but closer to 3:00A.M.. At that time I was in her room (R5) changing her (R5) roommate, she (R5) walked out of the room headed toward the desk. I don't know exactly where she (R5) went. No, I didn't see her anymore after she (R5) walked out of the room. Around 5:00A.M. or 5:30A.M. the nurse was looking for her to do morning care. That is when we realized she (R5) was missing. I didn't realize she (R5) was gone. After 3:00A.M., I assumed she (R5) was either in the dayroom, her bathroom, or her (R5) room. I assumed that because that was her normal thing. I couldn't say if anyone was at the nurses' station or not."
On 07/07/03 at 5:00A.M., from surveyor home, E9 (LPN) was interviewed via telephone about R5 eloping from the 4th floor. E9 stated, "My conclusion is she (R5) got off the unit on the elevator. We were never told that she (R5) tried to attempt to get off the floor. The last time she (R5) was seen was about 3:00A.M. At 3:00A.M., I was sitting at the desk, and didn't see R5 at all. I was here about a month and a half when that happened."
Surveyor ask E9 to explain where R5 was found. E9 stated, "I ask one of the housekeepers to show how could she (R5) have gotten into the boiler room. He told me it's like a double door, you have to use both hands to push the door open, and that the latch that pulls down that locks the door wasn't on at all. He says he didn't know how she got the strength to push the door open, the door was unlocked. After they found (R5), it was practically taken out of my hands. I was blamed for it, all I could do is take a blood sugar. I have one thing to add, the protocol as to what you are suppose to do when a resident is missing, I didn't know at all. I didn't get any orientation on missing persons."
On 07/03/03 at 1:40P.M. accompanied by E1 and E12 (maintenance director), the surveyor observed the following items in the boiler room: 2 ladders resting on a boiler; 1 rusted, unusable mop stick with a broken, splintered end; 1 1/4th full (5 gallon) container of sodium hydroxide (a corrosive chemical), 3 metal tubes for the boiler; 5 metal caps for the circulating pipes; 1/2 gallon container of coil cleaner; 1 box of pipe insulation; 4 boxes of fiber glass filters; several spare rail parts; 1 electric fan; 1 metal cart for moving equipment; and 1 metal band for flue pipes for the boiler. R5 had unrestricted access to all of these items during the 6 hours she was in this area and unsupervised.
The facility emergency transfer form to the hospital dated 06/14/03 states reason for transfer is for the evaluation of overall condition related to resident being missing for 6 hours. The emergency situation as explained by the facility is the resident was noted to be missing from the unit for 6 hours.
R5's returned to facility on 06/15/03. The transfer form revealed that the hospital admission diagnoses were Hyperkaliemia, Right Quadrant Tenderness.