Alden Park Strathmoor
Facility I.D. Number: 0044909
Date of Survey: 3/12/03
The facility shall have written policies and procedures, governing all services provided by the facility which shall be formulated by a Resident Care Policy Committee consisting of at least the administrator, the advisory physician or the medical advisory committee and representatives of nursing and other service in the facility. These policies shall be in compliance with the Act and all rules promulgated thereunder. These written policies shall be followed in operating the facility and shall be reviewed at least annually by this committee, as evidenced by written, signed and dated minutes of such a meeting.
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.
These REQUIREMENTS are not met as evidenced by:
Based on interview, observation and record review the facility failed to follow its procedure for responding to door alarms on 2/26/03 by not:
This is for 1 of 23 residents who reside on the facility's Alzheimer unit.
The examples include:
1.The facility sent an Incident/Accident Notification form to the Illinois Department of Public Health on 2/27/03. This report stated that R1 wandered out of the facility. The time of occurrence was listed as 4:10 p.m. The form documented that the resident was sent to the Emergency Room for evaluation and treatment. The resident was returned with an abrasion to left side hand and abrasion to left knee.
R1 was admitted to the facility on 9/27/02 according to R1's Admission-Discharge Form. The February 2003 Physician Order Sheet (POS) documents diagnoses of Alzheimer's Disease, Delusional and Dementia. The POS also documents that R1 is ordered Zyprexa 10mg every night as of 2/21/03 and has an order for Lorazepam (Ativan) 2mg, 1 every 4 to 6 hours PRN (as needed) for agitation indefinitely as of 11/25/02.
Review of R1's Quarterly assessment dated 1/21/03 identifies R1 as having long and short term memory loss and moderately impaired cognitive skills for daily decision making. R1 is identified as being easily distracted, having periods of altered perception or awareness of surroundings, displaying episodes of disorganized speech and periods of restlessness. R1 displays repetitive physical movements and is identified as a wanderer which occurred on 4-6 of the last 7 days of the assessment period. The wandering behavior was not easily altered. R1's Resident Assessment Protocol (RAP) for Mood State dated 10/2/03 states, "Resident recently re-admitted to facility. Has Hx of Alzheimer. Wanders about unit and attempts to go outside. Much coaching is needed to have resident sit for short periods of time. Medication does not seem to effect mood."
R1 has problems identified on his care plan which include: Wanderer/Potential for Elopement dated 12/17/02 the "Resident is a potential for elopement.
Frequently pushes on dining room and D wing door". Approach #8 is to "Redirect res. away from all exit doors" and Approach #9 is to "Frequently monitor res. whereabouts"; "Potential for injury due to falls and or high risk for falls" dated 1/27/03. Approach #5 is to "Keep environment free of obstacles; "Resident is unable to structure own leisure time secondary to advancing dementia. Res. spends majority of time wandering thru dining room and other resident rooms" dated 1/21/03.
Review of the February 2003 behavior monitoring for R1 documents 22 attempts to leave the unit. On February 26, 2003, R1 made 3 attempts prior to the elopement which occurred around 3 p.m.
Review of the nurses notes from September 30, 2002 to February 27, 2003 found 11 days documented with attempts to elope. On December 21 the note at 19:45 states, "Resident eloped from side entrance E/B alarm sounded. CNA with staff member exit outside door assisted resident back inside immediately...". Again on 1/19/03 between 3-11p.m., "Resident up ambulating without difficulties. Very busy picking up garbage cans, chairs, moving tables. Resident in their wheelchairs. Attempt to exit side entrance. Staff member x 2 redirected resident into facility...".
2.On 3/3/02 at 1:50 p.m. Z2 (local store employee) was interviewed about R1's elopement on 2/26/03. Z2 stated that at about 3p.m. that afternoon, a man came up to the loading dock of the furniture store. He was able to respond when asked his name but then started saying strange things which did not make sense. He approached the door of a car as two workers were loading furniture into it. One of the workers noticed R1's hand was bleeding and he had no socks or shoes on. Z2 was summoned. They got some rags to cover his feet. He was cold to the touch and shivering. There was dirt on the seat of his pants and his hands and feet were dirty. He sat down but then complained it was hurting. Store staff got a pillow for him to sit on, but he didn't stay seated.
He got up and down a few times. 911 was called and they said they would send someone over. A paramedic from a transport van nearby was summoned. This person waited with R1 until the ambulance came and the resident was transported to the hospital.
The local hospital Triage Assessment form dated 2/26/03 at 16:25 states, " Resident was found wandering behind local furniture store. 80 year old guess possible (from nearby facility). Person from facility here. R1 identified from Alzheimer Unit. Was found wandering around parking lot without shoes on. Skin cool to touch. Warm blankets applied. 2055 Lifeline ambulance contacted to transport back to facility. Facility staff were notified of transfer."
Z5 (local hospital nurse) was interviewed on 2/27/03 at approximately 2 p.m. regarding the condition of R1 on 2/26/03. Z5 stated that R1's feet were cold and muddy and the right foot had a small abrasion. R1's whole body was cold. R1 was confused and agitated and Z5 could only get an axillary temperature, which was 95 degrees. The resident was wearing pants and a long sleeved shirt. He had no coat, no gloves and no hat. He was given 2 liters of normal saline over 3 hours for volume depletion and hypernatremia.
