THE ABBEY OF CARBONDALE - LITTLE WILLOW
Facility I.D. Number 0041418
120 N. Tower Road
Carbondale, IL 62901
Date of survey 1/17/01
Incident Report Investigation
Residents shall only be admitted who have had a comprehensive evaluation of their medical history and physical and psycho/social factors, conducted by an appropriately constituted interdisciplinary team. No resident determined by professional evaluation to be in need of services not readily available in a particular facility shall be admitted to or kept in that facility. Additionally, emotional and cognitive histories shall be evaluated when applicable and available.
Sufficient staff in numbers and qualifications shall be on duty all hours of each day to provide services that meet the total needs of the residents.
The responsibilities of the director of nursing shall include, at a minimum, the following:
Planning an up-to-date resident care plan for each resident in cooperation with the interdisciplinary team based on individual needs and goals to be accomplished, physician's orders, and personal care and nursing needs. Services such as nursing, developmental, activities, dietary, and such other modalities as are ordered by the physician, shall be reflected 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 every three months.
Participating in the screening of prospective residents and their placement in terms of services they need and nursing competencies available.
In addition to the information that is specified above, each resident's medical record shall contain the following:
A physician's order sheet that includes orders for all medications, treatments, therapy and habilitation services, diet, activities and special procedures or orders required for the safety and well-being of the resident.
Nurse's notes that describe the nursing care provided, observations and assessment of symptoms, reactions to treatments and medications, progression toward or regression from each resident's established goals, and changes in the resident's physical or emotional condition.
AN OWNER, LICENSEE, ADMINISTRATOR, EMPLOYEE OR AGENT OF FACILITY SHALL NOT ABUSE OR NEGLECT A RESIDENT. (Section 2-107 of the Act)
These Regulations are not met as evidenced by:
Based on record verification, review of the facility's client file(s), the facility's investigation regarding the Incident of 9/13/00, review of the facility's policy and procedures, interviews, review of hospital records, and per review of the Coroner's Report (including the Autopsy Report, Police Report, and the Coroner's Inquest), the facility has neglected to ensure that clients admitted to the facility are provided services necessary to avoid physical harm for 1 of 1 client admitted to the facility during the month of September 2000 (R-1) who suffered a "fatal fall" within 48 hours of admission as a result of the facility's failure to:
1) Complete a comprehensive pre admission assessment to ensure that R-1's needs could be met by the facility;
2) Provide sufficient staff monitoring and supervision to R-1 to prevent injury as based on R-1's health status and history; and
3) Take effective and corrective action to prevent further injury from occurring after R-1 fell on 9/12/00 and received a laceration to his head which required emergency medical attention.
Findings Include:
A) Per record verification and per review of the facility's files on R-1, the Admission Nursing Assessment revealed that R-1 was a 6 year old male who was admitted to the facility on 9/12/00 at 2 p.m. with diagnosis of Sanfilippo Syndrome.
1) Comprehensive Pre admission assessment was not completed by the facility to ensure that R-1's needs could be met.
a) Comprehensive Pre admission assessment was not completed as per review of the facility's policy and procedures. Per review of the facility's Admissions Policy, the following is identified: "The following must be completed prior to admission:
1. A PAS (Pre Admission Screening) must be completed.
2. Medical information must have been reviewed including: a. Diagnosis b. Past surgeries c. Past medical history d. Therapy needs and past reports e. Special equipment needs f. Nutritional assessments
3. Educational information must have been reviewed including:
a. Psychological within past three years
b. Individual Education Plan
c. Speech and Language Report
d. Physical Therapy Report
e. Occupation Therapy Report
f. Social History
No admission can be completed without the receipt and review of the above by the IDT (Interdisciplinary Team) (Director, Nursing Supervisor, Physician and QMRP representative)."
Per interview of the facility's administrator/director (E-1) and the facility's director of nursing (E-2) on 10/10/00 in the facility conference room at 3:45 p.m.verified that they (E-1 and E-2) did not participate in an interdisciplinary team meeting with the Physician and or QMRP to determine if R-1's needs could be met by the facility prior to R-1's admission on 9/12/00 as per the facility's policy on new admissions.
