Statement of Violation

Cahokia Nursing & Rehab Center
Facility I.D. Number: 0039636
2 Annable Court
Cahokia, IL 62206

Date of Survey: 12/12/02

Incident Report Investigation of 11/21/02

“A" VIOLATION(S):

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.

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.

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 were not met as evidenced by:

Incident Report Investigation of 11/21/02. 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.

General nursing care shall include at a minimum the following and shall be practiced on 24-hour, seven-day-a week basis:

These regulations are not met as evidenced by:

Based on record review, observations, and interviews, the facility does not maintain an adequate system of supervision, enabling residents to leave the building without the knowledge of the staff, for 1 resident on the sample (R1).

Findings include:

) A Facility "IDPH Reporting Summary", dated 11/22/02, states "Resident was admitted to the Facility on 10/29/02 for short term rehabilitation. At that time a wander assessment was completed and based on assessment and family interview, resident was not considered an elopement risk. Resident is receiving OT (occupational therapy) and PT (physical therapy) and is scheduled to return home on 11/25/02. On 11/21/02 resident exited the front of the building after 6:15 PM. She was returned to the facility at approximately 6:30 PM by Z3 of St. Louis. He stated he found her at the end of the driveway. A full body assessment was completed. Resident had no injuries. She was dressed in shoes, socks, sweatshirt, sweatpants and a sweater jacket. Family and physician were notified. As per facility policy, a personal monitoring device was immediately placed on the resident. Staff interviews and statement from witnesses were obtained. Interview of staff reveal that the resident was last seen at 6:15 PM by the nurse's station. Prior to that she had been in the dining room for supper. The Q.A. (Quality Assurance) Committee has reviewed elopement prevention system and found that, though no identifiable failures were found, the facility has taken pro-active steps to prevent future re-occurrence such as, but not limited to, staff in-services and review of elopement risk assessment". This document is signed by E1, Administrator.
) R1's clinical record indicates that she was originally admitted to the facility on 10/28/02 for recovery from a fracture of the right forearm she received from a fall, prior to admission. R1's diagnoses include: Alzheimer's, History of Cerebral Vascular Accident, Congestive Heart Failure, Renal Failure and Non-Insulin Dependent Diabetes Mellitus. R1's Minimum Data Set, dated 11/1/01, Indicates that she has short and long term memory problems and moderately impaired cognitive skills for daily

decision making. R1 is hard of hearing, was assessed to have poor standing balance, and requires extensive assist with most ADL's (acitivies of daily living). During interviews with E1, and E2, Director of Nurses, and E5, facility nurse, it was stated that R1 is a "frail" woman and they do not know how she could have gotten out of the facility.

3.) On 12/9/02 at 9:45 AM, the Surveyor interviewed Z1, R1's husband, on the telephone. Z1 stated that he had taken R1 home from the facility on 11/25/02 stating "even though they didn't want me to, but I can take just as good of care of her at home. I was at home the night she got out, I don't go out after dark. Her getting out worried me - on a cold night she wouldn't last very long. I remember that it was cold outside. Her long term memory has really slipped lately - the other day she wanted to know how many brothers and sisters she had". The Surveyor then asked Z1 if he thought that she would be aware of dangers in her environment. Z1 stated "No - I don't think so, she's been having more problems with her memory".

4.) On 12/9/02 at 1:42 PM, the Surveyor interviewed Z2, R1's physician, on the telephone. The Surveyor asked Z2 if R1 would be aware of dangers in her environment. Z2 stated "Some - that's a real mixed answer. (R1) would make some rational decisions - she would know enough to leave a burning building but she could make a decision to elope and not worry about putting on clothing".

5.) The Facility Nurses Notes dated, 11/21/02, 8 PM, states the following: "Approx @ 6:30 PM stranger (Z3), came to nurses station stating do this lady belong here (that was in w/c at door entrance). Nurse look down hallway at door entrance and stated yes that's (R1). (Z3) then proceeded to shout and curse at staff. He then left the building. (Z3) also stated before leaving building resident was at a drug store........no injuries found. Nurse ask resident how she felt, resident stated O.K. Nurse ask resident why she left out of facility. Res stated, honey, I don't know.....". E5, the nurse who wrote this note confirmed that Z3 told her that he found R1 at a drug store, which is approximately 2 blocks from the facility. E5 further stated she had last seen R1 at approximately 4:30 PM on 11/21/02. The next thing that she knew, "a man came up to the nurses station screaming and hollering - asking is this your resident. He said he found her by a drug store. I don't see how she could have gotten that far - she pushes herself slowly in her wheelchair. She's confused too and gets twisted around. We were in shock because we didn't know she was gone. I was upset and worried about her. I asked her why she left and she said "Honey, I don't know".

