Illinois Veterans Home at Quincy
Facility I.D. Number: 0044107
Date of Survey: 07/29/2003
Incident Report Investigation of 07/15/03
Original Complaint Investigation
Adequate and properly supervised nursing care shall be provided to each resident to meet the total nursing care needs of the resident.
Based on observation, record review and interview, the facility failed to monitor R1's whereabouts during a high activity time and failed to maintain a video monitoring system in working condition. R1 left a secured unit door on 07/15/03, and walked off facility grounds. Staff were unaware that R1 was missing.
R1 is an 82-year-old male resident with diagnosis of Dementia - Senile Uncomplicated (Mild), Chronic Obstructive Disease, and Hypertension per current physician order sheet. Interview with R1 on 07/29/03 at 11:00a.m. noted him as confused and unable to answer simple questions such as: How do you cross a busy road? What do you wear outside on a hot day? R1 was oriented to himself only; he could not answer what city he was currently living in, or the facility in which he resides. R1 resides on a secured unit at the facility.
Observation of the secured unit door with E1 on 07/29/03 at 10:50a.m. notes locked double doors. E1 states that this is the door that R1 exited from. Outside the doors there is a large red button on the wall that you push to disable the alarm and unlock the door for entry. A doorbell was also noted directly next to the red button with a sign asking visitors to ring the bell to alert staff to let them into the unit. On the opposite side of the double doors (within the unit) a key pad was noted on the wall. A code number is entered into the key pad by staff that disables the alarm and unlocks the door allowing a person to exit the unit.
Review of R1's record noted an "ELOPEMENT RISK/SAFETY CONCERN RISK ASSESSMENT" form. This form assessed R1 as a "7" on the following dates 12/19/02, 02/14/03, and 05/09/03. A score of "7" indicates that a resident is an elopement risk.
Interview with E2, Public Information Officer (facility employee) on 07/29/03 at 10:30a.m. reports the following information: "I was coming back from town and entered the Il Veterans' Home entrance. I noted a man standing on the west side of 12th street, he looked familiar. He crossed 12th street by the radiator shop. I pulled my truck around and asked if he knew where he was going. He was incoherent, I asked him if he lived at the Veterans' Home, he said "yes". I asked him if he needed a ride back. He was wearing a stocking cap and gloves. I drove him back to the infirmary building connected to the secured unit. I met (E5, LPN, Licensed Practical Nurse), she took him back to the secured unit where he resides."
Interview with E4, RN (Registered Nurse) and also the unit manager of the secured unit where R1 resides on 07/29/03 at 10:40a.m. reports the following information: "Around 1:00p.m. someone fed R1. Between 1:00p.m. and 2:00p.m. R1 left the secured unit. I was told an employee saw him across 12th street at a radiator shop and returned him. He was not dressed appropriately for the weather, he had a low-grade temperature on his return, that quickly resolved." Nursing notes dated 07/15/03 at 2p.m. documents: "Temperature 99.0 degrees Fahrenheit, pulse 108, respirations 18, and blood pressure 105/64."
Interview with E3, LPN on 07/29/03 at 10:50a.m. reports: "I got a call from (E5), LPN from the infirmary asking if we were missing a resident. I didn't know. Last time (R1) was seen was 1:00p.m. when he was fed. He returned at 2:00p.m.. There was a lot of activity that day. The man that cares for the birds was in, the doctor, the respiratory therapist, the barber, and the food carts were brought in and taken out. All these people knew the access code. A family was also visiting that stand by the door and buzz each other out to take out a residents laundry. I called the supervisor. R1 was wearing a stocking cap and gloves which is typical for him, he refused to take them off." Interview with E3 on 07/29/03 at 1:20p.m. reports that R1 wanders all day long and usually walks the hallways with another male resident.
Review of the facility incident report regarding R1's elopement dated 07/15/03 notes that the secured door that R1 exited from is monitored by a video camera. This video camera is broken. A work order was placed on 07/9/03 prior to the incident. On 7/29/03 at 1:20p.m. the video monitor that views the hallway and the secured unit door was still not in operation, this was verified by E3. At this same time E3 was interviewed regarding R1 and any prior history of eloping. E3 stated that R1 just had an incident last month. He was outside with activity staff in the courtyard and walked outside of a gate that is supposed to be locked at all times. Nursing notes dated 06/16/03 verify this information, stating that security returned R1 to the Unit.
Telephone interview with E3 on 07/30/03 at 1:25p.m. states, "When we sit at the nurses station to do our charting we use the three video monitors to watch the entrance, side hallway and back hallway. There is not always someone there to watch the monitors, we are usually out on the floor doing treatments or passing medications. The CNA's (Certified Nurse Aides) and the ward clerk do not go behind the nurses station. On doctors visit day the nurses are behind the nurses station a lot longer assisting the doctor and processing new orders. The day R1 left the unit was a doctor day, if the monitor was working I might have seen R1 leave the unit."
Telephone interview with E6, Activity Therapist, states he was the staff person out in the courtyard with R1 and other residents the day R1 got out the unlocked gate. E6 stated that R1 could not have been outside the courtyard more than fifteen minutes when a lady (employee) saw him and called security. E6 states that he is a new employee, and was not aware that there was a gate that exited outside of the courtyard. He stated that maintenance was in the courtyard picking up sticks at the same time the residents were out with him. E6 states that the gate is locked from the outside and assumes that R1 walked out through the unlocked gate.
Interview with E1, DON (Director of Nursing), on 07/29/03 at 1:30p.m., when questioned regarding how the secured unit staff account for its residents throughout the day, E1 replied, "They do head counts every morning at 7a.m. and every two hours thereafter." E1 further stated that the unit would have done a head count at 3p.m. on the date of the incident.
On 07/30/03 at 8:00a.m. the Quincy Police Department verified via telephone interview that the speed limit on 12th street directly in front of the Il Veterans' Home is posted at 30 miles per hour. Telephone interview on 07/30/03 at 8:35a.m. with the Midwest Regional Climate Center in Champaign Illinois verified that the Quincy Regional Airport recorded the weather conditions in that area with a temperature of 87 degrees Fahrenheit on 07/15/03 at 2:00p.m. Central Daylight Time. R1 walked a total of 2/10ths of a mile from the secured unit where he resides to a shop across 12th street per odometer reading.