MANORCARE AT PALOS HEIGHTS Facility I.D. Number: 0033324 Date of Survey: 08/28/2002 Complaint Investigation “A" VIOLATION(S): The facility shall provide a Resident Services Director who is assigned responsibility for the coordination and monitoring of the resident’s 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 resident’s 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 clinical record review, staff interviews, police interview, review of facility incident reports and facility policy, the facility failed to properly supervise 1 of 2 higher risk residents from the Alzheimer/Dementia unit identified for wandering/elopement risks (R1). The facility failed to check the door alarms to the Alzheimer/Dementia unit to ensure they were activated 24 hours a day, failed to update care plan of R1 after elopement, and failed to provide the necessary supervision for R1. The facility was unaware that R1 was missing from the facility until facility staff were notified by local police. Findings include: R1 was admitted to facility on 3/18/02 with diagnoses of Alzheimers and Dementia. Review of incident report indicates that on 8/18/02, R1 left the building without supervision at approximately 9:35 A.M. and was found by local police on the east side of facility at approximately at 9:45 A.M. R1's record clearly indicates that R1 had a previous elopement attempt from nurses notes dated 7/5/02. Documentation reveals that "Resident went out the back door and got outside. Alarm sounded and went out and brought resident back." Further documentation throughout nurses notes from admission to present reveals R1 continuous wandering behavior and setting off door alarms. There was no evidence in R1's care plan that any changes were instituted after the first elopement attempt of 7/5/02 and the actual elopement of 8/18/02. Assessment dated 3/26/02, under behavioral symptoms scored 3 for daily and 1 (not easily altered). During the survey, the surveyor observed R1 pacing down the hall and going to door and hitting bar of door. Staff were not present at that time, and R1 turned away from door and continued pacing down the hall. E1 (Administrator) stated in interview on 8/26/02 that facility policy for exit seeking residents is to have an hourly check done by staff. Review of facility's residents hourly check sheets from 8/1/02 until 8/19/02 were inconsistent for documentation. Surveyor entered facility on 8/26/02 and discovered that R1 had eloped from the facility dedicated Alzheimer/Dementia (Arcardia) unit per review of incident of 8/18/02. A tour was made with E7 (ADON) to check door alarms on the Arcardia unit and all exit doors of the facility. During the tour, the surveyor observed the employee exit door (located approximately 30 feet from the locked Alzheimer's unit) propped open and unalarmed. Staff were standing outside of area which leads to back parking lot of facility. Several staff members in the area interviewed were unaware that door is to be closed and alarmed. E6 (maintenance director) came and reactivated alarm. E1stated during interview on 8/26/02 in conference room that signs were posted on the door for staff regarding doors being alarmed at all times. At 2:00 P.M. surveyor and E7 found employee door unalarmed and area was unsupervised. E1 was notified as well as E6. E1 stated that staff on the 2nd floor deactivated the alarm. E3 (personal care assistant in assisted living section) stated during interview on 8/26/02 at 3:30 P.M. that on Sunday on 8/18/02 at approximately 9:45 A.M. while setting the dining room up for lunch, a policeman came down hall and said "I think one of your residents is outside on the grass." E3 stated she went out the door from the assisted living section, walked down the sidewalk and saw R1 sitting on the grassy slope by the bushes. E3 stated R1 was alert and did not appear in any distress. E3 attempted to help R1 up but was unable to do it herself. E3 stated at that time other staff members came out to assist R1 and return R1 to the building. E3 demonstrated to surveyor where R1 was found. The area is located on the east side of the assisted living building, across from facility driveway and bordered on the east by a medical complex and parking lot. South of the location where R1 was found is bordered by Route 83 (a busy 2 lane highway). On 8/27/02 at 9:00 A.M., E6 measured with the facility tape measure from the east door of the Dementia unit, where facility believe R1 escaped to where she was found by E3. The area from the east Arcadia exit door to the area where R1 was found, measured out to approximately 269 feet. Z1 stated during phone interview on 8/26/02 at 6:00 P.M. that on 8/18/02 between 9:30- 9:45 A.M., while driving west on Route 83, Z1 observed R1 sitting on grass on the east side of the building pulling at the grass. Z1 stated R1 was alert and appeared in no distress. Z1 stated he went into building to alert staff that a resident was outside. Review of facility staffing schedule of 8/18/02 for Arcardia unit revealed there was 1 LPN (E9), 3 certified nursing assistants E8, E10, and E11 (CNA) scheduled for 30 residents. Interview with staff E8 on 8/26/02 at 11:30 A.M. stated that on 8/18/02 she was assigned to R1. E8 stated the last time she had seen R1 was at about 9:30 A.M. after she escorted R1 out of dining area so staff could clean up room. E8 stated R1 was escorted out of dining room and started walking and pacing down the hallway which is R1's usual behavior. E8 stated at approximately 9:45 A.M., E8 was informed by E5 that R1 had gotten out of facility. E8 stated that she did not check east exit door but was told by E11 that alarm to the east exit door was off. E8 stated a head count was done by staff at the time 30/30 residents were accounted for. E9 stated in phone interview on 8/27/02 at 1:30 P.M. that on 8/18/02 the last time she saw R1 was at approximately 9:00 A.M. in the dining room. E9 stated she was in a resident's room with E10 caring for another resident. E9 stated she was not aware that R1 had left the unit until E5 returned R1 to unit. E9 stated she assessed R1 and found R1 to have a skin tear and a small bruise in left elbow. E9 stated that at the time R1 was returned to unit, R9 noticed that the alarm light to the east unit door was not on and reactivated the alarm. Review of facility written incident investigation report and interviews with E1 and E2 each verified that the alarm to the east Arcadia unit door had been turned off by an unknown staff member. E1 stated the only staff that have a key to the door alarms are licensed staff on the Arcardia unit. E2 stated that the facility was unable to determine how long alarm had been turned off. Staff reported to E2 that east door alarm was working between 5:00-6:00 A.M. on 8/18/02 after R2 set the door alarm off. E12 indicated to E2 that did E12 did turn the alarm off at that time, but thought she had reset the alarm with the key. E6 stated in interview on 8/26/02 that facility policy at the time of the incident 8/16/02 the alarms were checked only monthly. Review of facility maintenance log for door alarm checks indicate the alarm doors were last checked on 8/7/02, 11 days prior to R1's elopement from facility. |