Maple Lawn Health Center
Facility I.D. Number: 0042424
Date of Survey: 7/29/03
Incident Report Investigation of 7/11/03
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 minium 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 met as evidenced by:
Based on observation, interviews and record review the facility failed to have a system in place to monitor the front exit door and failed to monitor the whereabouts of R1 after he exhibited exit seeking behavior. R1 is one of twenty-four residents identified as wanderers and wearing electronic monitoring bracelets.
R1 left the facility without staff knowledge and unattended by staff on July 11, 2003. R1 wandered across the highway and wandered two blocks away from the facility property.
R1 is a ninety-one year old male resident, has diagnoses of Alzheimer's Disease and Macular Degeneration according to the current Physicians Order Sheet (POS) dated 07/01/03 through 07/31/03. Incident report dated 07/11/03 indicated that R1 was found walking north one block from the facility on Highway 117 which runs in front of the facility.
Telephone interview with Z4 (Woodford County Sheriff's Department Dispatcher) at 2:30 P.M. on 07/23/03 verified that on 07/11/03 at 7:33 P.M. Z2 (State Trooper) called the Sheriff's Department to notify them that he had found R1. At 7:36 P.M. Z4 called the facility to notify them. Interview with Z3 (District Eight State Police Dispatcher) verified from State Police Incident Report No. 22035 dated 07/11/03, that at 7:27 P.M. Z2 found R1 walking north, along the side of Highway 117, on the north edge of Eureka. Z2 returned R1 to the facility at 7:36 P.M.
Interview at 2:40 P.M. on 07/28/03 with Z2 verified that he found R1 walking north along the white fog line, on the opposite side of the road (Highway 117) from the facility. Z2 identified the fog line as the white line along the outer side of the road. Z2 said that he found R1 two blocks north from where you turn into the complex property from the highway. R1 had crossed both lanes of the highway. Telephone interview at 10:00 A.M. on 07/28/03 with E4 (Receptionist) verified that she had received a call from the Woodford County Sheriff's Department at 7:00 P.M. on 07/11/03 notifying the facility that R1 had been found on Highway 117. E4 said that that was the first time that she was aware that R1 was out of the facility. Interview at 11:25 A.M. on 07/24/03 verified that statements taken, on 07/11/03, from the staff working during the time of the incident, indicated that none of the staff were aware that R1 had left the building.
Interview at 12:15 P.M. on 07/24/03 with E18 (Certified Nurse Aide) verified that she was working on the Dementia Unit 07/11/03 when R1 exited the facility. She stated that R1 was on the unit, restless, and wandering from resident room to resident room. She said R1 attempted to exit the unit two times that evening, being easily redirected each time by E18. One of the exit attempts was at the rear door to the unit and one was at the door between the unit and the front lobby. According to E18, at 6:00 P.M. this same evening, R1 exited the unit through the door between the unit and the lobby, setting off the alarm.
E18 said that, at that time, she was busy with other residents and could not follow R1. Approximately three to five minutes later she notified E12 (Registered Nurse) as E12 came on to the unit for medication pass. E12 said R1 was sitting in the lobby and was OK. Interview at 11:25 A.M. on 07/14/03 with E2 (Director of Nursing) indicated that R1 spent his waking hours on the Dementia Unit as part of a program to limit his wandering behaviors. R1 only left the unit to eat his noon and evening meals, to visit his wife in her room for an hour or two each afternoon, for supervised activities with the Dementia Unit residents and to sleep in his own room at night.
Interviews at 7:30 A.M. on 07/28/03 with E10 (Licensed Practical Nurse), at 2:40 P.M. on 07/23/03 with E12 (Registered Nurse) and written statement dated 07/11/03 by E9 (Licensed Practical Nurse) indicated that they had last seen R1 at 6:45 P.M. on 07/11/03. At that time he was seated in a chair, in front of the nursing office, in the lobby of the facility. This location is approximately thirty feet across the lobby from the front exit door. All three nurses were beginning their medication passes and went down different halls at that time. Interviews with staff working the evening shift on 07/11/03 verified that from 6:00 P.M. on 07/11/03, when R1 left the Dementia Unit, until R1 left the facility no staff were assigned to monitor or were monitoring R1's whereabouts.
Interview at 11:25 A.M. on 07/24/03 with E2 (Director of Nurses) indicated that at the time of the elopement there was an alarm, to alert staff when a resident leaves the building, on the front entrance outer door. E2 indicated that on 07/11/03, at the time of the incident, the alarm was not turned on. Telephone interview at 10:00 A.M. on 07/28/03 with E4 verified that at the time of the elopement she was not actively watching the door.