6.) In addition to the statement sent to IDPH concerning R1, E1 also had the following information documented: "On 11/22/02 at approximately 9:00 AM, (Z3) called the facility. He stated the night before he found a lady outside. He was very irate saying she was across the road and her w/c was on the other side. He stated when he brought her in no one was around except a staff in the library. He left the resident there and went to nursing station. He wanted to know why we didn't lock the doors. Adm. explained fire regulations. Also explained this lady had never been a wander risk. Also thanked him for bringing her in and advised she was fine and that normal procedure had been followed i.e. family and physician notified. He seemed to calm down and finally gave her his phone number". During an interview of E1 and E2 on 12/9/02, E1 confirmed that she did not ask Z3 where he found R1 nor did she inquire about R1's status when he found her. E1 stated "He never mentioned the drug store". The Surveyor asked if Z3 was asked where he found her and E1 stated "no". E1 further stated "We don't know exactly where she was - (Z3) said something to the staff about the drug store but that man was too irate to get a straight answer. She was on one side of the street and the wheelchair was on the other. An employees husband who was sitting in the parking lot saw two men bringing a wheelchair back just there by the hedges, so she couldn't have gotten far". E2 also added that R1 did not have a history of eloping from the facility therefore, they had not identified her as being at risk or they would have placed a bracelet on her which would alert them if she tried to leave the facility. The facility has a telephone interview with Z4, the husband of the employee who was in the parking lot of the facility, dated 11/22/02 which states "(Z4) was at the facility to pick up his wife who was working. He stated it was about 6:30 PM. As he pulled into the driveway he saw nothing (no lady was on the road or driveway). While sitting parked in vehicle in front of building he heard noise. He looked toward driveway and saw 2 men on left side of driveway with a wheelchair. They walked across driveway to a woman. He said she must have been in the shadow when he drove in. The two men brought the lady inside the facility". This document is signed by E1 and dated 11/22/02.

7.) Upon entering the facility 12/9/02, the Surveyor observed that there is a box alarm device located on the front door which "chimes" when the door is opened. The "chime" sound discontinues as soon as the door is closed. There was a receptionist sitting at a desk adjacent to the front door. During an interview of E1 on 12/9/02, E1 stated that the front door is under direct visual observation by a receptionist from 8:00 AM until 5:00 PM. There is no one at the front of the a facility after 5:00 PM. From 5:00 PM until 8:00 PM, the front door is left on "chime". The Surveyor noted that the "chime" is only audible when one is stationed near the front door of the facility. The "chime" is not audible at the nurses station or half-way down the hallway leading from the front door to the nurses station. The "chime" is not audible while in resident rooms. The front door main door alarm is not turned on until 8:00 PM, which is when visiting hours ends. The Surveyor checked all of the door alarms in the facility and noted that all are functioning properly. The main door alarm panel is at the nurses station and emits a very loud audible alarm when activated.

8.) The facility is located in a residential area with single family dwellings however, a busy commercial area is within two blocks. There are no sidewalks located in this residential area therefore, R1 would have had to proceed down the driveway to the road, which is oil and chip. There is a circular drive in front of the facility. It is approximately 72 feet from the front of the facility to the front border of the facility property. There is a road, which runs East and West, that also serves as the driveway into the facility which is approximately 160 feet in length. There are single family homes located on either side of this road. This road deadens into a North/South residential road. There was no posted speed limit however, this is a residential area. Approximately two blocks South on this road is a drug store. On the other side of the street is a dental office. There is a busy intersection where this road crosses State Highway 157, equipped with traffic lights. The speed limit on Highway 157 is 40 miles per hour. United States Weather Service climatological data shows that the maximum temperature on 11/21/02 was 48 degrees Fahrenheit, the minimum was 39 degrees Fahrenheit, with an average of 44 degrees Fahrenheit. There was trace precipitation.