| Belmont Village Glenview Facility I.D. Number: 0045013 Date of Survey: 8/4/03 Incident Report Investigation of 7/4/03 "A" VIOLATION(S): The facility shall notify the physician of any accident, injury, or unusual change in a resident’s condition. Each resident shall have proper daily personal attention and care. Personal Care, as defined in section is assistance with meals, dressing, movement, bathing or other personal needs or maintenance, or general supervision and oversight of the physical and mental well-being of an individual who is incapable of maintaining a private, independent residence or who is incapable of managing his person, whether or not a guardian has been appointed for such individual (Section1-120 of the Act). An ongoing resident record including progression towards and regression from established resident goals shall be maintained. The progress record shall indicate significant changes in the resident’s condition. Any significant change shall be recorded upon occurrence by the staff person observing the change. An ongoing record of notations describing significant observations or developments regarding each resident’s condition and response to treatments and programs. The resident’s record shall include information regarding the physician’s notification and response regarding any serious accident or injury, or significant change in condition as required by Section 330.1110 (f) of this Part. These regulations are not met based on : Based on record review, staff and other interviews and observation, the facility failed to ensure that one resident (R2) with the medical diagnosis of Dementia, who was observed by staff exhibiting some behavior problems, be given proper assistance and supervision to prevent elopement and possible injury. The facility also failed to reassess the resident’s mental and emotional problems after the first and second elopements. Findings include: Record review on 7/28/03 showed that R2 was admitted to the facility on 9/17/02 with the diagnoses of Arthritis, Heart Disease, and Dementia. Facility's initial assessment dated 9/16/02 showed that under redirection and guidance R2 needs maximum assist, wherein staff is to provide frequent reminders, cueing and drawing out of resident. Resident may exhibit occasional inappropriate behavior, poor judgement and moderate memory loss. Review of the nursing notes on initial admission, 9/17/02, 1 PM, showed that R2 appears calm, wandering around into other resident's rooms. Further review of the nurses notes showed the following: On 9/21/02, 12:10 AM, "Resident was noted knocking on door on the Neighborhood (Dementia Unit) door across from the laundry room. Door alarm is in working condition. Resident had eloped out onto the backyard. It's uncertain when resident got outside. Resident was alert but with some confusion per his usual self. Skin cool to touch, pale on color. Resident was only wearing top, no pants or diaper, no shoes or socks." Interview with Community Manager and Director of Nursing, on 7/31/03 via telephone revealed that the nurse who was on duty that shift is no longer working in the facility. DON stated that he is not sure how the door alarm was programmed that time. They were not notified of this incident, therefore there was no incident report written and no investigation done. The Community Manager stated that maybe the nurse thinks that the incident report is not needed because R2 just went out to the court yard. Nurses notes also showed that
After the elopement on 9/17/02 and inappropriate behaviors exhibited as mentioned above, the facility did not re-assess R2 as to his further elopement risk and/or safety awareness in order to re-evaluate the approaches/instructions that staff were to follow proper monitoring and supervision of R2. Review of Z4's (Psychiatrist) notes on 4/29/03 showed that family noted " frequent periods of lucidity, also increased verbalization, re: poss. vis hallucination." R2 is under the care of Z4 for his dementia. R2 is currently on psychotropic medications, Exelon 6 mg. cap, 1 cap BID (two times a day), Seroquel 300 mg. tab, 1 tab every hs (hour of sleep) and Remiryl 4 mg. tablet, 1 tab BID. On 7/4/03, 2:30 AM, nurses notes showed that R2 had eloped. Local police department came and informed E3 (Nurse) that they found a resident with the name of R2. After PAL's (Personal Assistant Liaison) checked and noted that resident (R2) was missing. Resident was brought to the facility at 2:35 AM in good condition, alert, verbally responsive, confused, walking, no complaint of pain or any discomfort. Resident was found in a private home's yard. E3 left a message to E2 and also notified E1 about R2's elopement. There was no documentation in the nurses notes that the physician was notified. Review of the facility investigation report by E1, 7/4/03, showed that R2 was last observed by staff awake in his apartment at approximately 11:30 PM - 12:00 AM. E3 also noted that after his return (R2), she checked all exterior doors and noted a gate off of the Neighborhood Unit was broken and open. E3 secured the gate so as to prohibit exit. When E1 arrived in the facility at 7 AM with E7 (Building Engineer) it was determined that a cylinder which causes the exterior patio gate to lock had been tampered with causing the gate to open. Review of the local police department report dated 7/4/03 showed that on 7/4/03, 1:35 AM, police were sent to a private residence for a report of a man lying on the ground next to the fire hydrant. When the policemen arrived, they saw a man was sitting on the ground next to the fire hydrant. They asked for the man's name. R2 identified himself and his birth date, but did not know his address or phone number. R2 also