Cardinal Health Care
Facility I.D. Number: 0044313
Date of Survey: 11/17/2003
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.
The DON shall supervise and oversee the nursing services of the facility, including:
Developing an up-to-date resident care plan for each resident based on the residents comprehensive assessment, individual needs and goals to be accomplished, physicians orders, and personal care and nursing needs. Personnel representing other services such as nursing, activities, dietary, and such other modalities as are ordered by the physician shall be involved in the preparation of the resident care plan. The plan shall be in writing and shall be reviewed and modified in keeping with the care needed as indicated by the residents condition. The plan shall be reviewed at least every three months.
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 record review, observations, facility policy review, incident report review, and interviews, the facility failed to provide adequate supervision to prevent the elopement of one resident (R1) from the sample of six. The facility identified six residents at high risk for elopement. R1, who is cognitively impaired and at risk for elopement left the facility on 11-01-03 without staff knowledge.
The findings include:
R1 is a 67 year old resident admitted to the facility on 10-04-02. R1's diagnoses include Alzheimer's Dementia, Insulin Dependent Diabetes Mellitus, and Peripheral Vascular Disease. The annual Minimum Data Set (MDS) assessment dated 10-23- 03 indicates that R1 has short-term and long-term memory loss and is severely impaired for making daily decisions. R1 has worn an electronic monitoring device since he was admitted to the facility. R1's behavior symptoms were identified as wandering and resisting care both occurring daily and not easily altered. R1 was observed 11-05-03 wandering about the facility ambulatory without assistance.
R1's Care Plan (not dated), "the nursing assistant component plan of care" identifies loss of memory and progressive confusion but does not identify a problem of wandering. The approaches state "R1 has a electronic monitoring device related to elopement risk and resident goes to doors several times a day and needs 1:1 redirecting to come inside". The care plan does not identify 15-minute checks to be done on R1 or any verbal cues R1 may give prior to elopement. This was confirmed by interview with E5 (Care Plan Coordinator) on 11-5-03 at 3:15 p.m..
During an interview with E9 (CNA) on 11-05-03 at 1:30 p.m., she stated on 11-1-03 at 10:40 a.m. that R1 was missing during the fifteen minute checks on C hall. R1 was last seen in the hallway standing by the DON's office at 10:30 a.m.. E9 and E10 (CNA's) both denied hearing any door alarms sound during this time period. E9 searched the immediate area, and R1 was not in his bedroom or on C wing. E9 immediately informed E8 (LPN in charge) that R1 was missing. A code yellow was announced at 10:55 a.m., and a full building and grounds search was conducted. R1 was not located. E1 (Assistant Administrator) and E2 (DON) were notified at 11:25 a.m.. The Energy Police Department was notified at 11:27 a.m. according to the 11-01-03 nurses notes in R1's clinical record and arrived at 11:30 a.m..
Per Energy police report on 11-01-03 at 11:30 a.m., a police officer arrived at the facility. A neighbor living on East College Street near the facility reported to the police that his 1979 white box van was missing. A "L.E.A.D.S." alert was issued regarding the missing resident and van by the Energy Police Department. The Energy Police Department and Fire Department searched the wooded area around the nursing home. Neither R1 nor the van were found.
Per interview with Z2 (Dispatcher) on 11-10-03 at 9:05 a.m., the Pulaski County Sheriff's Department was alerted by the Ullin Police Department on 11-1-03 at approximately 2:45 p.m. that an elderly man was driving a white van in Vienna headed toward Pulaski County. The driver was driving recklessly and was suspected to be either drunk or ill. Z1 (Deputy) stated the Sheriff's Department was looking for the van for an hour before they were notified by a farmer that R1 was present at a rural residence in Pulaski County at approximately 1:44 p.m.. The deputy also indicated the van was parked between the barn and a silo and was not visible from the road. R1 was reported to have entered a barn and was moving items around the barn. Z1 stated small farm equipment was in the barn area. The residence was located in a rural area in Olmsted - 50 miles from the nursing facility.
Per interview with Z1 on 11-10-03 9:15 a.m. when R1 was found, he was "almost dehydrated" with dry, cracked lips and appeared very sleepy. R1 was also confused to place and time but was able to state his name. R1 told Z1 he was on his way to Waltonville to do some work (Waltonville was approx 30 miles north of Energy). R1 stated he was thirsty and hungry. Z1 stated R1 walked slowly with an unsteady, staggering gait and was uncooperative at times. R1 followed Z1 around the Police Department.
The facility was notified that R1 was at the Pulaski County Sheriff's Department and E12 (Psych Tech) left to pick up R1. R1 was returned to the facility at approximately 5 to 5:30 p.m.. Upon re-entrance to the facility, R1's electronic monitoring device alarm sounded. R1 was noted to be incontinent of urine and had a blood sugar level of 79 upon return with no other injuries. R1 was served a meal tray and ate 100%.