Z3 (R1's physician) was interviewed on 3/3/03 at 2:30 p.m. Z3 asked about R1's community survival skills. Z3 replied, "Not good. R1 cannot make good decisions. He needs a locked unit. He tried to go out the door many times at a previous facility."
On 2/27/03 at approximately 3:30 p.m. E2 (D-wing nurse on 2/26/03) was interviewed. E2 was asked what R1 was like on 2/26/03. E2 replied that in the morning, on day shift, R1 tried to go out the side door twice. The first time the alarm sounded and he didn't get out. Staff stopped him. Then before lunch he tried to go out the patio door. The second time the side door sounded he did get out. R1 was making a running motion but not moving fast. E9 (Alzheimer unit activity aide) stopped him and guided him back inside. E2 held the door when R1 came back inside. R1 seemed to think that it was funny, he was smiling. A little while later E2 checked on R1 to see if he needed Ativan. He was laying in bed sleeping. At 2:20 p.m. E2 went off the unit to a nurses meeting and was there until 2:30 p.m. When E2 came back R1 was observed still lying down sleeping in someone elses bed. E2 went to the nurses station at the end of D wing to call physicians. There were 2 CNAs on the unit, E3 and E5. E5 was at the nurses station with E2 when they heard the door alarm sound. E5 asked E3 to please check the door.
The alarm was then turned off and E5 said there was no one outside. E2 said she asked E5 where R1 was and E5 replied he was laying down. E2 continued with making phone calls because all other wanderers were in sight in the dining room. Around 4p.m. a person from the local furniture store called asking if there was a resident with R1's name. When R1 returned E2 did a body check and found an abrasion to the heel of the left hand and 3 small abrasions to the left knee and his vitals were within normal limits. When asked about R1's ability to move, E2 replied that he can move quickly - he thinks it's funny. He has tried to get out many times.
E3 was interviewed on 3/5/03 at 7:35 a.m. about R1's elopement on 2/26/03. E3 stated she arrived on the D-wing at approximately 2:40 p.m. The alarm did go off on the side door at approximately 2:45 p.m. E3 ran to the side door and went out and looked as far as she could while holding on to the door. (If she let go she couldn't get back in). E3 looked and she didn't see anyone, staff or resident. E3 said she waved to E5 that she couldn't find anyone. The last time E3 saw R1 was when she and E5 changed R1 between 2:45 to 3 p.m. E3 was summoned to A-wing at approximately 3:10 p.m. E3 returned to the D-wing at approximately 4:10 p.m.
E5 was interviewed on 3/5/03 at 3:40p.m. about the elopement of R1 on 2/26/03. E5 stated she arrived on D- wing around 2p.m. E3 and E5 received their assignments and put another resident to bed. Then E3 & E5 went to the dining room. Around 3p.m. the alarm (D-wing side door) went off. E3 went to answer the side door. E3 said it was all clear. E5 and E2 took E3's word. No search was done after that. At that point E3 was pulled to A-wing. E5 was the only aide on D-wing while E3 was gone.
Review of the staffing schedule for D-wing on 2/26/03 found that while E3 was on A wing, there was only one CNA (E5) and E2 (nurse) on the unit for 23 residents. While reviewing the schedule with E7 on 3/10/03, it was confirmed that there was a period on 2/26/03 when there was only 1 CNA on the unit.
3. Observation was made of the area outside of the D-wing and between the facility and the furniture store. Just outside the facility door is a large paved area. Then the paving stops. Rocks and bushes start which line a ditch. This ditch is approximately 8-10 feet deep on both sides. To get to the furniture store you would have to walk through the muddy area, go down one side of the ditch, cross the bottom, scale the other side, and again walk through a muddy area. It is a straight line to the furniture's loading dock from there. It is visible from the end of the D-wing.
On 2/27/03 at approximately 3:15 p.m. the alarm system on the side of the D-wing was tested. It alarmed when the door was opened. E1 punched in the code to disarm the alarm. It was observed that once the code was entered the door was able to be opened for 30 seconds without an alarm sounding.
On 2/27/03 between 3:20 p.m. and 4:30 p.m. R1 was observed. R1 is a small male who ambulates independently and who was observed easily reaching to the floor and attempting to pick up something without losing his balance. On 3/5/03 at 11:44, R1 was observed walking down D-wing hall. R1 was questioned and was asked 'How are you?' Other questions were attempted. He made responses that did not make sense. R1 was wearing a wrist band. When asked what the band was, R1 could not tell me.
4. The facility's policy and procedure on Door Alarms was reviewed. Under B. Procedure, #3. Respond immediately when alarm sounds by checking alarm panel for location of alarm and proceed to door. #4. Investigate reason for alarm. #5. Determine if all residents safe and accounted for.
Weather conditions were reviewed at Weather Underground.com for February 26, 2003 between 14:54 (2:54 p.m) and 15:54(3:54 p.m). The outside temperature was 28 degrees Fahrenheit and the wind speed was 9.2 miles per hour.