Meadows Mennonite Home
Facility I.D. Number: 0011544
Date of Survey: 09/09/2003
Incident Report Investigation of 08/26/2003
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 resident's 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.
Each facility shall:
Maintain all electrical, signaling, mechanical, water supply, heating, fire protection, and sewage disposal systems in safe, clean and functioning condition. This shall include regular inspections of these systems.
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:
Based on observation, record review and interview, the facility failed provide adequate supervision to prevent one (R1) of nineteen residents who have been assessed at risk of leaving the unit unsupervised and who wear electronic monitoring devices, to leave the secure dementia unit and the building without staff's knowledge. R1 was found after dark, walking in a ditch beside a two-lane highway approximately 2/10th of a mile away from the facility. The facility also failed to ensure that it's electronic monitoring system was functioning properly, even when staff had direct knowledge that there was a recent history of malfunction. The facility still is conducting continued surveillance to monitor effectiveness of the alarm system which is still in the process of calibration. Facility is also awaiting installation of additional security hardware for Station 1 and Station 2.
The findings include:
1. R1 currently resides on the Station 1 dementia unit in the facility. Per review of current physician's orders R1 has a diagnosis of dementia, depression and hypertension. R1's annual resident assessment instrument (RAI) identifies R1 as having short and long term memory problems, highly impaired vision, and moderate impaired decision making ability. R1 wanders daily on the unit and is assessed as a high fall risk on the 07/17/03 fall assessment. R1 is assessed as independent in ambulation. The 07/22/03 assessment for cognitive loss/dementia states "Resident has severe dementia resulting in impaired cognition, need for supervision and assist for all decision making. Resident has very little safety awareness. Staff provides supervision and assistance as needed..." R1 was observed on 09/04/03 and surveyor attempted to interview at 10:45 a.m. R1 talked randomly and was not able to respond to or comprehend what was said to R1.
On 08/26/03, the Department of Public Health (IDPH) was notified by facsimile that R1 had eloped (left the facility grounds without staff's knowledge) on 08/26/03. The incident investigation report and nurse's notes dated 08/26/03 stated that a visitor (Z1) reported at 8:20 p.m. to a Station II Certified Nurse's Aide (CNA) that an older lady was walking outside by the stop sign (by a highway south of facility). The CNA, E3 went with the visitor in her car and found resident on the north side of Route 24 in the ditch bending down picking flowers. The resident willingly got in the car with E3 and Z1 and was returned to the facility at approximately 8:30 p.m. The notes document, and interview with CNA E3 on 09/04/03 at 2:00 p.m. confirmed that when R1 was brought back into the facility through the east double door entrance that the electronic monitoring bracelet that R1 was wearing did not activate the alarm at this door though it did activate the regular door alarm at the Station II nurses station.
CNA E4 who was assigned to R1 the evening of 08/26/03 was interviewed on 09/04/03 at 2:10 p.m. E4 stated that she started putting her group of nine residents to bed around 7:15 p.m. and had seen R1 at the nurse's station carrying her baby doll. E4 said she always puts R1 to bed last, so around 8:30 p.m. she started looking for R1 in the end rooms of the halls where R1 likes to go. When she couldn't find R1, E4 notified the Nurse E9 and they each took a hall and started to look. It had only been a few minutes when E3 brought R1 back into Station 1. E4 confirmed she heard no alarms and stated that sometimes the doors (west) didn't work like they should.
CNA E3 stated during interview on 09/04/03 at 2:00 p.m. when the visitor reported a lady outside by the road that E3 was unaware if anyone was gone but went to verify if it was a resident. When they arrived in the car at the stop sign E3 thought she saw someone standing in the ditch east of the road on the north side of the highway. They turned left and drove a short distance (approximately 20 feet) and E3 said she recognized R1 who was bending down pulling weeds and was carrying a baby doll and was talking about the pretty flowers. E3 said that R1 was wearing a sweatshirt, shorts and socks. E3 stated that it was dark when she discovered R1 beside the highway.
The surveyor, Administrator E1,and Interim DON E2 walked from the west lobby exit to the front parking lot and out to the street located on the west side of the building on 09/04/03 at 10:10 a.m. This is a residential street with a posted 25 mph speed limit that runs north and south and adjoins to the highway that is located approximately 2/10ths of a mile south of the facility. It
took approximately ten minutes to walk to the highway. There is a set of two railroad tracks that are located one block south of the facility that also would be crossed on the way to the highway. The town is surrounded by soybean fields on the east and west sides of the street behind the houses and corn fields on the south side of the highway. Highway 24 is a two-lane highway with a 55 mph speed limit. The grassy ditch where R1 was found walking is approximately four feet below the grade of the highway.
The Interim Director of Nurses (IDON) E2 was interviewed on 09/04/03 approximately 9:00 a.m., E2 confirmed that R1's electronic monitoring bracelet did not activate the monitoring alarms at three alarmed doors though the tester used on the bracelet that evening of the incident indicated that the bracelet was active. R1 was given a new bracelet that evening (08/26/03) and this did activate the bracelet monitoring alarm. E2 stated that she interviewed the staff present that night, 08/26/03, and established that R1 had last been seen on the unit around 7:40 p.m. by CNA, E10. It was E2's opinion that R1 probably exited the unit via the west double doors (#3) that lead off the unit into a hallway that leads through the building and ends up at the west lobby entrance of the new building. E2 stated the double doors are the most frequently used on Station I. These double doors only have the electronic bracelet monitoring system in place and not a secondary alarm or locking mechanism. E2 stated and interviews with CNA's E3, E4, E5, E10, and E12 and interview with Nurse E9 confirm that staff did not hear any door alarms that evening that would indicate that a resident had left the unit.
