Manor Care at Oak Lawn/95th

Facility I.D. Number: 0027540
6300 W. 95th St.
Oak Lawn, IL 60453

Date of Survey: 01/27/04

Incident Report Investigation of 01/14/04

“A” violation(s):

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.

Objective observations of changes in a resident’s condition, including mental and emotional changes, as a means for analyzing and determining care required and the need for further medical evaluation and treatment shall be made by nursing staff and recorded in the resident’s medical record.

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.

The DON shall supervise and oversee the nursing services of the facility, including:

Developing an up-to-date resident care plan for each resident based on the resident’s comprehensive assessment, individual needs and goals to be accomplished, physician’s orders, and personal care and nursing needs. The plan shall be in writing and shall be reviewed and modified in keeping with the care needed as indicated by the resident’s condition.

All exterior doors shall be equipped with a signal that will alert 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 requirements are not met as evidenced by:

Based on closed record review, incident report review, review of police report, emergency medical service report, staff/physician interviews, the facility failed to supervise and prevent one resident (R1) who had a previous history of dementia and wandering/exit seeking behavior, and was wearing an electronic monitoring device, from leaving the facility and who subsequently expired. This lack of supervision resulted in R1 being admitted to the hospital with hypothermia and subsequently expired.

Findings include:

Closed record review revealed, R1 a 75-year-old male was admitted to facility from the hospital on 1/8/04 with diagnoses that included chest pain, acute myocardial infarction, anemia and dementia. Review of R1’s nursing admission evaluation assessment dated on 1/8/04 and signed by E2 (LPN) reflects R1 as a wanderer. Further documentation in nurses notes reflects that R1 was also confused upon admission.

Review of transferring hospital records dated 1/7/04, revealed documentation in progress notes that R1 had potential for injury due to repeated episodes of attempts to get out of bed. R1 voiced he was going home with son. Further documentation revealed that R1 had an order for 1:1 supervision at bedside. This supervision was given by R1’s family until a sitter was obtained.

E2 stated in phone interview on 1/22/04 that she checked off the wandering behavior of R1 on the admission evaluation after reviewing R1’s hospital record. E2 stated that R1 had not exhibited any wandering behavior on 1/8/04. E2 stated that when she had worked on 1/9/04 she had heard from staff that R1 was wandering around and telling staff he wanted to go home. E2 stated when she checked R1 on 1/9/04 he did have an electronic monitoring device. E2 stated she did not obtain any history regarding R1 from family, only from hospital medical record.

Review of R1’s current physician order sheet (POS) and nurses notes indicated a lack of documentation as to why an electronic monitoring device was placed on R1. There is no documentation in the nurses notes that R1 was displaying any behavior of wandering.

There was no care plan addressing R1’s electronic monitoring device or his wandering behavior.

Review of written employee statements provided by facility on 1/20/04 (E2, E3, E4, E5, E6, E7, E8) and interviews with employees conducted by the surveyor on 1/20/04 and 1/21/04 revealed the following:

E9 (LPN) stated in interview on 1/22/04 in first floor conference room that she was assigned to work on the west wing on 1/14/04 on the afternoon shift. E9 stated she had not cared for R1 previously and was unaware that R1 had a wandering behavior or was wearing an electronic device. E9 stated she became aware of R1’s monitoring device on his right leg and his wandering behavior when he was found sitting on a bed in another resident’s room by staff around 6 p.m.

E9 stated R1 was redirected by staff to his own room and was later seen sitting by nurses station in a chair. E9 stated she went to lunch at approximately 8:05 p.m. and returned at 8:35 p.m. E9 stated she was informed by E10 (CNA) about 10 minutes later that she couldn’t find R1. E9 stated she and other staff started checking the unit first and then notified supervisor (E11) RN evening supervisor. E9 stated a “nurse 1,000” was paged throughout the building informing staff that a resident is missing.

E3 wrote in a statement provided by facility that on 1/14/04, “before lunch at 8:10, R1 was in the hallway in a chair sitting between Rm. 18 and Rm. 20. E3 further wrote that when she returned from lunch at 8:40 p.m. he was not in the chair. E3 also wrote that she had not heard alarms go off that night.

E4 (RN) stated in interview on 1/20/04 that she was the other nurse assigned on the west unit on the p.m. shift on 1/14/04. E4 states she saw R1 around 4 p.m. while passing medications. E4 stated she saw R1 going toward north exit door and redirected him away from door.

E5 wrote in a statement provided by facility that on 1/14/04 “I glanced at him when I came back from lunch at 7:50 p.m. at the nurses station, maybe a half hour later I think they said he was missing.”

E6 (CNA) stated during interview on 1/21/04 that she had cared for R1 since R1’s admission, and that R1 was confused upon admission and had been wandering in and out of other residents’ rooms. E6 stated that on 1/14/04 while working the p.m. shift on the west unit she observed R1 in the back hallway of the unit at back door and caught him before opening the door, and was redirected by staff. E6 further stated that the last time she saw R1 was between 7-7:30 p.m. sitting at nurses station in a chair. E6 stated she went to lunch at 8:10 p.m., which left 2 certified nurses aides and one nurse on the west unit. E6 wrote in a statement provided by the facility that she did not hear any alarms go off on 1/14/04.

