Facility I.D. Number: 0041426
Date of Survey: 08/07/03
Incident Report Investigation of July 2, 2003
Personal care shall be provided on a 24-hour, seven-day-a-week basis.
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.
AN OWNER, LICENSEE, ADMINISTRATOR, EMPLOYEE OR AGENT OF A FACILITY SHALL NOT ABUSE OR NEGLECT A RESIDENT. (Sections 2-107 of the Act)
This requirement is not met as evidenced by:
I. Based on observation, staff interviews and record review the facility failed to supervise a confused resident (R27) who wanders by:
These failures resulted in R27 leaving the facility undetected by staff. R27 was found 32 minutes later, 2 blocks from the facility on a busy, 40 mile per hour 2 lane road. R27 sustained a fractured humerus. This applies to 1 of 23 residents identified as wanderers in the facility.
The findings include:
1) R27 was admitted to the facility on 11/19/02 with diagnoses which included advanced dementia. R27's Minimum Data Set (MDS) dated 6/3/03 assessed her as having severely impaired cognitive skills for daily decision-making. The MDS also documented that R27 had short and long term memory problems and was not able to recall current season, location of room, staff names/faces, or that she is in a nursing home. R27 displayed a wandering behavior which occurred 1 to 3 times in a 7 day observation period. R27's comprehensive plan of care dated 12/2/02 documented that the facility had assessed R27 as a "wanderer". It also stated that R27 is very dependent on her husband (R45), wanders when not walking with husband and is confused of where to go when not with her husband. The approaches to this problem are limited to involving R27 in activities and bringing R27 to her husband. The comprehensive care plan dated 12/3/02 documented that R27's is at high risk for injury due to a fall prior to admission, poor safety awareness and use of psychotropic medications.
2) Nurses notes dated 7/2/03 at 1:00 PM document, "CNA reports to this RN that resident made a statement to her about going outside to find her husband. Resident's husband was discharged to [another] facility for treatment the day before. Resident very dependent on husband for direction." Nurses notes dated 7/2/03 also documented that an electronic monitoring device was placed on R27 between 1:00 PM and 8:00 PM. Nurses notes dated 7/2/03 at 8:35 PM, document, "received a call from an employee of another facility asking this writer if [R27] is a resident here. Same person notified this writer that this resident was walking on the sidewalk of a busy intersection...and that she fell and the cops were called. He also said that [R27] will be taken to the emergency room for evaluation."
3) A police report dated 7/2/03 stated that at 8:08 PM a police officer responded to a call to assist with an injured pedestrian. The report stated that a witness (Z1) was driving down a two lane road and saw R27 fall forward on the sidewalk approximately 30 feet south of the east entrance drive to the County Complex and that R27 was transferred to the hospital.
The report also documents that the police officer notified E8 (nursing supervisor) of the incident.
The Emergency Room report dated 7/2/03 documented that R27 was assessed to be disoriented, have a bloody nose, pain to left upper arm/shoulder and blood to her upper lip. R27 was diagnosed with a left proximal humerus fracture.
The facility's investigation report dated July 28, 2003, titled "Process Resolution Process Step 2", and signed by E1 (Administrator) documents the following, "A review of the documents related to [E9] and the incident which occurred on July 2, 2003 revealed that [E9] , after clocking out, heard the security alarm and turned it off. As a result, a resident eloped."
4a) E1 (administrator) and E2 (Director of Nurses) were interviewed on 7/29/03 between 1:00 and 2:00 PM and stated that they reviewed the surveillance camera to see what happened on 7/2/03. The tape showed that at 8:00 PM. a resident from the second floor was being wheeled through the first floor doors (which were alarmed) to go out of the facility with two family members. They put in the code and opened the first set of doors. Just as they finished going through the doors R27 came up behind them and followed them out. E1 and E2 stated that E9 (evening receptionist) was seen to return to the reception desk and turn the alarm off without checking the source of the alarm or informing nursing staff. Facility staff was not aware that R27 had left the building until an unidentified person called and questioned staff to see if they were missing a resident (R27).
b) On 7/31/03 at 1:10 PM E8 was interviewed and stated, "I saw E9 going through the doors. I expected her to check. Usually the receptionists will alert the nursing staff that a resident has gone out of the doors. My main focus at that time was with another resident who was choking. I cannot remember if I heard the alarm or not."
c) E9 was interviewed on 7/31/03 at 4:33 PM and stated, "I went to punch out. The door alarm was sounding when I came back into the lobby. I saw two students walking into the double doors. I assumed that something on one of them had set off the alarm. I turned the alarm off and left. I didn't see anything unusual."
d) E28 (daytime receptionist) was interviewed on 7/31/03 at 10:45 AM and stated that the door (referring to the electronic monitoring equipped door) was very sensitive and that a person's jewelry can set off the alarm. On 7/31/03 at 6:32 PM the alarmed sounded when surveyor was exiting the building through this door.
e) E10 (CNA), E11 (nurse), E12 (nurse) and E13 (CNA) were interviewed on 7/31/03 between 5:27 PM and 5:50 PM and confirmed that they had worked the evening of 7/2/03 on the first floor. E10, E11 and E13 stated that they did not hear the door alarm that evening. E12 stated, "we have a lot of alarms...I cannot recall if I heard that alarm." E10, E11, E12 and E13 all stated that it is difficult to hear the alarm sounding if you are in a resident's room with the door closed and/or a television is on.
5) On 7/31/03 between 10:20 AM and 10:50 AM the front exit doors of the facility were observed and tested. The exit path through the front door involves a series of 3 doors. The first set of doors are double doors and require that a code be entered prior to opening, otherwise an alarm will sound.
Beyond these double doors is the lobby where the receptionist's desk is located. The second door in the exit path is equipped with a magnetic electronic monitoring system that alarms when an electronic monitoring device passes through it. This high pitched alarm can be heard in the lobby (receptionist) area, the first floor nurses station and in the hallways of the 200, 300, 400 and 500 wings. The alarm cannot be heard in the vestibule between the second and final door to the outside. The final door exiting the facility is not alarmed.