Per review of R-1's client files on 10/10/00 at the facility, no pre admission assessment was found.
Per interview with the facility's administrator (E-1) and the director of nursing (E-2) at 3:15 p.m. in the facility's conference room, E-2 stated that the facility's Public Relations person (E-12) or the administrator (E-1) does the pre screening for admissions. The administrator (E-1) gave the surveyor a copy of the pre admission screening completed by E-12. No completion date was noted on any pages of the form by the surveyor.
Per interview of E-12 on 01/05/01 in the facility's conference room at approximately 10 a.m., E-12 stated that she had faxed the pre screening packet to the facility about the time she did the prescreening. (A facsimile date of 7/24/00 is noted on the form.) E-12 verified that she had not seen R-1 at the time the Pre admission Screening form was completed, nor did E-12 secure information from R-1's guardian (Z-1) to assist in the completion of this pre admission form. E-12 stated that she had secured the pre screening information from R-1's "School Superintendent and the School's Social Worker".
Review of the Pre admission Screening form completed by E-12 revealed general information, reflected R-1 was losing mobility skills, had behaviors of eating "things he shouldn't (PICA) and that R-1 would "almost be impossible to program". Additional documentation is noted that he (R-1) "might tap his head" but the behavior was not self injurious.
Review of the Pre admission Screening form also revealed:
a) under the section marked Family Guardian Goals Intentions, E-12 documented "intends to place in L.W. (Little Willow)..."
b) under the Team Review section, E-12's signature is the only signature on the form to identify that R-1's admission to the facility was approved.
Per review of R-1's client records, R-1 was not admitted to the facility until 9/12/00.
Per interview with E-12 on 1/05/01, E-12 stated that "R-1 was an emergency admission to the facility". E-2 (Director of Nursing) was also present in the conference room at the time of the interview with E-12, stated that "they (the facility) did not even know R-1 was coming, until the hospital called the facility two hours before the ambulance arrived at the facility with R-1 on 9/12/00". (Per prior interview with E-2 on 10/10/00, E-2 had stated that R-1's was not an emergency admission to the facility.)
b) Review of medical and hospital records revealed pending transfer to the Little Willow prior to R-1's admission to the facility.
Per review of R-1's client records, R-1 was admitted to Memorial Hospital of Carbondale on 9/03/00 prior to his admission to the facility (on 9/12/00).
Review of the R-1's hospital records, R-1 was seen in the Emergency Room of Memorial Hospital of Carbondale on 9/03/00.
Per review of the Emergency Services Report completed by the physician (Z-5) the following was noted:
"History: This is a 6-year-old white male with a history of Sanfilippo syndrome brought to the Emergency Room by his mother with a history of decreased intake over the past three days. The child reported he had broken a mirror three days ago and tried to eat some of the glass. He lacerated his buccal surface of the lower lip and now has two small ulcers that are present there. He has history of Sanfilippo syndrome, and mother states he is unable to swallow at this time..."
"Impression: Dehydration, Sanfilippo syndrome, anemia..."
"Plan: The plan is to place this child in long term care. The prognosis normally for people with Sanfilippo syndrome not to live beyond puberty."
Per review of R-1's hospital records including Integrated Progress Notes and Physician Orders completed during R-1's hospital stay, multiple entries were documented in regards to R-1's placement to the Little Willow facility. Examples include:
(from R-1's Integrated Progress Notes)
9/04/00 "...We have previously discussed placement at Little Willow and mom is now ready. I contacted Little Willow today..." Completed by R-1's attending physician (Z-2). 9/05/00: "...possible transfer to Little Willow; E-1 at facility - they need mom to come in and sign forms there, also need a stool cx (culture) for parasites before they can accept him..." Entry completed by Case Management (Z-3).
