Facility I.D. Number: 0002451
Date of Survey: 09/03/03
Incident Report Investigation of 8/12/03
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 resident's 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.
Personal Care, as defined in section 300.330, 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 (Section 1-120 of the Act).
All exterior doors are 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 require.
These Regulations are not met based on:
Observations, interviews, and record review revealed that the facility failed to:
a. Assess and intervene after R1 displayed increased confusion on 8/1/03;
b. Have signaling devices on exit doors to alert staff when they were opened.
On 8/2/03 R1 left the facility undetected by staff at 3:00 a.m.. R1 was found approximately by the local police 1 hour and 45 minutes later, 4 blocks from the facility on a residential street near the downtown business district.
The evidence includes:
R1 has the following diagnoses: Hypertension, Diabetes Mellitus, Loss of Hearing, Acute Mental Status Changes, Encephalopathy, Dementia, Ischemic Heart Disease, and Hypothyroid Disease per physician's orders for July 2003. The comprehensive assessment dated 8/12/03 documents that R1 has short and long-term memory problems and is moderately impaired in her decision-making skills. A ?Fall Risk Assessment completed on 8/12/03 documents that R1 is at high risk for falls.
Review of R1's Nurses Notes, dated 8/1/03 8:00 a.m., reveals, "Resident (R1) is walking around in a daze. Refused to take 8:00 a.m. medications. (R1) states "no". (R1) is unable to process her thoughts. (R1) can't say what she wants to do."
Nursing Notes dated 8/1/03 11:30 p.m. state, "Awake sitting in day room refused to go to bed."
Nursing Notes dated 8/2/03 document that R1 was last seen at 2:45 a.m. pacing in the front half of the 100 Hall, entering room number 100 but refusing to stay. The Nursing Notes further document that E12 was notified that R1was missing at 3:00 a.m. The Police Report dated 8/4/03 for R1 documents that the police were notified of R1's absence from the facility and grounds at 3:30 a.m.
The police report also documents that at 4:40 a.m. R1 was found at an intersection of two residential streets. According to the nurses notes dated 8/2/03 (late entry) R1 was returned to the facility by the police at 4:50 a.m. R1 was away from the facility for approximately 1 hour and 50 minutes.
Review of weather conditions on 8/2/03 between the times of 3:54 a.m. and 4:54 a.m. show the temperature was 62.60 degrees Fahrenheit per Weather Underground History for Rockford and vicinity.
During an interview on 8/27/03 at approximately 3:00 p.m. R1 stated, she did not recall ever being outside the building at night. R1 further said that she did not recall going to the emergency room to be evaluated.
During an interview on 8/27/03 at approximately 3:15 p.m. Z1 stated, "It is not safe for her (R1) to be alone. I do not believe that she would have found her way back to the facility. I saw her (R1) when they brought her back to the facility. She (R1) was very confused. I do not even know if she (R1) knew that she was outside."
During an interview conducted on 8/27/03 at approximately 1:30 p.m. E1 stated, "On 8/2/03 we had an electronic monitoring device on the front doors, that is all we had on the doors at that time. (This alarm would only sound if a resident wore a monitoring band.) R1 did not have a personal electronic monitoring device on at the time of the incident. R1 was not considered to be at risk for wandering."
E7 verified that R1 did not have a personal electronic monitoring device on the day of the incident. E7 further stated, "R1 was found about 4 blocks north of the facility. She (R1) told staff that she was digging for worms. She did have dirt under her nails when she was returned to the facility."
During interviews conducted on 8/27/03 between 2:40 p.m. and 4:27 p.m. and 8/28/03 between 7:45 a.m. and 8:20 a.m., E7, E8, E9, E11, and E12 all said that they did not remember hearing any door alarms go off on the morning of 8/2/03. All staff working the night the incident occurred said that R1 was awake and wandering when they came on duty at 11:00 p.m. R1 continued to wander up and down the 100 Hall and lobby area until she was determined missing by facility staff. None of the staff interviewed witnessed R1 exit the building.
During an interview conducted on 8/27/03 at approximately 4:45 p.m. E6 stated, "There is not always someone there to monitor the front doors especially during medication pass. On night shift, the nurse goes down the 300 Hall (locked unit) after first round. The nurse is down there for 1-2 hours. When this happens that leaves 2 CNA's up front answering call lights and 2 CNA's on break. There is no guarantee that there will be someone at the nurses station."
Environmental hazards in the area of the facility are:
a. Only a few street lights on residential streets, resulting in poor visibility at night.
b. A river is located approximately 4 blocks east of the facility.
c. A state highway is located 2 blocks east of the facility with a speed limit of 30 miles per hour.
Observation of the entrance doors on 8/27/03 at approximately 2:30 p.m. shows a personal electronic monitoring device was in place. Observation of the rear exit door located to the back of the dining area has a personal electronic monitoring device system. (This alarm system would only alarm if a resident wore a monitoring band.) No other alarm signaling devices were present on the rear exit door.