Scotchwood Health Care Center
Date of Survey: 01/06/03
Incident Report Investigation of 12/24/02
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 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.
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 a constant 24 hour a day supervision of the door, a signal is not required.
These requirements are not met as evidenced by:
Based on observation, interview and record review the facility's system for supervising R1 failed in that staff failed to appropriately investigate the cause of an unwitnessed activated door alarm, failed to account for all residents immediately when the cause of the alarm could not be determined, and failed to ensure that the facility's door alarm and paging system was audible to all staff to prevent R1 from leaving the building unnoticed. R1 was found lying in the snow behind the facility garage with weather conditions of 27 degrees Fahrenheit (F.)and blowing snow. R1's core body temperature was measured to be 93.4 degrees F.
The findings include:
1. R1 is 92 years old and has diagnoses which include: Senile Dementia, Alzheimer's type with Paranoid Depression, Seizure Disorder, Hypothyroidism and Anemia. The Quarterly Minimum Data Set (MDS) dated assesses R1 as having short-term and long-term memory problems, cognitive skills for daily decision making are severely impaired, and R1 had exhibited wandering behaviors on a daily basis that were not easily altered. R1 has a current physician's order to "Use (electronic monitoring device) Due To Resident Being Oblivious To Safety Related To Dementia." R1 is assessed as independent in ambulation, is 55 inches tall and weighs 113 pounds.
R1's Care Plan dated 12/11/02 identifies a "Potential for injury to self (due to) Wandering without regard to Safety or Surroundings", "Does not remember time, place, location of areas." with a goal to safely ambulate in designated resident areas. Approaches include; " #1 Maintain (electronic monitoring device) for effectiveness. #2 Redirect from harmful areas, #4 Ensure glasses are worn and #10 ambulate with through hallways if unable to redirect." Information was added to the care plan on 12/24/02 which states " Went outside door #7." Approach "#12. 15 minutes visuals (12/26/02)."
The Incident report transmitted to the Illinois Department of Public Health regional office on 12/26/02 documents that R1 was found on 12/24/02 at 5:50 p.m. outside in the facility's fenced in area lying on ground, returned to building with no apparent injury. The Vital Signs documented were Temperature (ear) 89 degrees F., Pulse 76, B/P 130/86, Respirations 28.
The 12/24/02 nurse's notes document that (R1) was wearing shoes, pants and a long sleeved shirt and that hands, feet, arms, legs and face were red, buttocks warm. Resident's temperature taken was 89 degrees F. The notes document that the Physician (Z3) was notified at 6:30 p.m. and Z3 requested a rectal temperature. R1's rectal temperature was measured at 93.4 degrees F at 6:35 p.m.
On 12/30/02 R1 was observed by surveyor, she was observed either ambulating in hallways, sleeping in bed or sitting in the dining room. R1 was often singing to self as she walked through the facility. The resident wears an electronic wandering device on her ankle. Per interview with nursing staff, R1's whereabouts were being monitored every 15 minutes.
Nurse ( E3) was interviewed on 12/30/02 at 2:15 p.m. E3 was working as the skilled nurse on the back hall of facility on 12/24/02. E3 stated that she had found R1 outside behind the facility garage lying on her right side in the snow up on her elbow. R1 put her hand up and called "Help me Help me!" E3 stated she (R1) wasn't able to get up by herself so E3 ran in and paged for help and then ran back out. E3 stated that she and E15, Certified Nurses Aide (CNA) helped R1 up and walked her back into the building. E3 verified that R1 was wearing a sweatsuit, shoes and socks. E3 said the socks and around the top of R1's shoes were wet, R1's back was cold and her incontinent brief was warm.
E3 stated she had last seen R1 around 4:30 p.m. walking toward the dining room. E3 stated that she had not heard alarms or pages after that time. E3 stated "A lot of people had their TV's on; it was unusually noisy." E3 stated if she is in a resident room and can 't hear a page clearly, she figures they will page again. E3 stated that CNA (E15 ) had come to her and said that she couldn't find (R1). E3 looked out the door #7 window and noticed some tracks in the snow. E3 said about a minute later she realized that the tracks lead away from building but did not come back and that's when she grabbed her coat and followed the tracks in the snow past the garage and found R1. Per surveyor observation on 12/30/02 the location where R1 was found was approximately 70 feet from the door 7 exit.
Interviews conducted on 12/30/02 and 12/31/02 with second shift employees E2, E3, E4, E5, E6,and E15 (who were working Christmas eve 12/24/02) confirmed that R1 was last seen by employees between approximately 4:30 p.m. and 5:00 p.m. walking around the building and in the dining room. Employees interviewed stated that it was R1's routine to walk the circle from the dining room, down Rosewood Hall, through Skilled , up Dogwood Hall and back to the dining room. Staff stated that R1 frequently goes into others rooms and lies down in their beds.