Per interview with Z6 (R1's physician) on 11-14-03 at 10:50 a.m., Z6 stated she was not made aware of R1's elopement, and that R1 would not be safe to drive a vehicle. Z6 also stated R1 was disoriented to time and place and would not be aware of safety hazards. Z6 stated residents on C Hall are not properly supervised by the facility as the residents exit and enter the facility without door alarms.
Per observation on 11-05-03 at 10:40 a.m. to 11:00 a.m. with E3 (Maintenance Man) on C hall, no audible door alarms sounded- -only the alarms with the electronic monitoring device system were working. Also per observation on 11-06-03 at 9:50 a.m. at the C Hall nurses station, E4 (RN) was in the medication room. The audible door alarms were turned off, and E4 stated she often turns the alarms off because she can not talk on the phone due to the alarms sounding so loud. Per interview with staff members, E7 (LPN), E4 (LPN), E6 (CNA), E5 (Care Plan Coordinator), E10 (CNA), and E11 (LPN) on 11-05-03 and 11-06-03, staff stated the audible door alarms on C Hall are not always on because residents and staff frequently enter and exit the doors. Staff also stated the alarms are often turned off. Per interview with E4 (RN) on 11-06-03 at 8:50 a.m., E4 stated 3 to 4 times a month she finds the electronic monitoring system alarms turned off and not re-set resulting in inactivation of the electronic monitoring devices.
The facility Policy and Procedure for Elopement and Monitoring of the Electronic Monitoring System (Revision May 2001) states "all exit doors will be checked for proper functioning" ... a check sheet will be marked noting the date and time the alarm was checked". The policy also states "The primary door alarm sounds at the nurse's station when the doors are opened to alert staff that someone is going through the door" and "These alarms will be checked at the change of every shift... A check sheet will be utilized and kept at the nurse's station and turned into the Director of Nursing Services at the end of each week."
Per interview with E2 (DON) on 11-05-03 at 11 a.m., she stated "the facility had been lax in checking and recording the functioning of the alarm systems until 11-01-03". No check sheet was found at the C Hall nurse's station for the electronic monitoring system or primary door alarms checks on 11-06-03 at 9:50 a.m.--confirmed with E2 and E4 (RN). Per interview with E2, she also stated E3 was responsible to check the functioning of the door alarm systems and record the same. No documentation of the checking of the alarm system has been recorded since August and one time only in September--confirmed by interview with E3 on 11-05-03 at 11 a.m.
The facility is located on 210 East College Street in Energy, Illinois. College street is a busy blacktop road in front of the facility. The facility is 2 blocks to the west of Route 148; and traveling east leads to Johnson City. R1 was found off Route 37 on a blacktop road in rural Pulaski County (50 miles south of the facility in Energy). Route 148 becomes Route 37 south of Marion and several stop lights are noted on this busy state highway. R1 would have had to proceed through several stop lights and cross a busy intersection of Route 13 and Route 148. Per interview with Z3 on 11-08-03 at 9:35 a.m., Z3 stated that R1 was confused to time and place and would not recognize safety hazards. When Z3 takes R1 out for rides in the car, R1 tells her to
go ahead on red lights after she has stopped. Per staff interviews on 11-05-03 and 11-06-03, all staff interviewed (E1 through E12) stated R1 would not recognize safety hazards. Per interview with R1 on 11-06-03 at 10:30 a.m. about safety hazards, R1 stated he would go ahead and cross the street without looking for oncoming traffic.
R1 was dressed appropriately in pants, shirt, and shoes on 11-01-03 at 10:30 a.m.. The air temperature was
55 degrees Farenheit and clear on 11-1-03 at 10:45 a.m. per SIU Weather Information.
Per record review of the six residents identified by the facility as elopement risk, all records did not have current elopement assessments (R1, R2, R3, R4, R5, and R6). The facility Elopement policy (dated May, 2001) states all residents will be assessed for a risk of elopement, and those at risk will be re-assessed quarterly. R1, R5 and R6 were not re-assessed quarterly in July for elopement--confirmed by interview with E2 (DON) on 11-06-03 at 2 p.m..
Not all residents at risk for elopement were identified on the care plan as an elopement risk with appropriate interventions. R2 and R4 did not have a care plan developed since admission on September 10 and 17, 2003, respectively. R5's and R6's care plan did not identify them as an elopement risk. R1's care plan (no date) states only that R1 has an electronic monitoring device, that he is an elopement risk, goes to doors several times a day, and needs 1:1 re-direction. No mention of 15-minute checks or verbal or physical cues when R1 attempts to leave the facility.