GLENSHIRE NURSING & REHAB CENTER
Facility I.D. Number: 0039321
Date of Survey: 12/18/2002
Incident Report Investigation of 11/04/02
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 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 record review, staff interviews, review of facility incident report, the local police report and facility policy, the facility neglected one resident (R1) who was cognitively impaired and required assistance from staff for transferring and toileting. R1 was left unattended by staff during toileting in a basement bathroom and was not found by staff for approximately seven hours. When R1 was discovered and assessed, he was found to have multiple bodily contusions and a blood sugar of 50.
R1 is a 55-year-old resident admitted to the facility on 08/16/2002, from the hospital. R1 diagnosis includes Diabetes Mellitus, Hypertension, Cerebral Vascular Accident and Organic Brain Syndrome (OBS).
Minimum Data set (MDS) of 08/20/2002 indicates R1's cognition is moderately impaired/decisions poor cue/supervision required, requires total dependence of staff for toilet use and locomotion (one person assist), wheelchair primary mode of locomotion and is incontinent of bowel and bladder daily and uses pads/diapers.
Review of R1's nursing notes of 11/04/2002, 3:30 P.M. documents "Unable to locate resident. E6 (Assistant Director of Nursing notified) E1 (Administrator) and E5 notified. 4th floor searched. Administrator notified local police of same. Building search initiated by administration."
Further nursing documentation from 8:00 P.M. reveals the following: "Resident found on floor in bathroom basement.-brought to 4th floor. Body check done. Family on site. Vital sign stable 80, 18, 130/84 and blood glucose monitoring 50. Resident with hematoma to left lateral upper arm, redness to left medial upper arm, contusion to right upper forehead, contusion posterior left ear, and redness to left lateral ribs. Resident complained of pain to left lateral ribs. Doctor (Z1) ordered X-rays. Will continue to monitor."
Review of facility accident/ incident investigation report dated 11/04/2002, for R1 describes the following incident: "Resident was discovered missing off unit at approx. 4 P.M.. Code Green called, building searched, ground search imitated, family called, report filed, police notified. Family arrived at facility to assist with search, resident found on bathroom floor outside therapy treatment room. No change in LOC (level of consciousness), no change in ROM (range of motion)."
Under incident report section "analysis of findings", the facility found R1 was taken to therapy restroom in basement as he requested and was assisted to bathroom by E4, who instructed E9 to assist R1 further. Written warning given to E4 for leaving resident unattended.
During an interview with E8 (4th floor RN) on 12/12/2002, at 3:50 P.M. in basement conference room. E8 stated she was working the 3-11 shift on the 4th floor. E8 discovered R1 was missing around 4:00 P.M.. E8 stated she asked staff (CNA's) if R1 has been seen and started a floor search on the closed 4th floor unit. The "Code Green" was called which indicates a resident is missing. E8 stated that there are no formal rounds done on the dementia unit. E8 stated she was notified by E1 that R1 was found in basement. E8 saw R1 in basement bathroom sitting on the floor between the toilet and sink. E8 stated R1 was alert, assessed R1 for injuries and then took R1 back to the 4th floor.
E7 (CNA) stated during phone interview on 12/17/2002, that on 11/04/2002, she had worked the day shift
(7-3) shift and stayed over to work the afternoon (3-11) shift. E7 stated she had seen R1 in the morning and at lunch. E7 stated" I think I told somebody I didn't see him, but R1 is always wandering around 4th floor in wheel chair." E7 stated that she is not certain that the facility requires rounds to check on the residents on the dementia unit. E7 further stated that R1 requires assistance in toileting and staff have to stay with him when being toileted. E4 (Rehab coordinator) stated during interview on 12/12/2002, at 2:15 P.M. and during phone interview on 12/17/2002, that on 11/04/2002, at 2:30 P.M., E4 went up to 4th floor to bring residents including, R1, downstairs for rehab therapy. E4 stated at about 2:30 P.M., R1 requested to use bathroom and
she wheeled R1 to bathroom across from therapy room, and R1 transferred himself to toilet. E4 stated she explained use of call light if he needed additional help and told R1 to come out when he was finished. E4 stated she thought other staff members working in the therapy unit that day saw E4 take R1 to the bathroom. E4 stated she left therapy room to go up on floor and do rehab on other residents. E4 returned to basement therapy room at approximately 3:15 P.M. and there were no residents in gym (therapy room) E4 left facility for home at 3:30P.M.. E4 stated that at 5:30 P.M., she received a phone call asking when was the last time E4 saw R1. E4 stated she told E6 (Director of Nursing) that the last time she saw R1 in the basement bathroom at 3:00 P.M..
E1 stated in written statements obtained on 12/12/2002, and during interview that on 11/04/2002, at approximately 4:00 P.M. he was notified by staff that R1 was missing from the 4th floor. E1 stated that a Code Green was initiated immediately. E1 stated that in his search, the basement bathrooms were checked by knocking and listening. E1 stated he did not open the basement bathroom doors to check if anyone was in there. E1's written statement indicates that at approximately 7:30-8:00 P.M., family called facility to get an update after the facility had notified them earlier. E1 further documents in statement that approximately at 8:45 P.M. family arrived at facility and assisted in the search. E1 documented that E5 (assistant administrator) did another search of basement bathroom at approximately 9:30 P.M. and found R1 in basement bathroom.
E5 stated in written statements obtained on 12/12/2002, and per phone interview that he was notified that R1 was missing from 4th floor. E5 stated he was involved in search for R1 in and outside the building. E5 stated he was instructed to go to local police department and file report because local police had not arrived at the facility to take a report. E5 stated he returned to facility after filing police report and went to search the basement one more time. E5 stated he knocked on north basement bathroom and heard a resident respond. R1 was on the floor and the pants and diaper were half way down to the resident's ankles.
The facility failed to supervise and monitor a confused resident who was taken off his closed unit by staff, placed on the toilet and left unattended for approximately seven hours. The interviews confirmed that the unit does not do rounds. Further, a staff member places a dependant resident on the toilet and does not assure that the resident is toileted and returned to the floor. R1 was unable to use the call light and remove himself from the toilet and leave the unlocked bathroom until discovered by the searching staff members at approximately 9:30 P.M.. He had missed his mechanical soft therapeutic diet and his medication for his blood pressure, Parkinson's disease, stool softener, and his blood sugar monitoring.