Facility I.D. Number: 0045294
Date of Survey: 7/21/03
Annual Licensure and Complaint Investigation
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).
General nursing care shall be practiced on a 24-hour per day, 7-day per week basis and shall include, at a minimum:
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.
These regulations are not met as evidenced by:
Based on observation, record review and interview the facility failed to monitor the front exit door to the facility during a period of time when R9 was exhibiting exit seeking behaviors and while R9 was on a fifteen minute monitoring program. R9 left the facility with out staff knowledge, wandering one block away from facility property.
R9, an eighty-year old female resident, has diagnoses of Alzheimer's disease, Hypertension, Anxiety and Agitation as listed on the current Physician Order Sheet (POS) dated 07/01-31/03. R9 was admitted to the facility on 01/03/03. The incident report dated 06/16/03 indicated that R9 was found walking down the street on 06/13/03.
Interview at 1:00PM on 07/07/03 with E6 and review of the facility's incident investigation dated 06/16/03 indicated that R9 was last seen by E6 at 10:15AM on 06/13/03 when R9 was seated in a recliner chair in the main dining room. Interview at 1:00PM on 07/07/03 with E3 verified that she saw R9 walking in the street that runs in front of the facility, next to the curb, with the flow of traffic, one block east of the facility at 10:25AM on 06/13/03. E3 indicated that at that time she was in her car transporting a sick employee home. They stopped to pick up R9 and brought her back to the facility.
The above interviews with E3 and E6, nurses notes dated 06/13/03 and incident report indicated that R9 had first been observed between the inner and outer two front doors by staff at 8:00AM on 06/13/03. E6 indicated that he saw R9 walking towards and trying to go through the front door so he redirected R9 to the dining room where he placed her in a recliner in front of the television. R9 was also placed on fifteen minute observation by staff as verified by the resident monitoring checklist for R9 dated 06/13/03, with the first entry at 8:00AM.
In the interview on 07/07/03, E3 stated, and the facility's incident report dated 06/16/03 indicates, that the facility staff determined that R9 had left the facility when a salesperson was entering the building through the front entrance to the facility. E3 further indicated that persons coming in to the facility through the front entrance did not activate an alarm while persons leaving the facility at that location did activate an alarm. Thus, if R9 had opened the door to leave the facility the alarm would have sounded. E3 also indicated that after R9 was returned to the facility all of the facility exit alarms were tested and found to be in good working order. Also, all staff working at the time were interviewed with none admitting to hearing any exit alarms sound between 10:00AM and 10:25AM on that day. At 1:45PM on 07/09/03 all of the exit alarms were functioning when checked.
At the time of the elopement on 06/13/03 there were no staff in the lobby near the front entrance to the facility. Staff in the office, which has a window between it and the lobby, said that they did not see R9 leave the facility.
While the facility is located in a residential area, it is on a city street with a speed limit of thirty miles per hour. The street usually has moderately heavy traffic.
During telephone contact with The Midwest Climate Control Center in Champaign, Illinois, at 11:30AM on 07/09/03, it was verified that at 9:52AM on 06/13/03 the Quad Cities Airport recorded the weather conditions in the area as being, clear with a temperature of seventy degrees Fahrenheit. E3 stated it the interview that R9 was wearing slacks, blouse, socks and shoes when returned to the facility.
R9's current care plan, dated 01/23/03 and updated 04/08/03, indicated under ?Communication, that R9's ability to understand information is poor due to severe confusion related to Alzheimer's. She does not make her needs known. Under the section ?Behavior it indicates that R9 has severe disorientation to time and place. Wanders about the facility frequently and sets off door alarms. At risk for elopements and picture in wanderers book Handwritten entry, on same care plan under Problem reflects 03/10/03 Out C-Wing fell in snow and when exit-seeking monitor every fifteen minutes. Assessments dated 01/03/03 lists R9 as "High Risk" for elopement and falls and describes a behavior of wanders, sets off alarms. A check of the wanderer's book located at the desk near the front exit door, at 2:30PM on 07/09/03, verified that R9's picture was in the book.
Nurses notes dated between 01/03/03 and 06/13/03 indicate that R9 had made six attempts to exit the facility with two actual exits. Also recorded during this time were four falls; three of these falls resulted in injury. Interviews conducted with E3,
E6, E4 at 12:45 PM on 07/07/03 and Z4 at 10:30AM on 07/08/03 indicated that R9 would not be aware of her own safety in any situation.
Two interviews were attempted with R9 on 07/08/03 one at 9:45AM and the other at11:00AM - resulted in no responses other than a blank stare from R9. Interviews with E3, E4, E6 and Z4 all confirmed that R9's usual response is a blank stare.