THE LINCOLN HOME
Facility I.D. Number: 0034678
Date of Survey:11/13/03
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 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 not met as evidenced by:
Based on interview, record review, and observation, the facility failed to prevent R6 from leaving the facility unsupervised on 10/11/03.
The findings include:
R6 has a diagnosis in part of organic brain syndrome and Alzheimers disease. He was admitted on 10/3/03 for a seven day respite care. At the end of the seven days, R6's wife requested that he be allowed to stay longer and R6 was not discharged until 10/13/03. The activity notes dated 10/03/03 stated that "R6 wanders ad lib in a wandering state. Potential for elopement--needs constant observation." The nurses notes on 10/03/03 stated that resident is "alert to person - confused to time and place." "Cont to amb in halls - pushing on exit doors & setting off alarms."
The nurses notes state that at 7:55 PM on 10/11/03, the facility received a call from the Belleville Police Department saying that R6 had been noted walking on 28th street in Belleville. This was approximately one block away from the facility. The facility is located on 27th street. R6 was returned to the facility by the Police Department.
Interview with E1, Administrator, stated that through his investigation it was not determined that facility personnel knew that R6 was missing until the Police called the facility. E1 and E2, Director of Nursing, said that R6 was not capable of being interviewed as to how he left the building. A body assessment was done after R6 was returned. R6 was found to have no injuries. R6 was dressed appropriately for the weather. R6 was last seen in the facility between 7:00 - 7:15 PM.
Interview with Z2, wife of R6, on 10/20/03 stated that he would not be capable of knowing how to walk home and would be a danger to himself to be out on his own. She said he dressed appropriately and could have easily been mistaken as a visitor.
During a tour of the facility on 10/20/03, all the door alarms were working properly. There was no door alarm on the patio door across from the receptionist's desk in the front lobby. The receptionist was asked about the door. She said that the door was locked at 8:00 PM when there was no longer a receptionist at the front lobby desk supervising the door. The facility concluded in their investigation that since no staff saw R6 leave through any of the doors or reported that a door alarm had sounded that possibly he had left through the patio door.