Fox River Pavilion

Facility I.D. Number: 0038877
400 E. New York St.
Aurora, IL 60505

Date of Survey: 11/06/2003

Incident Report Investigation of 10/14/03


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.

Based on observation, record review and interview the facility failed to:

  1. follow physician orders on 10/14/03 to monitor R1 closely (every few minutes) after direction from Z1 at 5 p.m.
  2. follow the facility's suicide prevention policy.
  3. have staff who were knowledgeable of how to manage residents who present suicidal ideations.

These failures resulted in R1 being able to crash through his bedroom window on the 4th floor, falling to a roof two floors below. R1 was pronounced dead at a local hospital 35 minutes later. This is for 1 resident out of the sample of 6.

The findings include:

1. A nursing admission assessment dated 10/13/03 documents that R1 was a 38 year old who was admitted to the facility on 10/13/03 at 2:30 p.m. from a local hospital. A physician order sheet for 10/03 documents diagnoses including suicidal gestures, suicidal ideation, and depression. A physician order dated 10/14/03 documents "Suicidal Precautions. Monitor closely." A hospital history and physical dated 10/5/03 documents that R1 had been admitted through the emergency room because of suicidal ideation and severe depression.

A nurses note dated 10/14/03 at 10:20 p.m. and written by E3 (RN) documents the following: Heard a loud noise sounded like somebody is breaking the window. Immediately headed to the resident room but stopped in the middle of the hallway to get help from other staff. Asked the certified nursing assistant (CNA) approaching to page for staff and male staff to check the room of the resident. At 10:30 p.m., called 911 to send paramedics and police to the building. At 10:35 p.m., found the window of the resident with broken pieces of glass and more glass on the floor. Police officers and paramedics on site to rescue the resident. At 10:55 p.m., spoke to emergency room staff--resident is pronounced dead.

2. E3 was interviewed on 10/15/03 at 1:30 p.m.. E3 indicated that she worked the day and evening shift on the 4th floor on 10/14/03. E3 indicated she first saw R1 at 10:00 a.m. on 10/14/03 during the medication pass. E3 said that R1 was in isolation for ringworm and that the door to the room was kept closed. E3 again saw R1 between 12:30-1:00 p.m. and again at 5:00 p.m.--both times were for medication pass. E3 indicated that R1 was dressed, gave one word answers, and was calm. E3 said that Z1 came in around 5:00 p.m. to see R1. At that time Z1 wrote orders for Suicidal Precautions/Monitor closely. E3 indicated she told E7 to check R1 hourly by seeing what R1 was doing in his room. E3 indicated that between 7:00--7:30 p.m. she gave R1 a snack and told him to call if he wanted more. At 8:00--8:30p.m. E3 gave R1 his medications which he took one at a time. At 8:30 p.m. E3 said that R1 came out of his room to ask if someone had paged him and then R1 returned to his room. At 10:00 p.m. E3 observed E7 (CNA) go into R1's room to take his blood pressure. E3 indicated E7 did not report anything unusual. At approximately 10:20 p.m. E3 indicated she was at the 4th floor nursing station and that she heard a loud sound of a window breaking. E3 indicated that when she arrived at R1's room R1 was laying on the roof which was two floors below.

During the interview on 10/15/03 with E3, E3 indicated that there was no awareness that something was going on--R1 did not verbalize anything. E3 indicated that R1 was a new admission--we were not worried that he was suicidal--we knew he was in isolation for ringworm. E3 did say that the door to R1's room was kept closed at all times due to being in isolation for ringworm. E3 indicated that she and E7 are the staff who cared for R1 on 3-11p.m. on 10/14/03. In response to having had psychiatric training, E3 indicated that she works mainly with residents who have Alzheimer’s and that residents who are on the 4th floor are there for medical needs--hip fractures and gastrostomy tubes.

E7 was interviewed on 10/27/03 at 1:50 p.m. E7 indicated that he first saw R1 at 2:05 p.m. on 10/14/03. E7 indicated that R1 was very calm. E7 indicated that he saw R1 every 45 minutes to one hour during the evening shift. E7 said that during the middle of the shift E3 told him to keep an eye on R1. E7 said that around 10:00 p.m., he went in R1's room to take his blood pressure and at that time R1 indicated that he wanted a sandwich. E7 indicated that a few minutes later R1 was at the nurses station returning a radio that did not belong to him. E7 indicated that is the last time he saw R1.

Z1 (MD) was interviewed on 10/27/03 at 1:35 p.m., Z1 indicated he saw R1 between 4:30 and 5:00 p.m. on 10/14/03. Z1 said that he discussed R1's history of depression and elopements and that R1 denied a plan for suicide. Z1 indicated an order was written for Suicide Precautions due to R1's history of suicidal gestures/depression and because R1 was new to the facility and Z1 did not know him well. Z1 indicated that with the order for suicide precautions that he would expect staff to check R1 at least every 2 minutes. Z1 indicated that he told E3 to check R1 every 2 minutes.

3. When R1's room was observed on 10/15/03 it was noted to be the last room at the end of the 4th floor hall--the room furthest from the nursing station. The room consisted of a single bed. The walls and window were bare. The lower window had been replaced. E1 indicated that the window R1 went through had been a single, double pane window. The window did not have a screen and started at approximately two and one half feet from the floor.

4. A review of the facility's policy and procedure for suicide precaution dated 8/10/98 included the following:

  1. Secure the resident on the first floor if possible in a safe room with one assigned staff person to monitor him continually. Do not leave the resident alone.
  2. The attending Psychiatrist must be notified immediately. Give in detail all the information regarding the incident. The Director of Nursing will be responsible for ensuring this is done and giving a report back to the Administrator.
  3. The Psychiatrist should give orders on how to proceed. The Psychiatrist must be aware that we will not accept any resident back from the hospital until the doctor documents that the resident is no longer suicidal.
  4. If the attending Psychiatrist cannot be reached, contact the Director of Psychiatric Services or then the Medical Director.
  5. The Director of Nursing will then receive with the Administrator the Psychiatrist's orders and plan of action. The administrator will then give instructions on what is to be done or determine if the resident is to be sent out to the hospital. One-to-one is not appropriate for more than 2 hours.
  6. If a Psychiatrist is unable to see the resident within 2 hours of reporting concern, arrange for hospitalization.
  7. Do not remove the one to one supervision until the Administrator gives their approval to do so and/or the resident is sent to the hospital.
  8. In the event a doctor or administration cannot be reached, arrange to hospitalize the resident.
  9. Thoroughly document the following: Conversation with the resident and staff regarding incident......

While meeting with E1 (Administrator) on 10/27/03 at 10:00 a.m., E1 stated that if a resident is on suicide precautions they are sent out of the building. E1 stated we are not equipped staffing wise to handle suicide precautions and we would not admit someone who needed suicide precautions.

E2 (Director of Nurses) was interviewed on 10/27/03 at 1:47 p.m.. E2 indicated that since R1 did not verbally express a desire to kill himself and because Z1 wrote an order to watch closely--he wrote suicide precautions, we did not do one to one's with R1. E2 stated the nurse and CNA were in R1's room every 45 minutes to one hour. E2 stated a psychiatrist was not called and that she was not notified until after it happened. E2 stated the suicide precaution policy was not followed.