CARDINAL HEALTH CARE
I.D. Number: 0044313
210 E. COLLEGE
ENERGY, ILLINOIS 62933
Survey Date: 4/28/00
COMPLAINT INVESTIGATION #0051850 AND LICENSURE - BED LEVEL UPGRADE
Resident as perpetrator of abuse. When an investigation of a report of suspected abuse of a resident indicates, based upon credible evidence, that another resident of the long-term care facility is the perpetrator of the abuse, that resident's condition shall be immediately evaluated to determine the most suitable therapy and placement for the resident, considering the safety of that resident as well as the safety of other residents and employees of the facility.
This Regulation is not met as evidenced by:
Based on staff interview, record review, and review of the facility's incident/accident log, the facility failed to protect a total of 22 residents from actual resident-to- resident abuse and failed to protect all residents from possible resident- to-resident abuse by not adequately assessing for and addressing known agitated and assaultive behaviors for 2 residents from the sample of 4.
The findings are as follows:
1. R-1 is an 84-year-old male resident who was admitted to this facility on 11-24-99 from Choate Mental Health Facility. R-1's admitting diagnoses included Alzheimer's Disease, Organic Brain Syndrome, and Hx of Seizure Disorder.
Per review of the discharge plan and other records from Choate, R-1 was a resident there from 5-5-98 until 11-22-99 when he was transferred to this facility. The records indicate that R-1's behaviors were "random physical aggression which arose at times of excessive supervision and/or excessive stimulus of unit activity" and "aggressive and assaultive behaviors".
Per review of R-1's record and per staff statements, R-1 has had numerous incidents of assaulting other residents at this facility. A thorough review of R-1's record, the facility incident log and incident reports, as well as other resident's records indicated there were 21 incidents where R-1 assaulted other residents, causing injury on 7 different occasions over a 5 month period.
On 4-26-00 during initial tour, R-1 was observed in a geri-chair in his room with the table top in place. E-3 stated that R-1 gets in fights with other residents and that they sometimes have to use wrist restraints on R-1. E-1 stated that R-1 had recently been moved to C wing because of the fights with A wing residents but that R-1 had to be moved back to A wing because he was fighting with C wing residents and was getting injured himself.
R-1 himself was physically abused on three separate occasions when residents whom he had hit retaliated. R-1, on 4-21-00 had to be sent to the emergency room for evaluation and treatment of a laceration to his nose after being hit by R-15.
2. R-4, a 41-year-old male, was a resident at this facility from 2-17-00 until 3-16-00. R-4 was admitted here from Choate Mental Health Facility where he had been living since 1-27-98. His diagnoses on admission here included Schizoaffective Disorder, Personality Disorder, hx of verbal and physical aggression and Seizure Disorder. The resident record and review of the facility incident log revealed 2 incidents of assaulting other residents with 1 resident injury. On 2-26-00 at 4:30 p.m., R-4 "punched" a peer in the left eye causing bruising and edema as is noted on the incident log and the incident report dated 2-26-00. On 3-2-00, R-4 was verbally abusive to another peer and made threatening remarks stating "I'm going to slam your ass...". On 3-16-00 at 2:45 p.m., a female peer told staff that R-4 was trying to kill her and that he had grabbed her neck. Staff observed red marks on both sides of this peer's neck. Staff noted that R-4 was yelling and cursing in relation to this female peer.
R-4 was transferred back to Choate on 3-16-00 after the 2nd assault occurred.