CNA E4 was interviewed on 12/30/02 at 2:00 p.m. E4 stated that on 12/24/02 she heard an alarm and heard E6 page to check door #7, two times when she was in the dining room before supper. E4 stated that she did not think she heard anyone call back to clear it. E4 stated she was right in the dining room but she did not go to check because there should be people back on skilled to check or " I figured (E6) would check it himself. I should have checked. From now on I'm going to be more aware." E4 also was not aware at the time that there was no (electronic monitoring system) for the back doors.
CNA E15 also verified that she heard a page on 12/24/02 before supper that she couldn't understand while in a resident's room. E15 stated that she stuck her head out to find out what it was and heard E6 paging Door 7 on the intercom. E15 stated that she thought E6 was talking to staff in the back. Later E6 told E15 that he had checked door 7. E15 stated that she did not start looking for R1 until sometime after 5:30 p.m. E15 stated that R1 frequently lays down in other's beds. E15 stated after she looked in all the resident rooms she told nurse E3 that she couldn't find R1, who instructed her to check again in all resident rooms and bathrooms. When the second check was complete she again notified E3.
Medical Records/CNA, E6 was interviewed on 12/30/02 at 3:45 p.m. E6 stated that his office is next to the nurse's station and that "The door alarm went off around 5:00 p.m (on 12/24/02) for Door 7. I paged 'check door 7' and no one responded, I paged again and no one responded, I dialed the extension to the nurse's station and no one was at the desk so I went back and checked the door myself. I opened the door and looked out the door , I didn't go out (in the yard) and I didn't see anyone. What I actually thought was the wind sometimes catches the door and sets off the alarm. It was windy." E6 stated that he didn't talk to anyone else about the door and verified that he did not initiate a head count of residents. E6 stated he went back to his office for awhile and left the facility at 5:36 p.m. (per time clock). E6 stated that he didn't find out that R1 had gotten out until they had called him at home about a half an hour later.
Physician, Z3, was interviewed per phone on 12/31/02 at 10:10 a.m. Z3 verified that the facility had called him about ten
minutes after they had found R1 and warmed her up. Z3 stated the temperature they gave him was the skin temperature of a cool ear and what he needed was a core temperature. Z3 stated the rectal temperature was 93 (degrees F.) and R1 was not severely hypothermic. Z3 stated that staff did not know how long she had been outside. When asked how long it would take to lower the core temperature, given the weather conditions, Z3 stated that R1 could have gotten to 93 degrees F. within 10-15 minutes.
Per observation and staff interview, the facility utilizes two door alarm systems to augment supervision of residents. There are three exit doors on the front (east) side of the building (#1,#2 and#3) that exit to the parking lot that is next to a 45 mph posted divided highway. There are two exit doors at the back of the building (#6) and ( #7) of the skilled wing that exit to the side and back yard of the facility which is enclosed by a chain link fence that has three accessible gates. Doors #6 and #7 lock and cannot be reentered from the outside without a key. There are keypads at the doors that staff can bypass momentarily to exit. All doors are equipped with a door alarm system that rings at a panel at the Intermediate Care nurse's station that is located in the main dining room at the east side of the building. The alarm system is monitored, activated and bypassed at this panel. The panel has a light that indicates which of the seven doors has been activitated. An additional electronic monitoring system with bracelets worn by residents is in place for the three east doors.
The facility has an elopement risk assessment that had identified eight residents at risk for elopement. The book is kept at the nurse's station and included R1 and R7 who wear electronic monitoring devices.
The book also includes R8, R9, R10, R11, R12 and R13 who do not wear monitoring devices and who have not attempted to leave, but are at risk.
On 12/30/02 and 12/31/02 staff were observed responding to activated door alarms by going to the panel at the nurse's station, silencing and resetting the alarm and then paging to check the door number. Staff then paged back if the door is clear. The nurse's station also has a camera monitor that shows the main entrance door. When the main entrance door alarm was activated, staff visually checked per camera and eye and reset alarm without paging. It was obtained through several staff interviews and observation that the sound of the door alarm could not be easily heard on the skilled wing when in the resident rooms and bathrooms. On 12/31/02 at 9:30 a.m. the surveyor and Director of Nurse's (E2) went into a resident room bathroom on the skilled wing and had the staff activate the door alarm. The door alarm and page could not be heard from bathroom with door closed. When the door was open the alarm could only be faintly heard from the back of the resident room and the pages could not be understood. There is no enunciator for the system in the back of the building. Door #7 is located at the Southwest corner of the building and is not visible from the dining room nurse's station.