E2 speculated that once R1 had gotten to the west lobby that it was possible that she followed dietary staff out the exit after they had punched in the key code that allowed the west sliding doors to open. E2 still had R1's old bracelet which bore a 09/03 expiration date. E2 demonstrated to surveyor on 09/04/03 at 10:45 a.m. that the tester box indicated the bracelet was working, yet when it was passed through the three doors, (#3,#7 and #9) it did not activate the alarm system.
On 09/09/03 at 11:35 a.m., a telephone interview was conducted with Z2 who had been working in the building from 6:00 p.m. until 8:00 p.m. on 08/26/03. Z2 stated that she left via the west lobby exit to the parking lot a little after 8:00 p.m. Z2 stated she did see a lady sitting at the desk in the volunteer area.
Z2 stated the lady did not leave with her but she could have followed behind as the sliding doors stay open for a while after you leave.
Administrator E1 stated during interview on 09/04/03 at 9:00 a.m. that following the incident on 08/26/03, the facility contacted a technician who was certified for this electronic monitoring device and an onsite inspection was conducted on 08/28/03. Per E1 and review of the Service Call Form it was identified that the two antennae for the west double door monitoring system were missing caps and were damaged. These antennae transmitters were replaced on 08/30/03. Per interview with E1 and Maintenance Director E6 the technician stated that the antennae may have been accidentally damaged by facility maintenance staff that were making adjustments to the antennae incorrectly.
During interviews with staff on 09/04/03, it was revealed that at least seven nursing staff were aware that the electronic monitoring system for the west double doors of Station I did not always activate when a resident wearing a monitoring bracelet left the unit but it did alarm when the residents were returned back into the unit. Staff described knowledge of four incident involving R2, R3 and R4. Per review of R2, R3, and R4's medical records these incidents were not documented. Per interview with E5 and E6 if the doors were checked and adjustments were made to the alarm system, it was not documented.
On 09/04/03 at 12:25 p.m., CNA E7 relayed an incident that occurred a few days before R1's incident where she observed another resident (R2) go through the west doors at breakfast time and the alarm did not activate. E7 stated when she returned R2 into the unit the alarm did sound. E7 stated she wasn't sure if she had reported this incident.
At 12:30 p.m. on 09/04/03, CNA E17 relayed an incident that occurred approximately three weeks ago when R2 had gotten off of the unit without staff's knowledge and was found by CNA E14 in the corridor outside of the rehabilitation room. CNA E14 confirmed during interview on 09/04/03, at approximately 1:10 p.m. that it was sometime in August she had heard R2 out in the hall outside of the room and escorted R2 back to Station I where she reported to a CNA that she found R2. E14 confirmed that the alarm did sound when she returned R2 to the unit and that the Station I staff were unaware that R2 was gone. E14 did not report the incident to anyone else.
CNA E10 during interview on 09/04/03 at 2:20 p.m. confirmed that she was present when R1 was returned to the unit on 08/26/03. "We didn't know she was gone. We've had a history of that double door not alarming when you go out and when you come back in it alarms. We inform the nurses." E10 was aware of two incidents that have happened since July 2003, where staff from another station found residents R3 and R4 wandering near the west entrance lobby and we didn't know they were gone." E10 stated she witnessed them being returned to the unit and the alarm did sound.
The Administrator E1 and Interim Director of Nurses E2 were not aware of these incidents involving R2, R3 and R4. E2 confirmed there were no incident reports. E1 stated on 09/04/03 at 4:30 p.m. that staff may not have documented the incidents because the residents were off the unit but not out of the building.
E10 was working on 08/26/03, and confirmed she was present when R1 was returned to the unit. E10 stated that they decided to run some of the other residents through the west double doors and found that the alarm was also not going off when some of the other residents wearing bracelets were lead out of the unit through the double doors. E10 stated "That's when (DON E2) had us check everyone for safety and a nurse aid was assigned to watch the doors until 9:00 p.m." E2 confirmed on 09/04/03 at 4:55 p.m. that before the antennae were replaced that some of the resident bracelets activated the west doors and some didn't.
Maintenance Director E6 was interviewed on 09/04/03 at approximately 9:50 a.m. E6 stated that all the door alarms are checked on a monthly basis and the Station 1 door alarms are checked on a weekly basis by E5 using a monitoring bracelet. E5 was interviewed on 09/04/03 at 11:20 a.m. and confirmed weekly checks on Thursdays or Fridays and showed documentation that the system was last checked on Thursday, 08/21/03.
E6 and E5 stated that when staff would report problems with the doors not alarming that they would check the system with their own bracelet and it would check out OK, if an adjustment to the signal needed to be made they would pop open the cover protecting the antenna and make adjustments the way they had been instructed by one of their electrical contractors over a year and a half ago.
E6 and E5 said they would also adjust the antenna if the yellow signal light was too bright. None of the adjustments that had been made were documented. E5 estimated he made adjustments every month.
E6 stated on 09/04/03 at 2:45 p.m. that they had not had an onsite inspection of the system by a trained technician in over a year and that facility staff did all the adjustments and confirmed that a technician from the company that installed the security system or one certified in that system was not contacted until after R1's incident.