In a statement written by E10 (CNA) on 1/15/04, E10 wrote on 1/14/04 when it got dark R1 started wandering into another resident’s room and was redirected by staff and to sit in a chair outside Room 18 and Room 20. E10 further wrote that she observed R1 sitting in a chair at 7 p.m. E10 stated in interview on 1/20/04 that she went to lunch on 1/14/04 at 7 p.m. til 7:30 p.m. E10 stated when she returned from lunch she had put other residents to bed which may have taken about ½ hour and around 8 p.m. she noticed R1 was not sitting in chair near Rm. 20. E10 stated she started looking for R1 herself and notified E9 when E9 returned from lunch (8:35 p.m.) E10 stated from 7:30-8 p.m. there were only 2 certified nurses aids on the unit and one nurse.

E10 wrote in her statement that she did not hear any alarms go off.

E8 (CNA) stated in interview that he last saw R1 sitting outside Rm. 20 around 7:45 p.m. At about 8:20 p.m., E10 started asking around if he had seen R1. E8 stated that R1 was found on 1/14/04 in another resident’s room and was redirected out of room by staff. E8 wrote in a statement provided by facility that on Saturday (1/10/04) that he observed R1 with his electronic monitoring device on and went toward the front door and the alarm went off. E10 further wrote that on Saturday R1 was sitting in wheelchair by front door and alarm kept on going off and was redirected back to unit. E8 wrote “no alarm went off.”

E1 stated in phone interview on 1/22/04 1/27/04 that visitors’ hours are over at 8 p.m. though some visitors may leave later and that the receptionist that monitors the front door leaves at 8 p.m. E1 stated the front door alarm is on an automatic timer that goes on at 8 p.m. E1 stated the electronic monitor device at the door is always on.

E11 (supervisor) stated in interview on 1/20/04 that on 1/14/04 at 8:45 p.m. she was informed by E9 that they could not locate R1. E11 stated a “nurse 1,000” was activated on the overhead system that a resident was missing. E11 stated staff did an initial search of the building and then an outside search of the building. E11 further stated that staff went driving around neighborhood looking for R1. E11 stated the police were notified at approximately 9:45 p.m. by staff who saw a police car at a nearby mall. E11 stated R1 was found approximately at 10:30 p.m. outside near facility. E11 stated she did not hear any alarms on 1/14/04 or check the door alarms immediately to see if they were function on 1/14/04 after R1’s elopement.

Review of local police report dated 1/14/04 at 9:40 p.m. revealed police were first notified by staff driving around looking for R1 and informed the officer that R1 had been missing since 8:05 p.m. Further review of police narrative supplement revealed R1 was found lying face down on the street in front of a residential area at 10:23 p.m. by a bystander and police officer. R1 was transported to the hospital emergency room and admitted for hypothermia. R1 expired on 1/15/04.

Review of local Emergency Medical Service record revealed the following: “R1 was being helped up by a bystander and police officer upon arrival. Patient was conscious and alert: chief complaint possible hypothermia and associated complaints of dementia. Initial vitals were blood pressure of 170/palpable, respiration 20, rhythm atrial fibrillation. Patient was warmed by the heat from the ambulance and hot packs.”

Review of hospital emergency record reveals R1 was admitted to emergency room on 1/14/04 at 10:30 p.m. with chief complaint of the following: Patient presents to the ED (emergency department) with history of hypothermia, mental status changes, shaking, chills, weakness/dizziness. Patient core temperature was 88 Fahrenheit. (Normal is 98.6) Further review of record revealed R1 received warm fluids and placed on a warming device. Phone interview with Emergency Room staff Z3 (RN) and Z4 (RN) stated R1 skin was cold to touch upon admission and resident was nonverbal and confused. Z4 stated R1 was wearing socks, shoes, seat pants a t-shirt and a sweater. Z3 stated R1 was wearing an electric monitoring device to right leg.

R1 gradually had an increase of body temperature and was admitted to hospital for telemetrym monitoring. R1 was found unresponsive, with pupils fixed and dilated unable to obtain vital signs by nursing staff on 1/15/04 at 9:30 a.m. R1’s body was sent to the medical examiner.

A typed narrative police report dated 1/17/04 obtained the following information: the detective was advised by the medical examiner personnel that a post mortem exam was conducted on R1’s body and a preliminary cause of death was listed as Bronchial Asthma and cold weather exposure.

Per phone interview with Z7 (coroner) on 1/27/04, Z7 verified he performed the autopsy on R1 on 1/17/04. Z7 stated that R1 had bronchial pneumonia and that the hypothermia was a contributory factor to R1’s death. Z7 further stated that with an initial body core temperature of 88.3 Fahrenheit taken in the emergency room, that “R1 was exposed to the cold temperatures for more than a few minutes and more like a few hours.”

Temperatures obtained from Z8 on 1/20/04 from the National Weather Service for Midway Airport on 1/14/04 ranged from 21-22 degrees from 8 p.m. through 11 p.m. Winds were at 12-22 miles with wind chill factor from 3 degrees above to 12 degrees below zero.