Kingsley Place at Lincoln Square
Facility I.D. Number: 0044040
Date of Survey: 02/26/2003
Incident Report Investigation of January 19, 2003
Every existing facility shall have each exterior door equipped with a signal in the area that will alert personnel if a resident leaves the building.
An Owner, Licensee, Administrator, employee or agent of a facility shall not abuse or neglect a resident.
These regulations are not met based on the following:
Based on record review, staff and other interviews, and observation, the facility failed to assure that one resident (R2) who was admitted for respite care was properly assessed for safety needs and received a safe environment. The facility admitted R2, a 94-year-old resident, who required special care due to her memory loss, wandering, and had been noted to be especially confused at night. Because the facility did not meet this resident's needs in this sheltered facility and provide ongoing maintenance care, this resulted in neglect when R2 eloped on 01/19/03, and sustained injuries to her left forehead and left elbow.
Per record review, R2 was admitted to the facility on 01/06/03, for a two-week respite while the family went on vacation. E2, (Director of Nursing) per her assessment and per her interview stated that R2 had a short-term memory loss. Z1 (R2's family MD) did a history and physical exam per family request before her admission on 12/17/02. A copy of exam was given to the facility on or before admission. This evaluation indicated that special precautions were advisable due to memory loss and that R2 needed assistance during the night due to memory problems. Per interview on 02/11/03, at 9:30A.M., Z1 stated that she has seen R2 in the past and that R2 has a history of Dementia as part of her Diagnosis. Interview of Z1 confirmed the memory loss. Review of the nurses notes indicated that R2 has confusion at times, had to be redirected several times back to her room and to her floor when she was found on other floors. Record review and interview with E6 described R2's behavior as looking for her purse all over the building. Interview of E3, E4, E5 and E6 all confirmed that they had taken care of R2 and that she had periods of confusion, needing redirection to go back to room or floor.
Per record review and interview with E1, R2 exited through the south exit door on 01/19/03, at 5:47A.M.. E7 and E8 were on duty from 11:00P.M. to 7:00A.M. on 01/19/03. E7 was in charge of R2. Per interview and documentation, E7 was busy getting a resident up on the third floor when E8 came down to notify her that the police were knocking on the front door. When the police finally were let in by kitchen staff, record review and interview with E7 revealed that the police were upset because nobody heard their knocking for about for ten minutes. Police had found R2 near the curb at 5500 West Lincoln Avenue which is one block south of the facility. Police interview with Z2 indicates that they had responded to call at 6:33A.M. and had found R2 lying on the curb without shoes and a coat, and with abrasions and a cut on the forehead. The recorded temperature confirmed by the National Weather Service at 5:53A.M. was 32 degrees Fahrenheit with the wind blowing at 11.5 miles/hr. The police had put R2 in their squad car and went to knock at the facility's front door. When they could not get anybody to respond after five minutes, the police called the paramedics. By the time E7 and E8 arrived, the paramedics were already working on R2. E7 and E8 could not identify her. So they went upstairs to determine who was missing and found that R2 was not in her room. They then went downstairs to notify the police who the resident was. Z1 confirmed that she saw the resident in the hospital that morning and was aware that the emergency room had treated R2 for minor abrasions and a cut on her forehead requiring three to four stitches. Per record R2 left the facility at 5:47A.M. and was found by police at 6:33A.M.
Per interview, E7 stated that she did not see R2 come out of the room all night during her rounds. She did not hear any exit door being opened because her radio/walkie-talkie needed re-charging and was in the nursing station being recharged. E8 also stated that she did not hear the south exit being opened or reset but had heard the east exit door open earlier when the dietary staff came in. There was no audible alarm on the exterior exit doors to notify staff when a resident such as R2 leaves the building unnoticed to the outside. The facility's protocol does not require residents to be monitored. Further the facility does have a locked unit on the fifth floor, but R2 was not admitted to that floor. Surveyor observed that R2's room was next to the south exit stairwell that led ultimately to the outside exit door.
Surveyor observed that the only mechanism staff had to monitor the exit doors was the radio system which indicates audibly that "south door is opened." When the door closes, the audible says "south door reset." Staff do not need to check or manually reset the door. Staff during interview stated that they do not need to visually check the door or note who goes in and out. When R2 exited the building, she could not get back in as the door was locked behind her, and there was no bell or alarm to allow her to get back in. No staff admitted to hearing the radio warning and one of the two monitors was not in use because the battery was being re-charged. The failure to monitor the doors or hear knocking from the outside also contributed to the staff not hearing the police knocking outside trying to get the facility's attention. Surveyor observed on tour the doorbell located at a front door and a back door only rings at the receptionists desk. This staff member is not on duty 24 hours a day. The desk is manned only on day shift and part of the evening shift. The two staff working nights do not hear the doorbell through their radios.
Based on observation, and staff interviews, the facility does not have a signal at the area of the exit doors to let staff know when these are opened. Their system consists of a radio walkie-talkie type of equipment that is worn by staff. The signal comes over the radio first to indicate which door is opened then the signal tells which door was closed and reset. The facility has no policy that requires staff to go and look at the door site. On the day that R2 eloped and was injured, one of the two devices was being recharged and not in use. The other staff member denied hearing the door signal. Information on which door had been opened and when was obtained by the surveyor from a computerized print out log on dates and times and locations of doors opened and closed throughout the day.