Highland Park Health Care Center
Facility I.D. Number: 0032854
Date of Survey: 12/4/2003
IRI INVESTIGATION OF 10/24/03
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.
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 requirements were not met on October 24, 2003 as evidenced by:
Based on observation, record review, and interview the facility failed to:
Supervise a cognitively impaired resident who was identified as an elopement/wandering risk by not
These failures resulted in R1 eloping undetected from the facility on 10/24/03. R1 sustained scratches/bruises to her face and knees and was hospitalized overnight This is for one resident (R1) out of 9 residents identified by the facility as being at risk for elopement.
The findings include:
1. A review of the facility's admission information sheet documents that R1 is an 87 year old who was admitted to the facility on 1/11/03 with diagnoses including Congestive Heart Failure, and Dementia with Agitation. A review of assessments dated 1/29/03 and 10/28/03 document R1 has moderately impaired cognitive skills for daily decision making and short term and long term memory problems. The assessments dated 1/29/03 and 10/28/03 document that R1 needed partial physical support during a test for balance and uses a transfer aid(cane/walker). A wandering/elopement care plan dated 1/29/03 through 1/28/04 documents R1 tends to wander from her room to the nurses station during the evening after dinner with the belief that her son is coming to take her home. A care conference note dated 7/29/03 documents that at sundown R1 becomes very confused and tries to sneak out of the building. A universal note dated 10/24/03 at 10:05 p.m. documents the following: received call from local police dispatcher asking if we had a resident with R1's name and that she was across the street at a neighbors house. We(nursing staff) told the dispatcher that we did have a resident of that name and that we would be there to pick her up. At 10:15 p.m. the universal note documents: R1 was in the ambulance with scratches to her face and knees and the paramedics indicated they would be taking R1 to the hospital. The universal notes dated 10/25/03 at 17:20 document that R1 was brought back to the facility by family and had bruises on both knees with dressings applied at the hospital, and bruises on the nose bridge, left cheek and chin.
The National Weather Service record was reviewed at www.weather underground history for 10/24/03 at 9:53 p.m. The report indicated that the temperature at that time was 48 degrees Fahrenheit with light rain falling.
2. E1(Administrator) was interviewed on 12/1/03 at 8:40 a.m. E1 indicated that R1 must have gone out the front door (East) at around 9:50 p.m. E1 indicated that E4 (West end nurse) went into R1's room at approximately 9:45 p.m. to administer a tube feeding to the roommate. E1 said that E4 told him that R1 was in bed at that time and became agitated because E4 had turned on the light in the room. E1 said that the facility became aware of R1 being missing when they received a phone call from the police on 10/24/03 at approximately 10:05 p.m. saying that R1 was at a house which was west of the facility. E1 said that the front door alarm is set at 8:00 p.m. when the receptionist leaves. E1 indicated that on 10/24/03 he observed E3 (East end nurse) turn on the alarm for the front door. E1 indicated that either the front door alarm did not activate or that the staff working that night (10/24/03) did not hear a door alarm sound.
A review of the facility's final investigation report dated 10/30/03 documents that 6 CNA's worked the evening of 10/24/03 and that none of them heard a door alarm sound.
Z1(home owner) was interviewed on 12/1/03 at 10:50 a.m. Z1 said R1 knocked on their front door on 10/24/03 between 9:30- 10:00 p.m. and wanted to know if their mother was at home. Z1 said R1 was very disoriented, unable to identify herself and was bleeding. Z1 said it was cold out that night and that R1 was wearing a jogging outfit and carrying a pair of pajamas. Z1 indicated R1 did not have a walker with her. Z1 indicated that they called 911. Z1's home is located on the far side of the street which is located west of the facility. To get to Z1's house 2 streets and one intersection would have to be crossed. The street leading to Z1's home is on a decline. Z1's home can be seen from the facility.
