Rockford Health Care Center
Facility I.D. Number: 0045286
Incident Report Investigation of 5/7/03
The facility shall provide a Resident Services Director who is assigned responsibility for the coordination and monitoring of the residents overall plan of care. The Director of Nurses or an individual on the professional staff of the facility may fill this assignment to assure that residents plans of care are individualized, written in terms of short and long range goals, understandable and utilized; their needs are met through appropriate staff interventions and community resources; and residents are involved, whenever possible, in the preparation of their plan of care
General nursing care shall include at a minimum the following and shall be practiced 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.
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 regulations are not met as evidenced by:
Based on observation, interview, and record review, the facility failed to:
1) follow the facilitys elopement policy and procedure when E12 heard the door alarm on 5/7/03, went to the door and did not follow the facilitys elopement policy and procedure turned the alarm off.
2)have staff conduct a thorough search of resident rooms to include closets and bathrooms and not doing a head count of residents at risk when the alarm sounded on 5/7/2003 between 5p.m. - 5:50p.m.
3) have a monitoring plan for a resident with impaired cognitive skills, who was a known wandering/elopement risk.
1. According to R11's Face Sheet and Physical Therapy Sheet dated 5/2/03, R11 was admitted to the facility on 5/1/03 and has diagnoses of Traumatic brain injury, Seizure disorder, Depression, Hypertension and Gastro-esophageal reflux disease. Review of R11's rehab progress notes dated 5/5/03 and 5/9/03 contained the statement, "I want to go home". On 5/5/03 these notes documented R11's inability to stand on one foot without upper extremity support and that R11 was unable to perform braiding without losing his balance.
Review R11's history and physical examination by Z1(personal physician) dated 5/3/03 revealed R11 has "significant impaired cognition".
Review of R11's nurses notes between 5/4/03 and 5/7/03 document gait unsteady, ambulates independently, alert and oriented times one and speaks often as to wanting to go home.
Review of R11's (incomplete) Risk Elopement Assessment shows that R11 has history of leaving at a previous facility by attempting to leave through doors. The assessment form contained documentation of R11 expressing a desire of wanting to go home, and not accepting the new placement.
Review of a faxed request to Z1(physician) dated 5/1/03 revealed R11 may go out on pass with responsible party. R11 has no orders for unsupervised outside privileges. R11's medication orders from the 5/1/03 physician telephone orders were: Paxil CR 20 mg daily, Neurontin 100 mg 2 capsules tid, Prevacid 30 mg daily, Propranolol 10 mg tid, Tylenol 650mg PRN, and MOM 30cc PRN. Physical therapy and Occupational therapy were also ordered.
A review of nurses notes on 5/7/03 at 5p.m. documented: E13 administered medication in hallway at R11's room. R11 then returned to room to watch TV. At meal time it was noted R11 was missing from main dining room. A search was conducted of each resident's room and staff were unable to locate R11 at this time. The sign out book was checked to see if R11 had signed out on pass. At 5:45p.m. a call was
placed to R11's spouse to see if his parents had taken R11 out of facility. R11's spouse informed the facility that R11 may be hiding in closets. A recheck of rooms and closets was done. E17(CNA) went outside to check around the facility. E4 (CNA) went in her car to check around the area. The administrator was called to inform him of missing resident. E4 returned and reported calling 911. The police indicated they had R11 in custody and were taking R11 to main police station.
At 6:30p.m. Z3 was contacted to inform her that R11 was being held at police station. R11 was at the police station until 10:30p.m. and was returned to his room after 11p.m. R11 was placed on one to one monitoring. Staff asked R11 what happened and R11 replied, " I went crazy".
There was no evidence in the clinical record that a body check had been done when R11 was returned to the facility after 11p.m. on 5/7/03.
Review of the incident report of R11's elopement on 5/7/03 was done. In addition to the information contained in the 5/7/03 nurses notes, the report included that 5:30p.m. staff were unable to locate R11 for dinner and upon readmission to the facility R11 was assessed and no injuries were noted.
Review of R11's Fixed Care Plan identified behavior problems as: at risk for wandering/elopement R/T (related to) history and/or assessment. The identified approaches: place monitoring device on resident that sounds alarm when resident leaves bed or chair; if resident elopes from facility, implement facility protocol for locating resident; remind resident visitors of need to inform staff if they are leaving the designated area with the resident; social services to evaluate resident for placement on secured unit; place resident on secured unit for safety as needed when at risk for elopement; The entries on the fixed care plan dated 5/7/03 were: resident eloped from building and 1 on 1 with resident until alternate placement obtained.
2) During an interview with E1 (administrator) on 5/16/03 at approximately 2:20p.m., it was learned that R11 was screened by E1 prior to admission. E1 stated that a departmental meeting was held and it was decided that R11was appropriate for admission to the facility. E1 identified R11 to have a steady gait, thought to have life safety skills, but was not oriented to all 3 spheres. E1 further stated that Z4 (from previous facility) had informed E1 of elopement issues. E1 stated that R11's elopement on 5/7/03 was achieved by him walking out of the facility's back door (that was alarmed) with another resident's family.
