Champaign County Nursing Home
Facility I.d. Number: 0001636
Date of Survey: 01/08/2003
INCIDENT REPORT INVESTIGATION OF 12/30/2002
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 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 requirements are not met as evidenced by:
Based on observation, record review and interview, the facility failed to provide visual supervision of an alarmed exit door during times when this alarm was deactivated. One resident (R1) with impaired safety awareness and impaired cognition left the facility unknown to staff. R1 was found .2 of a mile from the facility with no coat on and the temperature was 36 degrees Farenheit.
Review of the admission history and physical dated 09-17-02 records R1's diagnoses to include: Degenerative Dementia. The admission Minimum Data Set (MDS) dated 09-27-02 records R1 has long and short term memory problems, is moderately impaired for decision making and wandering with the need for supervision. Care plan dated 10-02-2002 list as a problem of altered cognition for R1. Alsolisted as a problem is, R1 has an alteration of thought process
and/or physical abilities. Listed as a goal is ...will understand what is expected of him and remain safe in environment. Approaches listed for this goal includes: related to dementia, related to deficit in understanding and expressing information; know whereabouts as res (resident) is up and about ad lib (as tolerated).
Interview with E10, Adult Day Care Director, on 01-06-03 at 12:20 P.M., stated R1 was brought to the Adult Day Care from August, 2002 until admission to the facility on 12-18-02. E10 confirms R1 was cognitively impaired and really needed twenty- four hour supervision.
The incident report dated 12-02-02 documents on 12-01-02 at 13:15 (1:15 P.M.), R1 was seen walking on the sidewalk in front of the facility by a passerby. He was headed west and was picked up by the police department. Documented under Location of Incident: (Front Door in Lobby of Nursing Home).
Interview with E3 on 12-30-02 at 11:05 A.M. confirms the front exit door is alarmed and has visual control by the receptionist. E3 stated the key pad alarm can be deactivated with the code, has a 20-30 second delay and if the door is not closed the alarm will sound and it can only be reset at the receptionist desk. Interview with E4, receptionist, on 12-30-02 at 2:00 P.M. confirms she gives visitors a slip of paper with the key pad code. She also stated if the code isn't used and the alarm goes off, it can only be reset by her at the desk.
The nurses notes dated 12-1-02 at 13:15 records R1 was brought back to the nursing home by the police department..."alert but confused."
The police department was contacted on 12-30-02 at 9:00 A.M. and the following information was provided by the dispatcher: that someone (no name was given) called in on 12-01-02 at 13:22 P.M. (1:22 P.M.) about an eighty year old man with no coat on. The man was found on the corner of Lerman and Main street. An odometer check confirms the distance from the front of the facility to this corner is .2 miles. The Midwest Climate Control was contacted on 12-30-02 at 9:15 A.M. and confirms the temperature on 12-01-02 at 12:53 P.M. was 36 degrees Farenheit.
Interview on 12-30-02 at 12:55 P.M. with E2, Director of Nurses, states she was relieving the receptionist at the front desk (located in the front lobby) with E5, RN who was on the phone talking with the pharmacy about medications. E2 stated there were lots of people at the front door plus a group of five people collectively gathered at the front door. E2 stated she took the pharmacy list to the nursing office so E5 could be observant to the surroundings. E2 stated E12, receptionist, had returned and called to inform her the police department was on the phone regarding a possible missing resident. E2 stated, "at that point I was not aware of anybody missing." E2 stated she called every unit asking if they could account for all the residents. E2 stated when she hung up the police department was bringing in R1. E2 stated when she asked R1 where he was going, he stated to work. E2 asked R1 how he left and he said, "the front door". E2 stated R1 was wearing a long sleeve shirt and pants but had no coat on. E2 also stated R1 did not have his walker with him. E2 stated "my only assumption is he walked out with other people. At that time it was very congested there. He walks like an average person walks-can keep up with the rest of us."
Interview with E5 on 12-1-02 at 3:50 P.M. stated she relieved the receptionist at the front desk while E12 was on break, somewhere between 12:00 P.M.-1:00 P.M. E5 stated she was at the desk 15 minutes and no alarms went off. E5 confirmed it was very congested in the area. E5 stated they never had trouble with R1 trying to go out previously.
Interview with E12, receptionist, on 01-06-03 at 3:15 P.M., stated she did not see R1 any time that morning. E12 stated R1 could have walked out with a family member-it gets busy there with family members on weekends. E12 stated, "I do other things at the desk; run copies, answer the telephone and make appointments for the family room. Sometimes your back is to the door." E12 stated she was back from lunch for only a couple of minutes when she took the call from the police department about a man on the corner of Lerman and Main with no coat on. E12 stated R1 comes to the desk and goes to the door but never goes out. Interview with E4, receptionist, on 12-30-02 at 2:00 P.M. confirms she gives family members a slip of paper with the front door code on it. She stated if the alarm goes off it can only be reset by her pushing the button at the desk.
Interview with E1, CNA (Certified Nurse Aide) on 01-06-03 at 11:40 A.M. stated she was assigned to R1 the day he left the facility. E11 stated R1 was restless that day and was behaving different than she was used to. E11 stated he had dressed himself after his shower and had on jeans, t-shirt, flannel shirt, a sweat shirt and two pair of socks with his shoes. E11 stated she walked R1 to the dining room but he followed her back to the hall 3 times before he sat down to eat around 12:15 P.M.. She stated most of the time he knows his name and part of the time he knows where he is. E11 stated she works at the front desk in the evenings and R1 would look out the window but never made an attempt to go out.
Interview with E9, LPN (Licensed Practical Nurse) on 01-06-03 at 10:43 A.M. confirms she was the charge nurse for R1 on 12- 01-02. E9 stated the last time she saw R1 was on the wing before lunch around 11:30 A.M to 12:15 P.M.. E11 stated she was in the smoking porch when she saw the police pull up with R1. No alarms had gone off on B wing. E11 stated there are times R1 responds appropriately and other times he doesn't know what he is talking about.
Interview with E13 on 01-07-03 at 8:35 A.M. states she was in the hallway coming back from the dining room and saw R1 who told her he was going home. E11 said this was around 1:00 p.m on "the day he left the building." E11 said she directed R1 to his wing and did not see him when she came back to the dining room.
Observation on 12-30-02 at 12:15 P.M. shows R1 in the dining room. When attempting to interview, R1 just laughed and said he didn't know anything. On the same day at 4:30 P.M. when asked what type of work he did, he said he was a "farmer" at the U of I (University of Illinois) and years ago was a "postman." When asked if he remembered going out of the facility and being brought back by the police he stated, "no, I don't know about that. Interview with R1 on 01-06-02 at 9:00 A.M. shows he did know his name and stated he worked at the U of I as a "baker." When asked about traffic lights and crossing the street he stated, "I don't know what you are getting at." At this interview he did not know what building he was in. During interview at 12:40 P.M.. R1 stated he must have slept through breakfast; however R1 was observed to be eating breakfast approximately 8:20 A.M. that morning.