HERITAGE HOUSE OF CHARLESTON
Facility I.D. Number 0031047
738 18th St.
Charleston, Illinois 61920
Date of Survey 12/02/99
Complaint and Incident Report Investigation
The facilitys governing body shall exercise general direction of the facility, and shall establish the policies and procedures for the facility related to its purpose, objectives, operation, and the welfare of the residents served.
Nursing services to provide immediate supervision of the health needs of each resident by a registered professional nurse of a licensed practical nurse, or the equivalent.
Residents shall be provided with nursing services, in accordance with their needs and which shall include, but are not limited to, the following: The Health Services Supervisors participation in:
All medications administered shall be properly recorded as set forth in Section 350.1620(g).
Each dose administered shall be properly recorded in the clinical record by the person who administered the dose. See Section 350.1620(g).
A medication administration record shall be maintained which contains the date and time each medication is given, name of drug, dosage, and by whom administered.
All exterior doors shall be equipped with a signal that will alert the staff if a patient leaves the building. Any exterior door that is supervised during certain periods may have a disconnect device for part-time use. If there is constant 24 hour a day supervision of the door, a signal is not required.
AN OWNER, LICENSEE, ADMINISTRATOR, EMPLOYEE OR AGENT OF A FACILITY SHALL NOT ABUSE OR NEGLECT A RESIDENT. (Section 2-107 of the Act)
1) The following are examples that the facilitys governing body did not exercise general direction of the facility:
a) The facility did not contact the Illinois Department of Public Health (IDPH) prior to installing a locked exit system in the facility. On 11/9/99 at 3:30 p.m., the surveyor was attempting to leave the facility by means of the south exit door.
Per interview with direct care staff, this door was locked and could not be exited from the inside. E20 confirmed that this door was locked and could only be unlocked and exited by entering a code.
b) Governing body did not ensure client safety for R9. R9 who has a history of elopement, eloped on 10/10/99 when he was in the patio area of the facility when the door alarm was not activated . On 10/14/99, R9 was in the patio area and the alarm was not activated.
c) Governing body failed to ensure R5's safety when R5's wheelchair was tipped over on 11/1/99. R5's Profound Mental Retardation non-verbal, non-ambulatory and non-mobile and cerebral palsy.
d) Governing body did not ensure that R74's health, safety and active treatment were protected when R74 was continually for long periods of time left in his room with the door closed and the lights out. R47 is a male with profound mental retardation, is non-verbal and has PICA behaviors. On 11/5/99, R47 was observed sleeping in urine and feces soaked bed. Additionally the room was smeared with feces some of which was caked and dried. E13 confirmed that some of the old feces had not been removed. Further the paper towels used to cleanse the feces from the furniture and doors was thrown in a wastebasket and left in his room. Per R47's IPP, he is not to have a wastebasket in his room due to his PICA.
2) Per file review, R9 has a long history of elopement. Per an incident report dated 10/10/99, R9 eloped when he left the facility patio area unnoticed, exited the building by himself and went across a busy state highway in front of the facility. He went into a gas station once across the street. The incident report states, ...Client has a history of elopement whenever staff is busy...it has been found that the buzzer to patio door was turned off...
Per observation on 10/14/99 after day training at approximately 3:30 p.m., R9 was out in the patio area of the facility. The alarm did not sound as the door was opened. Per interview with E10, he stated that they always turn the buzzer off right before and during meals.
Per review of nurses notes dated 10/10/99, the elopement incident is documented as having occurred at 2:50 p.m.
On 11/2/99 from 3:15 p.m. to approximately 6:30 p.m., door alarms were activated by the surveyor at least ten times. Only two times did staff respond to the alarms to investigate.
On 11/5/99 at 10:30 p.m., the front door was opened and alarmed on two occasions. No staff came to the area to investigate the door alarms.
Per review of R9's Behavior Management Program (BMP), he is to be given an edible reinforcement every hour with no PICA. This was not observed at day training on 11/2/99. The BMP also states that R9 is to have 1:1 staff to deter aimless wandering. Per observations made throughout the survey, R9 generally pushed his way past any staff who tried to block his exit/entrance to spaces. Per observation on 11/2/99 of Pop Club, two staff were assigned to the room of 7 individuals known to have high behaviors. At approximately 4:00 p.m., R9 left the room, went through the dining room and to the activity room with no staff. The activity door alarm was activated by the surveyor and no staff came to the area to investigate the alarm.
The BMP also indicates that staff are to direct R9's energy to exercise such as walks and riding a stationary bike. Neither of these activities were offered to R9 per all observations at the facility and at day training.
The BMP also states that R9 should not be taken to the dining room until his tray arrives. Per observation on 11/2/99, R9 was taken to the dining room at 4:19 p.m.
The BMP also states that R9's hygiene box is to be locked. Per observation of locked cabinet on 11/10/99 accompanied by E5, a pair of shorts were noted. No hygiene box was in R9's locked cabinet or in the direct care staff office area. Confirmed per E5.