Interview with E6 (CNA) on 5/16/03 at approximately 3:06p.m. found that on 5/7/03, E6 was passing food trays in the dining room at 6:30p.m. R11 was not in the dining room. E6 went to R11's room noting that he was not there. E6 then informed E3 (CNA) that R11 was missing. E6 stated that R11 did try to go out the doors of the facility after family would leave. R11 would walk up and down the hallways and through the dining room cursing and very upset. E6 stated that R11's family left the facility at approximately 5:45p.m. and E6 did not see R11 after 5:45p.m. E6 stated that R11, "walked good, but was unsteady and did walk fast".
Interview with E3 (CNA) on 5/16/03 at approximately 3:16p.m. revealed that on 5/7/03, E3 last saw R11 at 5:00p.m. when medication was given to him. E3 stated she was assisting E13 (LPN) in R5's room when the door alarm was heard. When E13 started to leave R5's room, the door alarm stopped. E3 stated that the alarm must be shut off with a key. E3 stated at 6p.m., E6 had questioned her as to R11's whereabouts. E3 stated that R11 had some life safety skills and felt that R11 had exited out the front door. E3 stated that she felt that R11 knew the exit code to the alarm from watching staff and other families entering the 2 digit code to exit the facility, and probably exited the front door. E3 stated that she had not seen R11 trying to exit with other residents families.
Interview with E12 (RN) on 5/16/03 at approximately 3:50p.m. revealed that on 5/7/03, she did not see R11 until the resident was returned to the facility at approximately 11:30p.m. when R11 was brought back by his parents. E12 stated that she did not hear any alarms going off that evening, nor did she see R11 exit the building. E12
300.3100d)2)stated that R11 was, "orientated to all 3 spheres and did have life safety skills". E12 indicated that he did not do a physical body assessment on R11 (when he returned) but R11 appeared to be okay. E12 stated on 5/7/03 that staff did do room checks. She went to the facility's front parking lot and checked around the outside of the building. E12 re-entered the building to check the door alarms and found all door alarms functioning.
During an interview with E4 (CNA) on 5/16/03 at approximately 3:31p.m. E4 stated that on 5/7/03 she observed R11 resting in bed, watching television shortly after 2:00p.m., when a short conversation took place between herself and R11. At approximately 6:15 to 6:20p.m., E4 stated that she had overheard E13 talking to E3 concerning R11's unknown whereabouts. At approximately 7:00p.m., E4 went searching in her car for R11. E4 called 911. E4 stated that she informed the police of R11's elopement from the facility. The 911 operator instructed her to wait for a call from the police. E4 stated that the police did return her call informing E4 that R11 was picked up by the police at the intersection of 4 lane highways with speed limits of 45 mph. The police informed E4 that R11 was in custody. E4 stated she returned to the facility at 8:40p.m. and informed E13 of R11's whereabouts. During the interview E4 stated she was unaware of the facility's elopement policy and procedure and felt that someone had to drive to try and find R11, being afraid of R11 being harmed.
R11's spouse was interviewed on 5/19/03 at approximately 2:35p.m. by phone. R11's spouse stated she was called by the facility between 6:30p.m. and 7:00p.m. inquiring if she knew the whereabouts of R11. She stated that at approximately 8:25p.m. the facility called back informing her that R11 had been picked up by the police. She said that R11 was picked up after a citizen had called 911 reporting that R11 was in a busy intersection.
3) R11 was observed on 5/19/03 at another facility. R11 was only oriented to self. When questioned about the 5/7/03 elopement, R11 had absolutely no recollection of that day. R11 was unable to state where he lived now, did not know the month, year, date, or who the President of the United States was. R11 was asked what his reaction would be if he was standing in a busy street. R11 replied, "I would flag someone down". R11 was unable to recite his home and parents addresses and did not know the phone numbers of either. R11 was asked what his immediate plans were, and he responded, "to find a job installing sprinklers, buy a red corvette and cell phone". R11 stated he was unsure how to acquire a taxi, how to use public transportation, and which direction was home. R11 was observed to have a fast unsteady gait.
A review of Weather information obtained from Weather Underground.com documents temperature at 6:54p.m. on 5/7/2003 was 51.80 degrees Fahrenheit.
Review of the local Police Department's investigation of 5/7/03 regarding R11's elopement documented that at 6:44p.m., R11 was found dressed in blue jean shorts and black shirt. The police were called in reference to a welfare check on a white male who then advised the officer he was trying to get home. The police officer placed R11 in the squad car for the safety of the officer and R11 due to "busy roadway".
Observation of the roadway on 5/19/03 and 5/27/03 revealed between the facility and the location where R11 was found he would have to cross a 4 lane highway which is 35 to 40 mph speed limit. The next road is a 2 lane road that has a 35 mph speed limit. The next street, where R11 was found has a 45 mile per hour speed limit.