Eldorado Care Center
Facility I.D. Number: 0036624
Date of Survey: 06/02/03
Incident Report Investigations of 5/17/03 and 5/25/03
Personal care shall be provided on a 24-hour, seven-day-a-week basis. This shall include but not be limited to, the following:
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.
AN OWNER, LICENSEE, ADMINISTRATOR, EMPLOYEE OR AGENT OF A FACILITY SHALL NOT ABUSE OR NEGLECT A RESIDENT. (Section 2-107 of the Act.)
The facility must ensure that each resident receives adequate supervision and assistance devices to prevent accidents.
This REQUIREMENT is not met as evidenced by:
Based on medical record review, facility observation, staff and other interviews, the facility failed to provide adequate supervision to prevent the elopement of one resident (R2) reviewed that is cognitively impaired, unable to recognize danger signals, and at risk for walking away from the facility.
1. R2 is a 63 year old confused and ambulatory male who was admitted to the Secured Alzheimer's
Unit of this facility on 5/22/03. His diagnosis includes Alzheimer's Dementia, Non-Insulin Dependent Diabetes and Hypertension.
On 5/25/03, R2 eloped from the facility sometime between 6:20A.M. and 6:35A.M. According to staff interviews with E1, (Adm), E2, (ADON), E3, (DON) and according to R2's medical record, R2 was adjusting well to the placement until 8P.M. on 5/23/03 when his daughter called him. The nursing notes indicate at 9P.M., R2 asked staff if he could call his daughter and staff explained he would have to wait until morning. At this time, he asked how to get out. Then on 5/24/03, at 8:15A.M., the nursing notes indicate R2 is up ad lib on the unit and is pacing back and forth. The notes state R2 is antsy and keeps looking out the unit windows and looking at his watch--asking when he can leave.
R2's vitals were documented in the nursing notes for 6:30A.M. on 5/25/03. A nursing entry dated 5/26/03, (Per E1,this is an error--should be 5/25/03) at 6:35A.M., documents a CNA on the unit informed E6, (RN) she was unable to locate R2. A search of the entire facility was conducted by all staff at this time. Per E1, she was notified at 6:35A.M. that R2 could not be found. E3 was also notified at this time. A search on foot and by auto was then initiated by staff. At 6:38 A.M., the police were notified of the need to locate the resident. At 8:30A.M., the facility was notified by the Eldorado Police Department that R2 was found at a gas station in Carrier Mills and was in route at this time to return to the facility.
R2 was returned by the Eldorado Police Department. A full body and skin assessment was done with no injuries noted. The resident was wet from rain. No pain or discomfort was voiced. R2 told staff he wants to go home to Missouri. Z3, (Gas Station Clerk) was interviewed by phone on 5/28/03 at 2:45P.M. Z3 told this surveyor she noticed a maroon car had brought R2 to the station then drove away. Z3 comments she did not notice the driver or license plates because it was pouring down rain. Z3 said R2 entered the station and asked where the river was. She indicated being new to this area, she did not know what to tell him.
Therefore, she states she told him to ask the two gentlemen in the station drinking coffee. One of the gentlemen told R2 to go straight down route 45 to Vienna. R2 then left the station and proceeded to walk South toward Vienna. Z3 states she told the gentlemen something did not seem right with this person and therefore, she called 911. Z3 said she reported a strange guy had came in the station asking where the river is and he had stated he did not know where he had came from. Within a few minutes, the police called Z3 back and told her a manhunt was going on in Eldorado and they asked her to bring him back to the station. One of the gentlemen present was able to coax R2 back into the station. After being asked his name, R2 told the gentleman his correct name. Z3 then called 911 back to give the police his name. Z3 states the police then arrived to pick him up. Z3 indicated R2 was very wet from his knees down, wearing a dark sweater, beige dress pants, and tennis shoes.
Z4, (Police Dispatcher) states he has no idea who picked up R2 and took him 8 miles to Carrier Mills.
R2 told E1 he was picked up by a young man in a pick-up truck on the road before the construction. However, Z3states she saw him get out of a maroon car. Therefore, it cannot be determined who gave R2 a ride or where R2 was picked up from.
Z5, (Wife) states they used to live in Missouri and they moved to Illinois about one year ago. When asked if R2 would be aware of cars and danger she stated, "who knows." Z5 also stated R2 was not familiar with Eldorado. After R2 was returned to the facility he was placed on constant observance. A 5mg Haldol injection was ordered and given at 10:15A.M. The nursing notes indicate at 12:30P.M. a CNA yelled up the hallway that R2 was eloping out of the dining room window with the CNA unable to stop him. Staff chased after him and walked 3 blocks with him encouraging him to return to the facility. It is documented that R2 was verbally abusive, threatening staff and resisting staff attempts to return him to the facility. A male staff member was finally able to convince him to get in his car and return to the facility. R2 continued to make threats of leaving the facility and to go home. At 2:15P.M., R2 was still agitated and Haldol 5mg IM was given per as needed orders. R2 continued to be verbally abusive. The Mental Health Professional (Z2) was paged for an evaluation. Z2 arrived at the facility at 4P.M. while R2 remained very apprehensive and anxious. The 4P.M. Nursing Note by E2 indicates R2 was demanding his wife to take him home. R2 stated he would leave one way or another. Z2 contacted the Harrisburg Psychiatric Unit for an admission and was told they were full. Z2 then called the Olney Psychiatric Unit for placement. Z2 was informed the doctor was not answering the page. Therefore, R2 was transferred to Ferrell Hospital Emergency Room for a Psychiatric evaluation. The ambulance arrived at the facility for the transport at 6:15P.M.
On 5/26/03, the nursing note of 8:30A.M. indicates Ferrell Hospital was contacted for information on R2. The hospital reported R2 was released with his daughter who supposedly took him to the Centralia Psychiatric Unit. According to Z5, R2 was discharged from the Centralia Psych Unit in care of his daughter who plans to care for him in her home.
In an interview with Z2 by phone, at 9:05A.M. on 5/29/03, Z2 states R2 has poor short term memory and feels he was so focused on getting home that she did not feel he would be aware of hazards and she thinks he was at risk for harm.