9/06/00: "...Little Willow transfer can go through after mom signs papers there...Continue care until transfer." Entry completed by physician (Z-4). 9/07/00: "...Little Willow transfer awaiting stool for O and P (ova and parasites), awaiting G-tube placement..." Entry completed by physician (Z-4).
9/07/00: "as above. Doctor (Z-5) consulted for g-tube placement. Will proceed prior to Willow's placement..." Entry completed by R-1's physician Z-2.
Documentation for 9/08, 9/09, 9/10, and 9/11/00 completed by the physicians (Z-2, Z-4) all reflected the pending transfer to the "Little Willow".
On 9/12/00 Physician orders were written by R-1's attending physician (Z-2) to "transfer R-1 to the Little Willow".
Per telephone interview with R-1's prior attending physician (Z-2) on 01/05/01 at 10:45 a.m., Z-2 stated she had talked with R-1's family, the facility's medical director (Z-7) and facility staff, and that R-1 had been scheduled for placement at the Little Willow. Z-2 confirmed that she did not consider "R-1 an emergency admission to the facility".
Telephone interview with the facility's medical director (Z-7) on 1/08/01 at 3:15 p.m. confirmed that R-1 was not an emergency admission to the facility.
During the investigation of the Incident of 9/13/00 involving R-1, no documentation was provided by the facility to verify that:
1) any staff person of the facility went to the hospital to screen R-1 for appropriateness during his nine day hospital stay;
2) any staff person of the facility reviewed R-1's hospital progress notes prior to admission to the facility on 9/12/00.
c) Review of client files and review of hospital records/progress notes revealed behavioral needs that were not identified on the pre screening assessment.
Per review of R-1's file at the facility and as confirmed per interview with the PAS (Pre Admission Screening) agent (Z-6), an ICAP (Inventory of Client and Agency Planning) was completed on 9/07/00 while R-1 was in the hospital.
Per review of the ICAP information, under the motor skills section, it was identified that "R-1 could stand alone and walk for a least six feet always or almost always without being asked". Under the behavior section of the ICAP, it was identified that R-1's behaviors of eating broken glass and head banging were "extremely serious, a critical problem".
Per telephone interview with PAS Agent (Z-6) on 1/04/01 at 8:25 a.m., Z-6 stated that she had talked with the facility administrator (E-1) prior to completing the PAS screening on R-1 and had discussed R-1's admission to the facility. Z-6 stated that she met with R-1's mother at the hospital and completed the ICAP on 9/07/00. Z-6 stated that when she was at the hospital, R-1 was in a crib with very high bars and had padding around the crib.
Per review of the hospital progress notes, documentation was also noted throughout R-1's Intergrated and Patient Progress Notes that R-1 had multiple episodes of agitated behavior requiring Ativan medication to assist in calming him down while in the hospital. Documentation was also noted of R-1 requiring constant supervision and 1:1 care while in the hospital due to agitation.
During the surveyor's investigation of R-1's Incidents for 9/12/00 and 9/13/00, the facility did not provide the surveyor with documentation to verify that the facility had reviewed R-1's hospital Progress Notes and or reviewed R-1's ICAP results prior to R-1's admission to determine if R-1's behavior needs could be met by the facility.
Per review of the facility's client file on R-1, documentation does not verify that the facility followed their own policy and procedures and reviewed all medical and behavioral information prior to admitting R-1 to the facility to determine if they (the facility) could meet R-1's needs.
Per telephone interview on 1/05/01 at 11:10 a.m. with the Forensic Pathologist (Z-8) (who completed the autopsy and autopsy report on R-1), Z-8 stated that it was his "professional opinion that R-1 was not adequately assessed by facility staff prior to his admission to the facility".
2) The facility failed to provide sufficient staff monitoring and supervision to R-1 to prevent injury as based on R-1's health status and history which resulted in R-1's death.
a) R-1's client file does not reflect R-1's needs for supervision as based on his admission nursing assessment and or his patient transfer form from the hospital.
Per review of R-1's client file, at the time of admission on 9/12/00, the licensed practical nurse (E-3) completed an Admission Nursing Assessment that identified R-1's diagnosis of Sanfilippo Syndrome.
