Facility I.D. Number 0040642
Date of Survey:3/4/03
The facility shall provide a Resident Services Director who is assigned responsibility for the coordination
and monitoring of the residents overall plan of care. The Director of Nurses or an individual on the
professional staff of the facility may fill this assignment to assure that residents plans of care are
individualized, written in terms of short and long range goals, understandable and utilized; their needs are met through appropriate staff interventions and community resources; and residents are involved, whenever possible, in the preparation of their plan of care.
The facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psycho social 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.
General nursing care shall include at a minimum the following and shall be practiced on a 24-hour, seven-day-a-week basis.
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 are not met as evidenced by:
Based on record review, observations, review of incident reports, and interviews, the facility failed to
provide adequate supervision to prevent the elopement of one resident, R1, from the sample of seven. The facility has identified 15 residents at high risk for elopement. R1, who is cognitively impaired and at risk for elopement, left the facility on 02/25/03, without staff knowledge. The facility failed to review the accuracy of assessments for wandering residents having the potential for elopement.
The findings include:
1. R1 is an 84 year old resident who was admitted to this facility on 09/06/01. R1 has diagnoses that included Syncope, Alzheimer's Type Dementia, and Osteoarthritis. The most recent assessment dated 12/12/02 indicated that R1 has short and long-term memory loss and is moderately impaired for making daily decisions. R1 has worn an electronic monitoring device since she became a resident in the facility.
The care plan for R1 identified a problem with onset of 09/13/02, of "Res. (resident) is a wanderer and res. (resident) wears (electronic monitoring device)". The continued short term goal is that the resident will not leave the facility unattended. There is a comment on the care plan that verified R1 wandered from the facility on 02/25/03.
Z1, visitor, stated during an interview on 02/27/03, at 1:30 P.M. that he was visiting R8 in resident room on 02/25/03. At approximately 11:30 A.M., he saw a woman walking toward the city street from the facility side parking lot. Z1 stated that he recognized R1 and hollered for E6, Certified Nurses Aide, who was in the hallway. Z1 continued to watch and observe R1 as a staff person went to get R1. Z1 watched as the staff person gave R1 her coat and walked R1 back to the facility. Z1 verified that R1 was on the city street in front of the assisted living facility that is located next door to the nursing home. Z1 indicated that the facility staff did not know R1 was out of the building until he told them.
E6, Certified Nurses Aide, was interviewed on 02/28/03, at 8:55 A.M. and stated that she was coming down the hall when Z1 told her that R1 was outside walking down the road. E6 called for help and ran outside.
E7, Certified Nurses Aide, was going out for a break and stated that she had on a coat and would go get her. E6 verified that R1 was on the road, Radcliffe Street, in front of the assisted living facility and that no one in the facility knew she was outside until Z1 let her know. E7 also verified this information.
E7 stated in an interview on 03/03/03 that R1 indicated she was cold when E7 got to her on 02/25/03, so E7 stated that she put her coat and jacket with a hood on R1.
E11, Dietary Staff, was interviewed on 02/28/03, and stated that she and E10, Dietary Staff, were out the side door of the kitchen taking a break when E10 saw R1 in the city street in front of the assisted living facility. E11 stated that she saw that R1 was tired so she went out to help get her back inside. E11 stated that R1 told her she was going home.
E2, Director of Nurses, stated in an interview on 02/28/03, that she interviewed E6 and E7 and obtained
statements. E2 stated that R1 was chilled when E7 brought R1 back into the facility and that her
monitoring device activated as she reentered the facility. E2 also stated that it was her understanding that
no one knew R1 was out of the facility until Z1 told E6.
R1's nurse's notes dated 02/25/03, at 11:30 A.M. document that a visitor came to E6 and told her R1 was outside on the road. R1 was walking back to the facility with another certified nurses aide. R1 was taken to her room and examined. No injuries were found. The family and the doctor were notified of this incident.
The facility incident/accident Report documents that R1 was found out of the facility and returned by a CNA (Certified Nurses Aide). The report also documents that R1 is confused.
E2 and E6 stated during interviews that R1 would not recognize dangers. Z4, R1's daughter, stated that she did not think her mother would be safe outside by herself.
During this survey on 02/27/03, R1 was observed to wander the facility. R1 stated during an interview on 03/03/03, that she did not remember being outside the facility on 02/25/03, or any time recently and could not tell where she lived previously.
Z2, physician, was interviewed on 03/04/03, at 9:05 A.M. and stated that it would not be safe for R1 to be outside by herself due to the very cold weather on that day and the fact that she would not recognize dangers due to her Alzheimer's Dementia.
The facility is located at 1301 East Deyoung Street which is also State Route 13, a busy state highway. To the east of the facility is a wooded area and to the west of the facility is Radcliffe Street and a residential area. Just south of the facility is an assisted living facility.
According to the Southern Illinois University Weather Center, on 02/25/03, at approximately 11 A.M., the sky was overcast, the temperature was 19 degrees Fahrenheit, and the wind chill was seven degrees Fahrenheit.