Manorcare at Palos Heights West
Facility I.D. Number: 0041319
Date of Survey: 3/26/2003
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 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.
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 upon observation, interview and record review, the facility failed to monitor and supervise one resident (R5) that was assessed to be at risk for elopement. R5 was able to leave the facility unsupervised on 03/17/03, at 8:40P.M. and did sustain injury while away from the facility. R5 had numerous documented efforts of verbal and physical attempts to leave, as well as R5 had packed his bags in an attempt to leave the facility on 03/14/03. R5 was documented to often leave the second floor via elevator to go to the first floor without second floor being aware of R5 being off the floor. The facility staff was not aware of R5 leaving the facility on 03/17/03, at 8:40P.M. even though R5 was wearing an electronic monitoring device.
R5 was admitted to the facility on 03/11/03, from the hospital. Based upon facility's incident report of 03/17/03, at 8:40P.M., R5's wheelchair was found outside in front of the building's main entrance and R5 was nowhere to be found. The nurse's note documents that at approximately 9:20P.M., neighbors found R5 walking outside near the townhouses and they returned R5 to the facility. E2 stated during interview on 03/20/03, at 3:00P.M. that R5 was assessed to have sustained abrasions on the palms of both hands during this elopement. A small amount of mud was found in both hands. R5 was wearing a leg attached electronic monitoring device.
R5 had been hospitalized for multiple falls and had been assessed on admission to the nursing facility to be at risk for falls. R5 was given a chair alarm and bed alarm on 03/11/03. R5 was also assessed to be at risk for elopement and approaches were placed on the care plan on 03/12/03, to utilize an electronic monitoring device and to monitor R5's whereabouts and to redirect and keep R5 from the exits and elevator doors.
The care plan for the elopement risk was developed on 03/12/03, with approaches to keep R5 away from the elevator and exit doors, monitor for changes in mood, cognitive and daily routine, and monitor residents whereabouts. Prior to this elopement, the nurses's progress notes document on 03/14/03, at 9:20P.M. that R5 was up in the chair refusing to go to bed and threatening to leave the facility, clothes packed in his room, and on 03/15/03, at 5P.M. resident stating he wants to leave the facility, and at 8:10P.M. on 03/17/03, E4 (R5's nurse) brought R5 up to the second floor from the first floor where he had wandered. Additional and more frequent monitoring approaches were not implemented and added to the care plan in response to these assessed events.
E4, E6, E7, E8, and E9 (RN, LPN, CNA) care givers on first and second floor, were interviewed on 03/20/03, at 2:00P.M. regarding whereabouts of R5. The care givers stated R5 would leave the second floor via the elevator when a staff wasn't observing him especially on the evening shift. The staff on the first floor would take him back up to the second floor. E7 and E9 stated at first they were not aware of the identity of this resident. There was no clear expectation of how long this resident could remain on the first floor without the staff taking him back to the second floor. E6 was R5's CNA on the evening shift on 03/17/03. E6 stated R5 "was not suppose to go to the elevators and to the first floor, but he would frequently get on the elevators and they would bring him back ." E4 (LPN) stated "he isn't suppose to go off the floor, but he wanders around all over the place. He doesn't have just one person to watch him, but everyone is aware of his wandering, if don't see him, try to figure out his whereabouts." However, a structured process was not implemented so that specific staff persons were aware of R5's whereabouts at all times especially since staff were familiar with this residents's wandering tendency.
The facility was aware of changes in this resident's behavior that indicated an elopement threat, but failed to implement a process to monitor for these changes and prevent the elopement. The facility documented on 03/14/03, at 9:20P.M. that resident was threatening to leave the facility, and clothes were packed by him. Also on 03/15/03, at 5:00P.M., R5 was stating he wanted to leave the facility.
E1 (Administrator) was interviewed on 03/20/03, at 9:40A.M. E1 stated "residents that may elope have electronic monitoring devices. The sensors are located at the doors and alarms at the nurses's station and the location where triggered. (R5) was recently admitted. We knew he was an elopement risk and put an electronic monitoring device on him. (R5) went out to smoke in the afternoon about 8:20P.M. on 03/17/03. The receptionist leaves at 8:00P.M. The alarm didn't ring at any station. We guess someone held the door open for him. After 8:00P.M., we have to override the code to get out of the facility. There are a few visitors that know the code."
E3 (Maintenance Director) stated on 03/20/03, at 10:40A.M., "There is someone at the front desk from 8:00A.M. to 8:00P.M.. The front door will lock down if a resident gets too close to the door. I checked all doors and the alarm system was working properly as well as the electronic monitoring device that (R5) was wearing was checked and the device was operating properly when (R5) returned."
Based upon review of the literature describing the functioning of the electronic monitoring system, the system operates as follows: When the electronic monitoring system interfaces with the facility alarm system, the electronic monitoring system locks the doors when a resident approaches the door. Then quietly unlocks when resident leaves the area."