(Per review of the Autopsy Report completed by the Forensic Pathologist (Z-8), Z-8 identified that "with this decedent's condition (Sanfilippo Syndrome) falls and eventual inability to get out of bed are normal".)
Under the functional status section of Admission Nursing Assessment, this assessment identified that R-1 required "1 person assist to transfer" and "1 person assist to ambulate".
Per review of the Patient Transfer Form that was sent to the facility on 9/12/00 with R-1, documentation under Nursing Assessment and Recommendations identified "patient needs constant supervision will crawl out of crib or bed".
Per review of the admitting physician's orders completed by the director of nursing (E-2) and signed by the facility's medical director (E-7):
R-1's need for "1 person assist to transfer and 1 person assist to ambulate" were not included in
R-1's physician's orders as identified on the Admission Nursing Assessment; and
R-1's need for constant supervision was not included in R-1's physician's orders.
Per review, R-1's admission physician's order sheet does not include orders for special procedures or orders required for the safety and well being of R-1.
Per interview with the director of nursing (E-2) on 1/03/01 at 10 a.m. in the facility's conference room, E-2 stated that she did not put "needs constant supervision" on R-1's admitting orders because the "facility does not provide clients with one on one".
Per interview with the facility administrator (E-1) in the facility conference room at 11:45 a.m., E-1 stated that she had talked with R-1's mom (Z-1) and informed her that the facility could not provide constant supervision to R-1. E-1 stated that Z-1 had agreed with this. E-1 later provided the surveyor with a copy of documentation (no date) that had been completed by her (E-1) that stated:
"Upon return from the hospital, mother and I discussed situation of the facility not being able to give one on one for R-1. I explained to mother we would put him as close to nurses station as possible and do frequent checks on him to ensure his safety. There was no objection from mother."
Per telephone interview with R-1's mother (Z-1) on 1/03/01 at 10:15 a.m., Z-1 stated that she had "told the facility that R-1's balance was off and that he fell a lot. Z-1 stated that she had "warned them ahead of time" (prior to admitting R-1 to the facility). Z-1 stated that she could not watch R-1 twenty four hours a day, "so that's why I put him there". Z-1 stated that the facility had discussed the low profile bed with her, but the facility had never told her that they could not provide R-1 with constant supervision. Z-1 stated "if they had told me they could not provide constant supervision to him (R-1), I never would have left him there".
On 1/05/01, while at the facility, the surveyor was presented with a letter from R-1's prior attending physician (Z-2). Per review of the letter written by Z-2, the following was noted:
"R-1 was an inpatient at Memorial Hospital Carbondale from 9/04/00 through 9/12/00/ While hospitalized, a full time sitter was provided because we were unable to provide and appropriate, safe environment. Upon his transfer to Little Willow, there was no intention that he would require or receive full time, one-on-one care. I suspect that the notation on the transfer sheet was from the nursing staff based on their experience with R-1..."
Per telephone interview with R-1's prior attending physician (Z-2) on 1/05/01 at 10:45 a.m., Z-2 stated that R-1 had been supervised while at the hospital by family, sitters and the nurses. Z-2 stated that R-1 would "bang his head" and "crawl out of his crib". Z-2 stated that "the nurses had tried mattresses on the floor around the crib, but R-1 would not stay on the mattresses and the floor was tiled underneath". Z-2 also stated that while in the hospital, "nursing staff had padded R-1's crib, but this didn't work". Z-2 stated that while R-1 was in the hospital she had discussed with his family, the Little Willow staff and the facility's medical director (Z-7) regarding R-1's need for a helmet, need for a chair restraint during the day, and R-1's need for supervision during waking hours.
Per review of R-1's client file, no documentation was noted that identified Z-2's discussion with facility staff regarding R-1's needs for a helmet, need for a chair restraint, and or R-1's need for supervision during waking hours.
