Rosewood Care Center Rockford
Facility I.D. Number: 0041756
Date of Survey: 09/03/03
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.
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:
Based on observation, record review and interviews, the facility failed to supervise R2, a new resident with Alzheimers Disease, by not:
a)Identifying a new admission as a potential wanderer and a possible elopement risk.
b)Verifying if a resident had set off the exit door alarm at 3:54 p.m.
c)Having a means to notify staff of all new admissions.
d)Staff failed to identify that R2 left the facility on 8/21/03 at 3:54 p.m.
These failures resulted in R2 successfully eloping from the facility on 8/21/03, being absent for 2 hours and, while gone, being driven by a stranger, to a town 15 miles away from the facility.
The findings include:
The August 2003 Physician Order Sheet listed R2s diagnoses as Alzheimers Disease, Arthritis, Bladder Spasms, and Depression. The nursing note of 8/21/03 documented, Guest is alert, disoriented times two Guest is ambulatory with supervision.
During an interview on 8/26/03 at 11:10 a.m., E4 stated, (R2) had lived with her sons. They were admitting (R2) for respite care for the weekend because (R2) couldnt handle her medications and her meals alone. (R2) is incontinent at times and wears disposable briefs. (R2) knew her name; but did not know where she was or the date.
The facilitys policy and procedure on Monitoring of Wandering Guests states, Guests will be assessed during initial screening process and at time of admission for the potential risk or history of wandering about or away from the facility.
During interviews on 8/26/03 and 8/27/03, E1, E4, and E5 all stated that the family had not identified R2 as a wanderer. The facilitys policy did not address what potential risks residents may have in order to identify residents as wanderers.
During an interview on 8/27/03 at 4:00 p.m., E5 stated, I assessed (R2) on 8/13/03 with her son here at the facility. I already had most of the information. (R2) only made light conversation (yes, okay, etc.). The son told me that (R2) has a poor short-term memory and attends an adult day care program several days per week. (R2) would spend the nights with one of her two sons.
During an interview on 8/27/03 at 4:15 p.m., E2 stated, Nursing did not know that she attended an adult day care program or that she required so much supervision.
R2 was observed and interviewed on 8/27/03 at 9:15 a.m. at the adult day care center. R2 appeared well groomed. R2 smiled easily and was very friendly. R2 knew her name. R2 did not know the date, time of year, where she was, or who the president was. She was unable to subtract seven from one hundred. R2 had no recollection of the events that had occurred on 8/21/03.
During an interview on 8/27/03 at 9:30 a.m., E7 stated, (R2) has a very short term memory. She doesnt remember my name and she comes three times per week. (R2) needs help with everything. She is able to feed herself. (R2) can no longer write her name. (R2) is very sociable but doesnt know what she is talking about. (R2) would not be safe outside alone.
During an interview on 8/27/03 at 3:00 p.m., E6 stated, I know (R2). She attended both the morning and afternoon activities. After the 2:00 p.m. activity, (R2) left the area. (E1) saw (R2) in the hallway and brought her back to activities where we were serving refreshments. She stayed until about 3:30 p.m. (R2) did not verbalize very much. (R2) needed redirection during the day. She did not know where her room was and needed to be redirected.
During an interview on 8/26/03 at 12:50 p.m., E3 stated, I start work at 4:00 p.m. A person was coming out the inside door of Door 6 and the alarm was sounding. I keyed in the door code and I entered the inside door of Door 6 and she left through the outside door of Door 6. I ran to the nurses station near Door 6 and (E7) was sitting at the desk nearest to Door 6. I asked him if that lady was a resident or a visitor. (R2) was visible through the window. I said, Look, look right there. (E7) lunged forward and said, She is just a visitor. Dont worry she is just a visitor. He didnt get up. I punched in at 3:54 p.m.
The facilitys policy and procedure on Guest Security states, Staff working in that area of the building will go visually check the door to determine if a guest has exited out the door. If necessary the staff will go outside and check the area to determine who set off the door alarm.
Review of the time cards documented that E7 worked on 8/21/03 from 11:55 a.m. to 4:24 p.m. In an undated written statement, E7 stated, A dietary aide asked me who the woman was who had gone out the back door, by station two nurses station. I told her I didnt know but thought it was a visitor. I thought this because I had not been told we had a new guest in the building. The woman walked out towards the outside smoking/break area and visitors are always using this door.
During an interview on 8/26/03 at 8:25 a.m., Z2 stated, Our driveway had been resurfaced the day before so I parked in the cul-de-sac. At 4:00 p.m. I walked out to my car and a sweet lady came up to me and asked, Do you know where (Z3) lives? I invited her to my home and looked up the name in the telephone book. (R2) called the number and (Z1) answered. She looked flushed and I gave her water. I then took (R2) by car about 15 miles to (R2s) home. I realized on the way that (R2) was confused when she didnt know the way or recognize anything.
During an interview on 8/26/03 at 9:00 a.m., Z1 stated, On 8/21/03 around 4:05 p.m. I received a call from (R2) asking for (Z3). I told her that Z3 was still at work. (R2) stated, Im stuck in Rockford. I asked her how she got there and she said, I walked. She gave me (Z2s) name and telephone number. I contacted (R2s) family and learned that she was supposed to be at the nursing home. At 4:30 p.m., I called the nursing home and asked if they had (R2) there. They said, Yes. I asked, Is she physically there? They said, Ill get here nurse. I was on hold a long time and then I had to hang up. I called back and they indicated that they had lost her.
Review of the nursing notes on 8/21/03 at 6:05 p.m. documented that E1 was called and R2 was at home with her son.
During an interview on 8/27/03 at 10:45 a.m., Z6 stated, (R2) was last seen by the nurse practitioner on 8/15/03. Her notes indicated that (R2) has been having increased confusion and several falls. (R2) is unable to remember falling. She needs to be watched all the time. (R2) is a possible elopement risk.
Weather information found documents the temperature for Rockford on 8/21/03 at 3:54 p.m. was 93.20 degrees Fahrenheit, 49% humidity and no precipitation.