Sunbridge Care and Rehab B Edwardsville
Facility I.D. Number: 0042689
Date of Survey: 12/11/03
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 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).
All necessary precautions shall be taken to assure that the resident's 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 were not met based on record review and interviews wherein it was determined that the facility failed to provide adequate supervision to R5, which resulted in R5's elopement. The facility has identified 14 residents at high risk for elopement and/or wandering. R5, who is cognitively impaired and was assessed by the facility as being at low risk for elopement, left the facility on 11/29/03, without staff knowledge.
R5 is a 91-year old resident who was originally admitted to the facility on 11/5/03. R5 has diagnoses, in part, of Osteoporosis, CHF, Hypothyroidism and Aortic Valve Dysfunction. The most recent Minimum Data Set (MDS), dated 11/16/03, indicates that R5 has short and long-term memory problems and is moderately impaired decision making skills. R5 utilizes a wheelchair for mobilization and is assessed by the facility as having unsteady sitting and standing balance, but is able to rebalance self without physical support. Upon admission to the facility, R5 was assessed as being at low risk for elopement/wandering.
On 11/29/03, R5 eloped from the facility without staff knowledge. The facility incident report states: "On November 29, 2003 at approximately 12:00 midnight a door alarm sounded at the nurses station that showed the Therapy Room door had been activated. After 10 to 15 minutes of searching the immediate outside area around the therapy door, the alarm was silenced. At approximately 12:50 AM it was discovered by the CNA that (R5) was missing. She was located outside the door by the Independent Dining Room. The family and doctor were notified since she had been outside for an extended period of time and she was sent to the Emergency Room at (the hospital). The outside temperature was approximately 25 degrees when the incident occurred. As of 6AM, the resident has returned to the facility with a small splint to her left wrist. The wrist was X-rayed and determined to have an old fracture, but a precautionary splint was placed. The resident is resting comfortably with no other symptoms resulting from the incident. She is currently on 15-minute checks. Upon review of the alarm panel, it was discovered that the door alarm that did activate was labeled as Therapy Room. However, the Therapy Room is currently located at the end of the C Hall, which is where the search was conducted and not the front of the building. The door that was activated is in the Independent Dining Room. It was noted by some of the staff that had been here for awhile that the Therapy Room used to be located in the Independent Dining Room."
E1, Administrator, was interviewed concerning R5 eloping from the facility on 11/29/03. E1 stated that E5 and E6, the nurses on duty the night of 11/29/03, heard a door alarm sound at approximately 12:00PM, and went to the panel on the wall by the nurses station to determine which door had been opened. (This is a panel that has lights for each exterior door. These lights illuminate when an exterior door is opened. An audible alarm also sounds when an exterior door is opened). The illuminated light on the panel indicated that the exterior door located in the Therapy Room was opened. The Therapy Room is currently located at the end of C Hallway. Staff went to this area, conducted a search, and did not find anyone in the area. They then went and turned off the alarm at the panel by the nurse's station. A head count of residents was not conducted. At approximately 12:50PM, E7, Certified Nurses Aide (CNA) was conducting rounds and taking resident's vital signs. E7 noted that R5 was not in her bed and immediately notified the nurses. A search of the facility was begun at this time. E6 noted that a wheelchair was sitting inside the exterior door located in the Independent Dining Room. E6 immediately opened the door and saw R5 lying directly outside the door - the upper part of her body was on the concrete pad and the lower half was on the grass.
E6's written statement is as follows: "I have no recollection of the time sequence but do recall that the alarm went off and we looked at the panel and it was lit up in the Therapy Room. (E8) looked all over C Hall because the Therapy Room was on C Hall. At some point, E7 came to the nurse's station and said, I can't find R5 anywhere. I told the CNA to go down and look in all of the rooms to see if she's in one of them. R8 was sitting at the nurse=s station and said "she never walked past me here". I then started looking in the Dining/TV room area and saw a wheelchair in front of an exit in the fine dining room. I opened that door; the alarm sounded and found R5 on the ground behind the door. She stated, "I'm cold and I'm hungry". I called for help and she was assisted up and placed in a wheelchair and returned to her bed".
On 12/3/03, the surveyor interviewed Z1, the ambulance attendant who picked up R5. Z1 stated that the facility called the ambulance dispatcher at 1:10AM, after first telephoning R5's sons and the physician. Z1 stated that the nurse at the facility called it in as "non-urgent" and further stated to the dispatcher that R5 had a core body temperature of 85o Fahrenheit. Z1 stated that the ambulance arrived at the facility at approximately 1:40AM. Z1 stated that R5 was lying in bed with no pants on and a thin bath blanket covering the lower portion of her body. She was wearing a shirt on her upper torso. The Emergency Medicine Technicians (EMT), took R5's temperature when they arrived at the facility. Z1 stated that R5's temperature was 88 o at that time.
A review of the hospital notes show that staff in the Emergency Room slowly raised R5's body temperature. Hospital record further indicates that R5 was complaining of pain in her left wrist. An x-ray was taken and the impression from the Radiologist was "Fracture deformity involving the radial styloid of uncertain age. Clinical correlation is recommended". R5 was returned to the Facility at 5:32AM, on 11/29/03, with a body temperature of 98.2 o Fahrenheit.
On 12/9/03, the surveyor interviewed Z2, who took R5 to see Z3, an orthopedic physician, on 12/4/03. Z3 stated that Z2 told them that R5's wrist had been injured sometime in the past and had been re-injured recently - probably the night of 11/29/03 when she eloped from the facility. R5 was to have been discharged from the facility to her home on 12/5/03. However, due to the injury, Z3 felt that she should remain at the facility until 12/31/03. At that time, Z3 will recheck R5's wrist and ascertain if R5 may have her splint removed and return home.
The facility's policy entitled "Elopement Practice Guidelines", states: "the following steps are taken when a resident is found to be absent from the facility without staff knowledge:
a.Divide the local area around the facility and assign a staff member to thoroughly search each area and report back to the coordinator when the search is completed.
b.Determine the areas/sites in the community that the residents may have familiarity with or attempt to find. Assign necessary staff to conduct search at these sites".
The surveyor interviewed Z4, R5's physician, on 12/11/03, at 8:25AM. Z4 stated that R5 would not be aware of dangers in her environment. Z4 stated that R5 should not have been outside the facility by herself, "I don't think that she would purposely leave on her own - I think that she just got lost and confused".
At the United States Weather Bureau's St. Louis Station, the minimum air temperature on 11/29/03 was 24o F. The maximum air temperature was 51o F. The average air temperature was 38o F. There was no precipitation. The average wind speed was 10.4 miles per hour.