Per review of the Patient Transfer Form that was sent to the facility on 9/12/00 with R-1, documentation under Nursing Assessment and Recommendations identified "patient needs constant supervision will crawl out of crib or bed". Per review of R-1's Patient Transfer Form and per telephone interview with the registered nurse (Z-9) (who completed R-1's transfer form from the hospital to the facility on 9/12/00) at 3:55 p.m. on 01/03/01, Z-9 stated that R-1 had required constant supervision and had required sitters while at the hospital. Z-9 stated that R-1 would climb over and out of his crib and the hospital had attempted mattresses on the floor to prevent injury. Z-9 stated that R-1 would still climb out and off of the mattresses and would be all over. Z-9 stated that she had contacted the facility at about 8 a.m. on 9/12/00 and had given report. Z-9 stated that she had talked with a male nurse (E-4) at the facility and had informed them at that time of R-1's need for constant supervision. (Hospital documentation reflected that a call was placed to the Little Willow on 9/12/00 by Z-9 at 8:30 a.m. to give report of transfer at 1 p.m.)
Per review of the facility records and R-1's client file, no documentation was noted of Z-9's call to the facility to report R-1's transfer to the facility and R-1's need for constant supervision. Additionally, no documentation was noted in R-1's file to verify that the facility had contacted the hospital and or R-1's prior attending physician (Z-2) to clarify the recommendation for R-1's need for constant supervision.
Per review of the facility's schedule and as verified per the facility administrator through review of the time cards on 1/08/01, E-4 (the facility's only male nurse on 9/12/00) had worked a 12 hour shift and was present and on duty at the time Z-9 telephoned the facility.
Per telephone interview with licensed practical nurse (E-4) on 1/05/01 at 10:30 p.m., E-4 stated that he did not recall working the morning of the 12th. E-4 stated that he did not recall taking a call from the hospital informing the facility that R-1 was being admitted. E-4 stated that if he had of taken a call from the hospital, he would have documented the call on a piece of paper and passed the information on. E-4 stated that he thought the DON (Director of Nursing) (E-2) had told him that morning.
b) Nursing documentation for R-1 on 9/12/00 and 9/13/00 did not reflect that R-1 was provided with adequate supervision to prevent injury.
After R-1 was admitted on 9/12/00, documentation at the time of admission reflected that R-1 was placed in a crib and began thrashing around so he was placed in a wheel chair and then into a low lying bed.
Per review of the licensed practical nurse's (E-3) Employee Statement, E-3 documented: On September 12th, I admitted R-1 to Little Willow facility....Later that night I took R-1 to his room and laid him down. He got up out of bed and began heading for the doorway. He was unsteady on his feet so I took his hand and walked him up to the front nursing area so that I could keep a eye on him. I placed him in a play pen that is right next to the nurses desk so that I could keep a eye on him and he attempted to climb out of the play pen. I then gave him Ativan 1 mg IM (Intramuscular) and took child into my arms and rocked him for comfort until my shift was over at 10 p.m.
Per review of an Employee Statement completed by licensed practical nurse (E-4), the following was noted:
"On 9/12/00 at app. (Approximately) 11:15 p.m. when going down blue hall passing meds (medications) I looked into R-1's room. R-1 was up by the wall between his bed and the air conditioner. He was leaning on the wall and taking short unsteady steps towards the air conditioner. At this time I went in and assisted him back to bed."
Per telephone interview with the licensed practical nurse (E-4) on 1/05/01, E-4 stated that R-1 had a low profile bed and mats on the floor because he remembered having difficulty walking on the mats while helping R-1. When E-4 was asked by the surveyor as to what nursing measures were taken due to R-1's wandering behaviors with unsteady gait? E-4 stated that "I thought I told the tech to keep a closer eye on R-1". E-4 stated that he did not remember if he documented this or not.
Per review of R-1's nursing notes, no nursing documentation was noted for 9/12/00 after 8 p.m. until 9/13/00 at 1:15 a.m. R-1's incidents of wandering were not documented in R-1's nursing notes as appropriate.