E4(Licensed Practical Nurse) was interviewed on 12/1/03 at 12:20 p.m. E4 worked 3-11 p.m. on 10/24/03 on the west end of the facility where R1 resided. E4 indicated that she last saw R1 in her bed at 9:50 p.m. when she (E4) went to administer a tube feeding to R1's roommate. E4 indicated that R1 wanted the room light turned off. E4 did not know how R1 got out of the facility and indicated that staff assumed R1 went out the front door. E4 indicated that this is a busy time of the night and that if she was in a room with the door closed she would not hear the door alarm. E4 further indicated that the Certified Nursing Assistants (CNA's) can get the key to the front door and unlock it so they can go to their cars. E4 said it was raining that night and it was slippery. E4 indicated R1's eyesight was poor, that the lights might frighten her and that she might not know what to do.
E3(Licensed Practical Nurse) was interviewed on 12/1/03 at 12:50 p.m. E3 worked the 7-3 p.m. and 3-11 p.m. shifts on 10/24/03 on the east end of the facility. E3 indicated that she had locked the front door that evening and also had checked the back door alarm on the lower level going to the employee parking lot and the alarm on the ambulance entrance door which is located on the north end of the facility near to the east end nurses station. E3 indicated that it had to have been close to 10:00 p.m. when R1 left the building. E3 indicated that she was in a resident's room administering a tube feeding around 9:50 p.m. and did not hear any door alarms. E3 indicated that she saw R1 earlier in the evening and that she had sent her back to the west end. E3 indicated she had a lot of paper work that evening and that most of her evening was spent at the nurses station. E3 indicated she became aware of R1 being missing from the facility when she received a phone call from a police dispatcher. E3 indicated that R1 is disoriented.
E5 (Certified Nursing Assistant) was interviewed on 12/1/03 at 11:45 a.m. E5 worked the 7-3 p.m. and 3-11 p.m. shifts on 10/24/03 on the west end of the facility. E5 indicated that she heard no door alarms go off that evening and does not know how R1 got out of the facility.
E6(Certified Nursing Assistant) was interviewed on 12/1/03 at 11:55 a.m. E6 worked the 3-11 p.m. shift on 10/24/03 on the west end of the facility. E6 indicated that he removed R1's hearing aid at about 8:00 p.m. At 9:45 p.m. E6 said he went to R1's room and found her walker there but that R1 was not present. E6 indicated that when he went to look for R1 he was told by E3 that the police had found her. E6 indicated that he did not hear any door alarms that evening.
E7(Certified Nursing Assistant) was interviewed on 12/1/03 at 12:00 p.m. E7 worked the 7-3 p.m. and 3-11 p.m. shift on 10/24/03 on the east end of the facility. E7 indicated he did not see R1 on that evening and that he did not hear any door alarms.
E8(Certified Nursing Assistant) was interviewed on 12/1/03 at 3:00 p.m. E8 worked the 3-11 p.m. shift on 10/24/03 on the west end of the facility. E8 indicated that she did not see anything or hear any door alarms that evening. E8 does not know how R1 got out of the facility.
E9(Certified Nursing Assistant) was interviewed on 12/1/03 at 3:50 p.m. E9 worked the 7-3 p.m. and 3-11 p.m. shift on 10/24/03 on the east end of the facility. E9 indicated that no door alarms went off that evening. E9 further indicated that one of the residents(R3) been brought back to the facility through the north end ambulance door and that maybe that door had not been re locked and that is how R1 was able to leave the facility. E9 said the ambulance door is close to where R1's room was located.
E2 (Maintenance Supervisor) was interviewed on 12/1/03 from 9:20 a.m. through 10:00 a.m. while completing a check of the facility's door alarms. In reviewing the north end ambulance door alarm, E2 suggested that this would be the door to exit from undetected because of the following: this door only has one alarm which is turned on and off by staff when deliveries are made through the door. E2 indicated that if staff does not realarm the door this would be the way to go.
Z2 (Physician) was interviewed on 12/1/03 at 1:30 p.m. Z2 indicated that R1 would not be able to deal with issues if she got out of the facility and that it would not be safe for her to be out alone.
3. R1 was observed on 12/1/03 between 8:55 a.m. through 9:15 a.m. R1 sat quietly in the west end dining room. R1 was interviewed at 9:15 a.m. R1 had no recollection of having left the facility on 10/24/03. R1 had no recollection of having eaten breakfast that morning. R1 was observed at 11:40 a.m. leaving the west end dining room. R1 used a rolled walker, had a purposeful gait, and walked to her room.