Dolton Healthcare Centre
Facility I.D. Number: 0043141
14325 S. Blackstone Ave.
Dolton, IL 60419
Date of Survey: 2/9/04
Complaint Investigation
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 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.
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:
Overseeing the comprehensive assessment of the residents needs, which
include medically defined conditions and medical functional status, sensory and
physical impairments, nutritional status and requirements, psychosocial status,
discharge potential, dental condition, activities potential, rehabilitation
potential, cognitive status, and drug therapy.
Developing an up-to-date resident care plan for each resident based on the
residents comprehensive assessment, individual needs and goals to be
accomplished, physicians orders, and personal care and nursing needs.
Personnel representing other services such as nursing, activities, dietary, and
such other modalities as are ordered by the physician shall be involved in the
preparation of the resident care plan. The plan shall be in writing and shall
be reviewed and modified in keeping with the care needed as indicated by the
residents condition. The plan shall be reviewed at least every two
months.
These REQUIREMENTS are not met as evidenced by:
Based on observation, interview and record review, the facility failed to
adequately supervise one resident (R4) who suffers from Alzheimers and
has a history of elopement from the facility. 1/23/04 at approximately 8:15
p.m., R4 eloped from the facility improperly dressed and in inclement weather
while wearing an electronic monitoring device.
The findings include:
- Per clinical record review and incident review dated 1/23/04, R4 is a
74-year-old female admitted to the facility 8/27/03 with a diagnosis of
Alzheimers dementia, Hypertension and Psychosis. At approximately 8:15
p.m., 1/23/04, R4 eloped from the facility wearing only pants, t-shirt and
non-skid footies. The facility was unaware that the resident had eloped until a
motorist driving on 143rd street observed the resident walking east toward
Interstate 94s exit ramp. The motorist, who was familiar with the area,
concluded that R4 was a resident of the facility, stopped her car and went into
the facility to inform staff (E4, Charge Nurse) of R4s whereabouts. At
the time of this incident the outside ground was frozen and snow covered from
previous snowstorms with temperatures in the single digits.
- E4 was interviewed, 2/3/04, at approximately 4:15 p.m. in the facility
conference room concerning the incident. E4 is the staff member that the
motorist reported R4s elopement to and the author of the 1/23/04 progress
note in R4s clinical record concerning the elopement. E4 stated that R4
was put to bed (resident in room 103, north end of the one story building) at 8
p.m. At approximately 8:10 p.m., the resident was out of bed in the north
hallway walking toward the dining room (located across from the vestibule and
front door, center of building). E4 observed R4 go into the dining room where
two staff members (E5, E6) were charting. E4 further stated that between
approximately 8:15 p.m. and 8:20 p.m., a lady (motorist) rushed into the front
door of the facility saying, Somebodys outside! She saw a
woman without hat, coat or shoes walking toward the expressway ramp and figured
the woman was a resident of the facility. E4 immediately thought of R4 and went
to look for her. E4 went out the back door of the facility because of where the
motorist said she saw the woman. When she got out the door, she saw Z1 (Police)
already engaged in searching for the resident. Z1 went south down the alley and
E4 went north down the alley toward the expressway ramp (ramp is over 500 yards
from facility). E4 spotted R4 who was walking at a good pace toward the ramp.
R4 was almost to the ramp before E4 caught up with her. R4 resisted going back
to the facility and Z1 had to help get her back in. E4s progress note
dated, 1/23/04 states the resident had only socks, footies and slippers
with rubber bottoms on her feet.
- 2/3/04, the Z3 (Police Department) was called in an attempt to interview
Z1. The Officer was off duty however Z4 (Police) confirmed that the facility
had not called the Z3. How Z1 became involved with R4s elopement could
not be confirmed.
- 2/3/04, during a noon dining observation that started at approximately
11:30 a.m., R4 was observed wandering into the dining room wearing shirt,
pants, socks, non-slip footies and an electronic monitoring device. The
resident was going from table to table before being redirected by staff. During
the investigation, staff was asked to show how the monitoring device worked at
the patio door off the dining room; front door off the vestibule and the back
door in which E4 went out to find R4s using R4s actual device to
trigger the alarm. All 3 doors worked exactly the same way. R4 had to push the
doors open in order for the alarm to sound. Therefore, if the staff is not in
visual range of a resident wearing an electronic device, that resident can be
easily out the door before staff hears the alarm. The facilitys present
system gives no warning before the door is open.
- 2/3/04, R4s clinical record was reviewed. R4 was admitted to the
facility 8/27/03. Her initial elopement assessment dated 8/27/03 was scored in
a 3, which meant the facility was to follow their Wandering policy and
procedure. 12/8/03, R4 scored 6 on the reassessment. R4s Wandering care
plan was initiated 9/8/03. The care plan made no mention of an electronic
monitoring device. The date (12/8/03, 3/8/04) on the care plan was the only
change made to it for 2 quarters although R4 had made numerous attempts to
elope from the facility (first attempt 9/2/03) and actually eloped (got out of
the door and was retrieved from outside) from the facility on the following
dates:
Date Time Door
11/26/03 10:10 p.m. South door
12/13/03 7:30 p.m. Front door
12/22/03 9:45 p.m. South door
01/23/04 8:25 p.m. ?
No elopement re-assessments were found after any of the actual elopements in
R4s clinical record.
6.2/3/04, starting at approximately 3:45 p.m. in the facility conference
room E1, E2 and E3 were interviewed concerning what the facility had done, and
when, to prevent R4s elopements. The first question asked was about the
electronic monitoring device R4 was wearing. No physician order was found for
the device. No care plan or assessment. E2 stated that because the facility was
made aware of R4s wandering from the family at admission, the facility
immediately (admit date 8/27/03) put the device on the resident. Therefore, R4
was wearing the device every time she eloped. E1, E2 and E3 were asked what did
the facility do any differently after each of the actual elopements? E2 stated
that the facility started 1:1 monitoring of the resident. Per record review,
R4s Wandering care plan was not updated with 1:1 monitoring in order to
prove that the facility had indeed changed their approach after one of the
elopements. However, in the progress notes, the facility clearly had staff
documenting on a day to day basis if R4 made (also how many times during the
course of a day) or did not make an attempt to escape. This
documentation clearly showed the facility was doing 1:1 monitoring before,
during and after the resident successfully eloped from the facility. The
facility did not reassess their strategy for keeping the resident from eloping,
1/23/04. The 1:1 monitoring of R4, also, did not prevent an incident dated
12/23/03 (time 9 p.m.), in which R4 drank a sanitizing solution at the
nurses station.
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