told the officer that he has a brother who lives in a subdivision in the same area. Police communication was able to locate the address and telephone number of the brother and tried to call but did not get an answer. Z5 (Police officer) went to the brother's house but no one came to the door. Z6 (Police officer) went to the the facility and confirmed that the man lived there. R2 was then transported to the facility and was released to the midnight shift supervisor nurse. On 7/30/03, 1:30 PM, the surveyors drove to the location where R2 was found. It is approximately 1.3 miles north of the facility. A fire hydrant was observed in front of the house where R2 was found. Interview with E1 on 7/28/03, 2:20 PM, in the library revealed, that R2 was able to unscrew the lock to get out of the facility. Further interview with E1 on 7/30/03 via telephone revealed that the other doors in the unit have alarms that when somebody opens the door, it continuously alarms until somebody turns it off with a key. The door in the dining room, where R2 got out, does not alarm continuously. The alarm will stop once the door closes. E1 stated that since there was a locked gate next to this door a continuous alarm is not needed. R2's room is 40 feet away from the exit door in the dining room and the door is 13 feet away from the gate in the courtyard. Interview with E3 on 7/28/03, 2:20 PM, in the library, revealed that on 7/4/03 she checked all the residents in the unit at 12:30 PM and observed that R2 was sleeping in his room. E2 she did not hear the alarm go off on the dining room door. Interview with E2 on 7/30/03, 4:10 PM, in the library revealed that this is R2's first elopement since the facility opened. E2 stated that he has been talking to the staff to keep an eye on residents that tend to wander. When E2 came in that Monday after the incident (7/7/03) he talked to E5 and asked about the incident and if the physician was informed. E2 believed that E5 told him that the physician was informed at around 6:30 AM that morning (7/4/03). Interview with E7 on 7/30/03, 8:43 PM, via telephone, revealed that this gate is always locked. The only one who has the key is himself and E1. The lock screws into the gate and it goes through the hole in the post. E7 stated that R2 was able to unscrew this piece. Interview with E8 on 7/30/03, 8:26 PM, via telephone revealed that she was on duty that night but was not in the area where R2 lives. E8 stated that she did not hear any alarm that night. Interview with E13 on 7/31/03, via telephone, revealed that he was on duty that night when R2 eloped. E13 stated that he saw R2 between 11:30 PM and 12 AM. Then E13 did the residents laundry. At about 1 AM, E13 did his second round checking the residents and found out that R2 was no longer in bed. E13 started checking each and every room in the unit. E13 was still looking for R2 when the police came at about 1:30 AM and brought R2 to the facility. Interview with Z3 (R2's Family) on 7/30/03, 4 PM, via telephone revealed that the family was notified by the facility about the incident. R2 was able to relate to her the next day that he went out. Interview with Z4 (Psychiatrist) on 7/31/03, via telephone revealed that he was not notified by the facility regarding this incident. Surveyor told Z4 briefly about R2 and the incident that happened on 7/4/03, 1:35 AM. Z4 stated that he sees R2 once a month and clinically he is stable. R2 has dementia and is prone to some confusion, disorientation and poor judgement. When asked if R2 was capable of unscrewing the lock, Z4 stated that R2 "could do that". “R2 was a handyman and has that capability. Dementia affects R2's ability to make good judgements. "When R2 sees bars, he might think that he is in prison and will try to get out. R2 is a escape risk." Other staff interview also revealed R2 was a handyman. R2 was able to remove the hinges in the bathroom door in his room and had also removed the toilet seat cover. Interview with R2 on 7/30/03, 2:50 PM in the unit showed that R2 has periods of confusion. When surveyor asked R2 where he went when he got out of the facility that night, R2 stated that it was a very dark night so it was not clear to him where he was. R2 further stated that it was up near and very close to where he was. R2 continued that he was sitting in the front lawn of the house when the policeman saw him and his wife was with him. " We had two cars and we met in Northbrook ". When surveyor asked R2 how he was able to get out of the gate, R2 stated: "I think you've come to the area where I have to stop now." Observation during tour of the unit on 7/28/03, 1:30 PM and 7/30/03, 2 PM showed that in R2's apartment the two drawers in the bathroom cabinet were gone. E5 who was with the surveyor stated that R2 pulled the drawers apart. E5 further stated that one time R2 also pulled the refrigerator out and tried to put it in the bathroom. The refrigerator was already by the door of his bathroom when staff saw it and intervened. On 7/30/03 surveyors tested all the exit door alarms. They were in working condition. At the exit door by the the dining room, alarm stops as soon as the door closes. The gate was observed locked. E7 told surveyor, when interviewed, that he fixed it in such a way that nobody can unscrew it again. R2 has Dementia and facility did not meet his needs for care and supervision to ensure R2's safety. R2 was able to get out of the facility twice since admission.
On both incidents the facility failed to notify Z4 and by failing to do so Z4 was not able to re-evaluate R2's mental and emotional problems as shown in R2's exhibited inappropriate behaviors, poor judgement and memory loss and unable to re- adjust R2's treatment if needed. |