Per review of the facility's staffing schedule and as confirmed per telephone interview with the facility's administrator on 1/09/01 at approximately 11 a.m., only two nurses (E-4 and E-5) and one direct care staff member (E-6) were present and on duty on 9/13/00 from 12 a.m. until 2:07 a.m. (due to a call in) to provide R-1 with closer supervision and to care for the needs of 35 other clients of the facility.
Per review of R-1's client files at 1:15 a.m. on 9/13/00 (after being in the facility less than 12 hours), R-1 sustained an unwitnessed laceration to his right forehead which required emergency medical attention and suturing.
Review of R-1's nurse's notes revealed that at 1:15 a.m. on 9/13/00, the licensed practical nurse (E-4) "was called to blue hall. Child (R-1) was standing in front of Rm (room) 106. Child has abrasion et (and) 3/4 inch (above) right eye. Cause unknown. First Aid given by (E-5) RN (registered nurse) et (and) pressure to stop et (and) slow bleeding".
Review of R-1's nurse's notes, documentation revealed that Z-2 (R-1's physician) was contacted and orders were received to send R-1 to the Emergency Room for evaluation and treatment. While at the Emergency Room R-1 received 5 stitches to his right forehead. R-1 returned from the Emergency Room back to the facility at about 5 a.m. on 9/13/00.
Review of the Jackson County Ambulance Services Emergency Medical Technician (Z-10) Voluntary Statement taken by the Carbondale Police on 9/14/00 the following was revealed:
"9/13/00 1:30 a.m. Got a call to the Little Willow for a patient that has fallen out of bed and has a laceration to the head... Patient had an approximately 3-4 cm laceration on his forehead just above right eyebrow... Patient's laceration appeared so deep that it looked as if you could see his skull..."
When R-1 was returned to the Little Willow at about 4:30 a.m. (4:51 a.m. per Transporter Report) Z-10's statement revealed that there were "no rails on R-1's bed" nor "pads to keep him from falling out of the bed again". R-1 was placed in bed by the transporters (Z-10 and Z-11) and nursing staff left the room. Per Z-10's statement, "When Z-11 and I (Z-10) were leaving, no one had gone back in R-1's room to check on him or change his diaper. I (Z-10) felt this to be another accident waiting to happen".
Per telephone interview on 1/05/01 at 10:30 p.m. with the licensed practical nurse (E-4) who was on duty at the time R-1 was returned to the facility (9/13/00 at 4:51 p.m.), E-4 stated he did not recall if the mats were down by R-1's bed or not when he (R-1) was returned back to the facility.
Per review of the nursing notes and per review of the Emergency Room Records dated 9/13/00, within 18 hours of being returned back to the facility after requiring Emergency Medical attention, R-1 was found by facility staff in his bedroom, unresponsive. Nursing staff began CPR (Cardio Pulmonary Resuscitation) and R-1 was again transported by the Jackson County Ambulance Service to the Carbondale Emergency Room in "full arrest" at 11:07 p.m. R-1 was pronounced dead by the Emergency Room Physicians at 12:02 a.m. on 9/14/00.
Per review of the Death Certificate, R-1's cause of death was identified as "Subdural bleed secondary to fall". The Death Certificate also identified Skill Nursing Facility as place of injury.
3) Facility failed to take effective and corrective action to prevent further injury from occurring after R-1 fell on 9/12/00 and sustained a laceration to his right forehead.
Per interview with the facility's administrator (E-1) on 10/10/00 at 10 a.m., E-1 stated that no actual investigation had been completed by the facility. E-1 stated that no actual final report had been completed that identified actions taken by the facility.
Per review of the facility's investigation, no documentation was provided to the surveyor that identified that the facility had investigated how R-1 sustained a laceration to his right forehead on 9/13/00.
Telephone interview with the licensed practical nurse (E-4) on 1/05/01 at 10:30 a.m., E-4 stated "No" when asked by the surveyor if he had checked for a blood path or pattern to determine how R-1 sustained the laceration to his head?
Per review of the facility's staffing schedule and as confirmed per interview with the facility's administrator, E-4 (licensed nurse), E-5 (registered nurse) and E-6 (direct care staff) were on duty on 9/13/00 when R-1 fell.