The BMP also stated that R9 is to have a 15 minute check book. Per review of the 15 minute check book on 11/9/99, there were no documentation sheets for R9 for 11/99. Confirmed per E5 that the sheets had not been in the book.
The BMP states that elopement is not a targeted behavior. It has not been updated since 3/17/99.
Per review of QMRP summaries, the last monthly summary (including day training data analysis) was dated 7/12/99.
Per review of data sheets for R9, multiple blanks are noted in the documentation of R9's behavior log. Data for R9's other programs is also lacking. R9 has a program to say want clearly which was not observed to be implemented in a functional setting. Additional examples for R9's other programs.
The facility failed to proactively assure that R9 was not subjected to serious and immediate threat as evidenced by 1) the patio door alarm was deactivated after R9 had eloped when it was previously deactivated, 2) staff did not respond to activated door alarms, 3) R9's BMP was not updated to include elopement as a priority behavior, it was not implemented , and data was not accurately documented, 4) the QMRP summaries are not current and, 5) data for programs is not consistently documented.
Additional examples regarding elopements are noted for Rs 11, 7, 38, 55, and 17:
a) R7, Profound Mental Retardation, ambulatory and nonverbal, was escorted to a van for an activity on 10/24/99. Once staff went back into the building, R7 left the van and went across the busy state highway in front of the facility to a gas station. On 10/27/99 at 11:44 p.m., R7 went across the street to a gas station. On 10/30/99 at 7:00 a.m., R7 went out the B wing door and was on the street.
b) R11, Profound Mental Retardation, ambulatory and nonverbal. On 11/1/99 at 8:00 p.m., R11 left the activity room door and went out to the street.
c) R55, Severe Mental Retardation, ambulatory and verbal, eloped from the C wing door and went past the fence on 10/16/99 at 9:00 a.m. R55 also eloped on 10/17/99.
d) R38, Profound Mental Retardation, ambulatory and nonverbal eloped out the front door.
e) R17, Profound Mental Retardation, ambulatory and nonverbal eloped on 10/11/99 at 5:00 p.m.; was laying in the road in front of the facility per incident report.
3) Additional example regarding facility failure to ensure client safety noted regarding R1. R1 is a 58 year old male who sexually aggressed up R63 on 9/99 during the night while she was sleeping in bed nude.
On 10/26/99, an IDT meeting was held at which time a light beam motion detector to R1's doorway was discussed. No light beam was noted at R1's doorway through the survey. Nurses notes indicate incidents of night wandering.
On 11/6/99 at 10:30 p.m., R#s 50, 58, and 33 were observed in bed in their own beds, sleeping in the nude and R64 had on underwear only.
4) The facility neglected to ensure that R67 did not abuse R5. R5 is a 33 year old female with Profound Mental Retardation, is nonverbal, non-ambulatory, non- mobile, Micro cephalic, Spastic Quadriplegic, has Generalized Epilepsy, Contractures and Constipation.
On 11/1/99, a facility generated incident report states that on the above date at approximately 7:25 a.m., R5 was found tipped over in her wheelchair with her seat belt still fastened. A scratch-like area was observed over her left eyelid with slight edema.
The incident report further states that there is a history of R5's roommate (R67) tipping over R5's wheelchair.
R67 is currently on a Behavior Management Program (BMP) for physical aggression, self abuse and excessive verbalization. R67's physical aggression is defined as hitting, scratching, pinching, grabbing staff or clients, hair pulling, pushing dining room table and attempting to tip people over in their wheelchairs. The BMP further states that due to R67's low functioning level, she may not be able to conceive the consequences of her behavior.
Future preventative measures to be taken, per the incident report, are that staff will monitor closely and keep the door open when R67 and R5 are in the room alone unless personal care is being given. After R67 receives her a.m. Meds, R67 will be taken to activities and not left in her room.
Per interview with E1 on 11/17/99, E1 stated that R67 has pushed R5's chair over at least two times in the past and that it was purposeful behavior. E1 also confirmed that the plan as reflected in the incident report form was the plan to be implemented. E1 felt that the 11/1/99 incident was also the result of R67 pushing R5's wheelchair over.
On 11/2/99, E8 also stated that R67 had pushed R5's wheelchair over before and also felt that the 11/1/99 incident was again the result of R67's behavior. E8 also confirmed that R5 and R67 were not to be in their room together with the door closed.
On 11/4/99 at approximately 4:45 p.m., R67 and R5 were observed in their shared bedroom together both in their wheelchairs. The door to the bedroom was closed.
On 11/8/99, a special IDT meeting concurred that R5 should be moved to another room. A work order for room changes is signed on 11/10/99 by maintenance/housekeeping, social services, nursing, dietary and the QMRP. R5 was not moved until 11/10/99 which was 9 days after her 11/1/99 incident.
The facility neglected to ensure R5's health and safety in that after the 11/1/99 incident, (and all previous incidents) R#s 67 and 5 were still left alone in their room together with the door closed and R5 was not moved to a new room until 9 days after the 11/1/99 incident.
5) The facility neglected to ensure that R47 and R74 received supervision and care according to their developmental and behavioral needs.
