Friendship Home Facility I.D. Number: 0042876 Date of Survey: 10/07/03 Complaint Investigation The facility must provide the necessary care and services to attain or maintain the highest practicable, 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. 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 resident receives adequate supervision and assistance to prevent accidents. 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. Based on observation, interview and record review the facility failed to adequately supervise R1 which led to R1 eloping from the facility without staff knowledge. R1 was noted to be missing on 09/21/03 at about 3:00 PM when Z1 informed E3 with a phone call to the facility about R1's whereabouts. R1 was 0.9 miles from the facility and was returned unharmed by E5. R1 was assessed as an elopement risk and had a resident-specific, electronic, exit door monitoring device on (exit monitoring device), but the system had not been working since 09/18/03. Per the facility policy when their exit monitoring device system is out of order, they put their two elopement risk residents (R1 and R2), of a total facility census of 44, on half-hour checks. Again per the facility's policy, the facility kept the other alarm, or main door alarm system, in the "off" mode, for the front door at the time of the incident. This state of affairs, with only the half-hour checks being in place to monitor R1 during the day, allowed R1 to elope without staff knowledge. Findings include: R1 is an 88 year old female admitted to the facility on 07/14/03. R1 has diagnoses which include Alzheimer's disease, Depression, and Macular Degeneration. R1's initial assessment (Minimum Data Set - MDS) dated 07/27/03, indicates R1 has short term memory problems and has "moderately impaired" cognitive skills for daily living . This assessment also indicates R1 exhibits wandering behaviors daily. R1 was interviewed on 10/02/03. When asked about the incident of 09/21/03 she indicated she did not recall anything about it. R1's Care Plan dated 07/14/03 includes taking precautions so R1 "will not leave facility grounds." An exit monitoring device was placed on R1's ankle on 07/14/03, per a doctor's order (Z1 - R1's Physician), to alert staff if R1 attempted to leave through the front door. On 09/18/03 the facility noted that their resident-specific exit alarm system for the front door was not working and put R1 and R2 on 1/2 hour checks. This is documented in the facility's incident investigation report dated 09/22/03. Also per the facility policy, as explained by E1 (administrator) per interview on 10/02/03, the main door alarm for the front door was not "on" at that time. The door alarm policy states, "The front exit is armed with a system that triggers only by a resident wearing a transmitter....If an alarm is noted to not be functioning, staff will initiate at 1/2 hour check on all residents who have been determined to be at risk for wandering." E1 (Administrator) indicated per interview on 10/07/03, that this meant that the main door alarm was not activated, or "on", for the front door even when the the resident-specific alarm was out of order. When E1 was asked if the regular front door alarm would ever need to be activated per this policy previous to the incident of 09/21/03, she indicated that it would not ever have needed to be activated even at night because the main entrance is locked from 8:00 PM to 6:00 AM, also per this policy. E1 indicated the front door is used so much during the day by staff and visitors they consider it monitored in that way. Documentation about the elopement of R1 on 09/21/03 includes the following: R1's nurse notes dated 09/21/03 state the following: "2:00 PM - [R1] has been asking for sister, et (and) mother, et father. Found on phone trying to call her mother...too many times to mention today. "3:20 PM - Returned to fac. (facility) per staff without injury or incident. "3:30 PM - returned to facility per CNA car...stating 'have to go home, Mom and Dad are waiting for me.' pacing hall." The facility's incident investigation report of R1's elopement, dated 9/22/03 states the following: "On 9/21/03 at approx. (approximately) 3PM, [R1] was unable to be located.... "At approx. 3:08 Pm the facility received a phone call stating they had seen [R1] walking down the street.... E5 (Certified nurses Aide - CNA) was sent to pick her up. "On return to facility, [R1] was given a full exam...there was no harm to the resident. "On 09/18/03 it was noted during daily checks that they alarm system was malfunctioning - new parts were immediately ordered and 1/2 hour checks had been initiated." Interview information obtained on the survey about R1's elopement of 09/21/03 includes: Z4 was interviewed on 10/02/03 and indicated that she saw R1 coming towards her across her yard at her residence. Z1 indicated she recognized R1 and knew she was a resident of the facility. Z1 asked R1 if she could help her because it was apparent R1 was lost. Z1 indicated that R1 "was ambulating just fine...was appropriately dressed...was not agitated...knew who she was...knew her home address and said that is where she was headed." Z1 indicated she called the facility and told them about 3:15 PM. Z1 indicated R1 "was easily redirected" when she told R1 she had arranged a ride for her. Z1 indicated the weather was "nice," and R1 was "not afraid...not thirsty...and not in ill health." E5 was interviewed on 09/26/03 and indicated that the last time she remembers seeing R1 was 2:20 PM. E5 indicated staff found out that R1 was seen walking outside the facility from two unknown visitors, who came to the nurses desk during the shift change report a little after 3:00 PM. E3 and E7 went to look for R1 near her home, which is approximately 0.5 miles South (measured by surveyor with car odometer on 10/02/03) on the same street that the facility is located. E5 indicated that a phone call then came through to the nurse station desk from Z4. Z4 told them where R1 was located (Z1's residence - approximately 0.9 miles from the facility). E5 went to pick her up in a car. Z3 was interviewed on 10/02/03 and indicated that R1 "walked well...her walking is safe, except for her eyesight." Z3 indicated R1 "would have a tendency to sneak out when upset." Z3 indicated R1 was taken care of on a daily basis in the community by R5. At the time of the incident R5 was also a resident at the facility and was terminally ill. It was upsetting to R1 that R5 was no longer able to attend to R1. The distance from the facility to Z4's residence was measured on 10/02/03 to be 0.9 miles by car odometer. Many of the residential streets do not have sidewalks along this route and R1 had to have crossed at least two busy streets in the process, including highway Route 108, a highly traveled route passing through Carlinville. |