This alarm is turned off in the morning when the receptionist comes to work and is turned on in the evening at about 8:00 P.M., when the receptionist leaves for the day. At the time the receptionist leaves the door is also locked, requiring anyone wanting to come in to push a door bell and wait for staff to come and let them in.
E2 stated there was also an electronic monitoring alarm attached to the inner front exit door, which is triggered by a special bracelet which the facility attaches to certain residents. When the person wearing the bracelet attempts to open the door the alarm would sound until someone resets the alarm on the alarm at the door. At the time of R1's elopement, the exit door had one monitoring alarm antenna affixed to the left side (facing out) of the door.
R1 was wearing a bracelet on each wrist, at the time of the elopement. Interview with (Receptionist) verified that she was in the immediate area of the lobby all evening. She only heard the alarm sound one time when a family returned a resident to the facility, this did not coincide with the time of the incident. E4 also stated that she did not notice R1 that evening until R1 was brought back into the facility by staff at around 7:30 P.M.
Interview on 07/24/03 with E2 and review of the incident report dated 07/11/03, indicated that when R1 returned to the facility the bracelet on his left wrist was not functioning. Staff replaced the bracelet immediately. The bracelet on his right wrist was functioning and set off the alarm when R1 was brought back into the building. E2 said that the staff had theorized that R1 left the facility when an unidentified visitor was leaving and that their bodies blocked the signal between the door antenna and R1's bracelet.
E2 said that after R1 was returned to the facility on 07/11/03 she tried going out, with a working bracelet on. E2 positioned her body between the bracelet and the antenna and the alarm did not sound. The facility policy is that all of the bracelets are checked on the 11 to 7 shift each night with the results entered on a log sheet. Review of the log sheet dated 07/10/03 indicated that R1's bracelets were functioning properly at that time. Interview at 12:40 P.M. on 07/24/03 with E17 (Activity Aide) indicated that at 10:00 A.M. on 07/11/03 she had taken R1 out through the front door for an activity and that R1's bracelet set off the alarm.
Observation between 9:00 A.M. and 9:55 A.M. on 07/23/03 revealed that all of the facility's exit alarms were functioning properly at that time. The testing device for the bracelets was also checked and found to be functioning properly at that time. Review of the facility's procedures for checking the function of the exit alarm systems at the facility verified that the last monthly check was recorded on the log sheet, dated 06/26/03. At that time all of the exit alarms including the front two, were functioning properly.
The facility is located in a residential neighborhood on the north side of town. The building is on a major North/South state highway, which has a speed limit of forty miles per hour, and has moderately heavy traffic.
During telephone contact with Z1 (At The Midwest Climate Control Center in Champaign, Illinois) at 8:10 A.M. on 07/24/03 it was verified that at 7:00 P.M. on 07/11/03 the Peoria Airport recorded the weather conditions in the area as being clear, with a temperature of eighty degrees Fahrenheit and humidity at forty-nine percent. Review of the incident report dated 07/11/03 verified that R1 was wearing slacks, shirt, sweater, shoes and socks when returned to the facility.
R1's Care Plan dated 06/25/03 indicated that R1 exhibits confusion, more in the evening than at other times and has poor vision. According to this Care Plan, R1 ambulates independently and is supposed to use a white cane because of poor vision, wanders and is difficult to redirect at times, and wears an electronic monitoring bracelet. R1's Admission Record Nursing Assessment dated 12/05/02 listed R1 as having a history of wandering and nurses notes of the same date indicate that an electronic monitoring bracelet was put on R1 at that time. Interview at 11:25 A.M. on 07/24/03 with E2 verified that the bracelet was applied at that time and had been in place since that date.
Nurses notes dated between 12/30/02 and 05/20/03 indicate that R1 had made seven attempts to exit the facility, with no actual exiting recorded. Review of the Monthly Summary for R1 dated 07/08/03 indicated that R1 is a moderate risk for falls, scoring fourteen with a score of fifteen being a high risk. The previous month R1 was a high risk with a score of seventeen. Nurses notes dated between 03/20/03 and 06/08/03 indicate that R1 had eight falls, one with injury.
Interviews conducted between 07/23/03 and 07/28/03 with E10, E12, and E15 (Nurses), E7, E11, E13, E14 and E18 (Certified Nurse Aides), E16 (Social Service Designee), E17 (Activity Assistant) and R2 (R1's Wife) indicate that R1 would not be aware of his own safety when out of the facility by himself.
Interview attempted with R1 at 9:55 A.M. on 07/23/03 verified that R1 is confused and did not know the time, date or the name of the facility. R1 did not remember the incident of 07/11/03. He said that he was visiting his mother who lives upstairs from where he was sitting, in the lobby. There is no upstairs to the facility. Interview at 10:35 A.M. on 03/23/03 with R2 verified that R1's mother died many years ago.