Harrisburg Care Center
Facility I.D. Number: 0045799
Date of Survey: 07/24/03
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.
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 record review, interviews, and observations the facility failed to take measures to prevent one confused resident (R2) from a sample of three residents from leaving the facility unsupervised by staff. The facility has identified six residents at risk for elopement. R2, who is cognitively impaired and at risk for elopement, left the facility on 7-3-03 without staff knowledge.
A review of the incident report showed that on 7-3-03, R2 was reported as being found several blocks from the facility unsupervised. A review of the chart showed that this 74 year old male was admitted to the facility on 6-17-03 with the diagnosis of Senile Dementia, Urinary Obstruction, Malaise, and Fatigue. A review of a comprehensive assessment conducted by the Veteran's Administrative staff dated 6-17-03, showed that the resident was found to be confused, wanting to go home with making offers to pay staff for taking him home. A portion of the same assessment was completed by a Physical Therapist who documented, "Pt. did well with functional activities, it would be a safety risk for the pt to return back home without supervision." The current facility record further showed activity staff, and nursing staff noting R2's confusion.
The current physician's orders identified that R2 needed supervision while leaving the facility. An interview with Z3 (R2's physician)on 7-22-03 confirmed that R2 could not be out in the community unassisted as R2 is dependent on staff for all care. The Wander Risk Assessment showed that at times R2 would exhibit ambulation that appeared aimless in nature. Despite this, E7 (Director of Nurses) marked R2 as not at risk for wandering.
An interview with R2 on 7-22-03 at 9:50 A.M., showed that R2 was confused to place and time. R2 did not remember leaving the facility, and mumbled things about kids being old enough for something. R2 then stated that he was going to Harrisburg, and then Marion. R2 was able to tell surveyor what a stop sign meant, and that a yellow sign meant caution. R2 was observed on 7-22-03 at 1:38 P.M. to stumble while walking down the hall by himself.
An interview with Z2 (ambulance personnel) via phone at 9:30 A.M. on 7-11-03, showed that R2 was found on 7-3-03 at approximately 3:27 P.M., approximately one mile from the facility. Z2 stated that R2 had sustained an "evulsion of the tip of one of his fingers", and was extremely confused. Z2 stated that R2 had no idea where he was and stated that he was 39 years old. Z2 stated that it was very hot that day, but R2 was not treated for heat exhaustion. Z2 stated that R2 was transported to the Harrisburg Hospital. A review of the hospital notes showed that R2 also sustained an abrasion to the left knee. The three abrasions to R2's knee were observed on 7-22-03 to be scabbed with one area showing red inflammation. R2 was also observed to have a urinary catheter (as he did on departure), and needed staff assistance of one to dress and walk. The record did confirm that at the time of departure R2 was receiving physical therapy to increase balance, strength, and endurance.
An interview on 7-23-03 at 10:41 A.M.,with Z4 (police officer) who found R2 on 7-3-03 showed that upon arrival to the scene, R2 was in the middle of the joining streets of Gaskin and South Main. Z4 stated, passersby were lifting R2 off of the street. Z4 described R2's legs as lying flat as he was being moved off of the street. Z4 described R2 as moving very slowly, and that it was very hot that day.
A call to Southern Illinois University Weather station on 7-17-03 at approximately 1:00 P.M., showed that Z1(weather reporter), reported the weather on 7-3-03 at the times of 2:45 P.M., and 3:45 P.M. as being 89.6 degrees Fahrenheit, with the heat index as 98 degrees Fahrenheit. Interview with Z2 and other facility staff showed that R2 was fully clothed, wearing a long sleeve shirt, a hat, and was carrying a bible.
An interview with E1 (CNA) on 7-22-03 at 2:00 P.M., showed that R2 had a history of attempting to leave the facility one to three times a week , three to four times a shift (evening shift). E1 stated she knew when R2 was going to attempt to leave the facility because he would put his hat on, and would also grab his bible. E1 identified that the only way R2 could exit is by the front door, or dining room door because some residents know the code and turn off the alarm. Interviews with E5 (CNA)and E6 (CNA/Physical Rehabilitative Aide) on 7-22-03 at 9:30 A.M., and 9:10 A.M. respectfully, showed that they also considered R2 as an elopement risk due to behaviors of prior attempts at leaving the facility. An interview with E4 (activity/social service staff member) on 7-22-03 at 1:30 P.M., showed that R2 was last seen on 7-3-03 in the resident council meeting around 2:50 P.M.. E4 reports R2 as not making sense when he conversed, and said that he was worried about his car. E4 stated that when she took him to his room he was looking for his car keys. However, interviews with administrative staff (E8/administrator and E7/director of nurses) on 7-22-03 at 8:40 A.M. and 8:00 A.M. respectfully, showed that they did not consider R2 as an elopement risk. On 7-22-03 E8 stated, for the first few days after being admitted, R2 was on a wander watch which should be documented. The record review, and interview with E7 on 7-23-03 at 7:30 A.M., confirmed that there was no documentation of any monitoring of R2 prior to 7-3-03. The monitoring sheets showed that the monitoring of R2 started at 1900 on 7-3-03. The monitoring sheets failed to identify monitoring of R2 between the times of 7:45 P.M. on 7-4-03, and 7:00 A.M. on 7-5-03( with the exception of a 4:00 A.M. entry in the nurses notes). E7 stated that the wander bracelet was placed on R2 on 7-3-03 upon return to the facility.
The record and incident investigation report showed that the facility was unaware of R2's departure on 7-3-03, until E9 (part- time R.N.) called the facility, nor did the facility know how R2 departed. E7 explained to surveyor upon entry of 7-22-03 that all doors are alarmed, and the front door only has a chime, but also has a wander alarm for those residents who wear a wander alarm bracelets. E7 also explained that on 7-3-03, R2 was not considered a wander risk and did not have a wander bracelet on, nor did he have any identification on his person upon leaving. All staff interviewed who worked on 7-3-03, failed to hear an alarm going off to signal staff. Upon entry of 7-22-03 surveyor found the doors to the patio to not have an alarm sound when exiting. E7 who also was present, identified that someone must have put the alarm on pause as she pushed the buttons of the alarm device which made the alarm sound.