Per review of the statements taken by the facility, no questions were asked of E-4, E-5, nor E-6 in regards to how R-1 could have sustained his injury.
Per interview with the facility's administrator (E-1) and per review of the information submitted by the facility to the surveyor on 1/05/00, the only modification made to R-1's environment after his fall, was the placement of a door alarm that was attached to R-1's bedroom door .
Per interview with direct care staff (E-7) on 1/03/01 at 2:15 p.m., E-7 stated that at the time they (E-7 and E-8) found R-1 on 9/12/00 at 10:30 p.m. E-7 stated that R-1's bedroom door was shut with the alarm set. E-7 verified that R-1 could not be seen by staff in the hall until staff opened R-1's bedroom door.
R-1's client file revealed that the facility's medical director (Z-7) ordered a helmet for safety on 9/13/00 (at approximately 1 p.m.). No constant supervision was provided to R-1 while he was in his bedroom for safety until a helmet had been secured. No helmet was secured by the facility prior to R-1's death.
Per review, no documentation was provided to the surveyor by the facility as to how staff were to monitor R-1 while he was in his bedroom with the door shut, to prevent further injury from occurring.
As based on review, after the facility secured employee statements completed by the licensed practical nurses (E-3 and E-4) that revealed that R-1 had been found twice by nursing staff walking unsteadily in his bedroom on 9/12/00 ( with mats in place), and after R-1 fell on 9/13/00 at 1:15 a.m. and sustained a laceration to his forehead requiring suturing, the facility neglected to place sufficient safeguards into place to ensure that R-1 was free from serious and immediate threat(s) to his physical health and safety.
Per review of the facility's statements taken during their investigation and as confirmed per interview with the facility's administrator on 10/10/00, the facility neglected to investigate to determine how R-1 sustained a laceration to his right forehead on 9/13/00 and to take effective and corrective action to prevent further injury from occurring to R-1.
After returning from the Emergency Room on 9/13/00 at approximately 5 a.m., less that eighteen hours later, R-1 suffered an unwitnessed "fatal fall" in his bedroom at the facility.
Per review of the Incident Report Employee Statement completed by the facility's administrator (E-1) dated 10/19/00, E-1 documented:
"After reviewing all employee statements as to the events of 9/12/00 - 9/13/00 concerning the injury and death of R-1. I am unsure as to the cause of death of this little boy. I can not see where staff acted inappropriately in this sad and unfortunate situation."
Per review of the Forensic Pathologist Report completed by Z-8, the following was noted:
"Cause of Death: Intracranial Hemorrhage due to blunt trauma consistent with fall due to Sanfilippo Syndrome.
(Approximate interval from onset to death was identified as minutes.)
Manner of Death: Accident
Opinion:Based on the history provided me, including the statement by Z-10 (Emergency Medical Technician), and on my findings in a forensic autopsy, my opinion is that R-1 died from bleeding inside his head caused by a severe blow to his head, consistent with a fall onto a hard floor. Comment:
As the posterior scalp did not lacerate full thickness with this fall, it is possible a thin layer of soft material was between the decedent's head and the apparently asphalt tile on concrete floor. The Emergency Medical Technician's (EMT's) description of the pads on the floor seems to fit such a material.
The relative healthiness of this patient, even with the many small bruises, is striking commendation for the excellent care render to him for more than six years at home by his mother and family until just two days prior to his demise. With this decedent's condition, falls and eventually inability to get out of bed are normal. However, the provision for protection from the falls was questioned by the EMT (Emergency Medical Technician) on delivering the decedent to Little Willow after his fall and laceration of his forehead the night before. Less than 24 hours after that fall, the decedent suffered his fatal fall. The results of two days under the responsibility of Little Willow staff are quite different from those rendered at home. The combination of Sanfilippo Syndrome and R-1's size and activity clearly justified placement under professional care. This case indicates the care was not as professional as one might have wished; protection against falls and damage from them was not adequate."