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 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 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 resident’s comprehensive assessment, individual needs and goals to be accomplished, physician’s 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 resident’s 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 Alzheimer’s 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:

  1. 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 Alzheimer’s 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 94’s 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 R4’s whereabouts. At the time of this incident the outside ground was frozen and snow covered from previous snowstorms with temperatures in the single digits.
  2. 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 R4’s elopement to and the author of the 1/23/04 progress note in R4’s 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, “Somebody’s 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. E4’s progress note dated, 1/23/04 states the resident had only “socks, footies and slippers with rubber bottoms” on her feet.
  3. 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 R4’s elopement could not be confirmed.
  4. 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 R4’s using R4’s 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 facility’s present system gives no warning before the door is open.
  5. 2/3/04, R4’s 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. R4’s 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 R4’s 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 R4’s 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 R4’s 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, R4’s 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 nurse’s station.