R47 is a 21 year old male with Profound Mental Retardation, Autism, PICA, is nonverbal and is ambulatory. Additionally, R47 is on a BMP for property destruction for ripping mattress covers and papers, PICA, throwing objects such as furniture, inappropriate urination, self stimulation, and inappropriate touching. R47 also, per his BMP, has a locked closet. R47 and R11 (R47's roommate) also are to have 15 minute checks due to their behaviors. Per review of both individuals 15 minute check documentation sheets, documentation is sparse.
On 11/5/99, there is no documentation of 15 minute checks for R47 until 3:00 p.m.
Per a document provided by the facility on 11/10/99, the Human Right Committee has concurred that R47 is to have a locked night stand and closet. (There is, however, no night stand in R47's bedroom).
A 3/5/99 special note in the IPP states that R47 has no trash can in his room due to inappropriate urination.
On 11/5/99 at approximately 8:25 a.m., R47 was observed in his bedroom, when surveyor opened the door to his room. R47 was wearing no clothing and was sleeping on his bed. The fitted sheet and the bedspread were pulled down by the foot of the bed.
On the floor between R47's bed and R11's bed (R47's roommate), there were two separate formed bowel movements. There was a clear yellow colored liquid on the floor next to the bowel movement. As the surveyor walked across the room, the floor was very sticky. Confirmed per E3 when she walked into the room.
The back of the door leading to the hallway and the door casing were both smeared with bowel movement. Bowel movement was also observed on the door handle. The room smelled strongly of urine and feces.
While R47 slept, dried BM was observed on the light blue sheet that was partially on the bed and on the metal foot board at the end of R47's bed. R11's bed was also observed to have a sheet partially torn off of the mattress with BM smeared on the sheet also.
R47 had dried blood around the entire inside of his mouth and dried yellow secretions in his nose.
The surveyor notified E3 who returned to the room with the surveyor. E13 came into the room and as she was cleaning up the various BM spots stated, ...sometimes there is not enough help... E3 also confirmed that the BM on the end of R47's bed was flaky and had been there for more than a day. E3 left the room. E13 left the room to obtain more cleaning supplies. E13 had wiped BM off of the door/door areas and bed and had thrown the paper towels in the waste basket. R47 (now awake) got out of his bed, retrieved the waste basket and set it on his bed (R47 has PICA and is not to have a waste basket in his room per his IPP) amongst the BM smeared bed clothing.
E3 and E13 re-entered the room. E3 pulled R47's BM smeared bed linens off of his bed. The surveyor pointed out that R47 had something in his hand. E3 and E13 removed a clothing tag from R47's hand. (R47 has a history of PICA of clothing tags)
At 8:55 a.m., E13 put R47's bedspread around him and took him to the shower area. Per E13, R47's and R11's clothing are locked and she did not have a key and did not know where it was so she could not get in his closet for clothing. She stated that both Rs 47 and 11 had robes.
When E13 later got a key to R47 and R11's closet, she stated that R47 will throw/push BM under his closet door. When E13 opened the closet door, E13 confirmed with the surveyor that there was a dark line across the opening to the closet. E13 concurred that the dark line was dried feces and that it had been there for some time.
Per interview with E25, he stated that E26 was responsible for R47 this morning. E25 stated that E26 had not been on C-wing caring for R47 because he had reassigned her to cover B-wing due to call-ins.
On 11/5/99 at approximately 9:22 a.m., R74, Profound Mental Retardation and nonverbal, non-ambulatory and non-mobile and has seizures, was observed in his room in his wheelchair.
A clear yellow liquid was observed on the floor behind R74's wheelchair. E23 who was also in the room confirmed that R74 had been incontinent of bowel and bladder. Bowel movement was observed on R74's white underwear as E23 placed R74's soiled clothing on the chair seat.
E23 then put clean underwear, sweats, shoes and socks on R74 as he sat in his wheelchair and began pulling them up. The surveyor asked if R74 had been cleaned yet and E23 replied that she was pulling R74's garment up to his knees for privacy. E23 then went to the door, opened it slightly and asked for assistance. E22 brought a bath towel and a pericare bottle to the room. E23 was observed to spray the towel with pericare solution. E23 then stood R74 up and held him up with one hand in front of R74 (around his gait belt). E23 proceeded to clean R74's anal area with the towel. The towel had only been sprayed with a small amount of pericare solution. E23 continually flipped the towel over and over as she wiped R74's anal area to obtain a clean area on the towel that was not soiled with BM. E23 was using her bare hands, no gloves on. E23 continued in this manner pulling the mostly dry towel up through the inner sides of R74's buttocks. R74 appeared to be extremely uncomfortable.
R74's wheelchair was observed to have an incontinence pad on it. However, BM was also noted on the wheelchair seat as the pad was not situated in a position as to fully protect the seat. E23, still holding R74 up with one hand, wiped the BM off the wheelchair with the same towel, put the towel inside of the incontinence pad, rolled it up and threw it on the floor. E23 then proceeded to pull up R74's underwear and pants. E23 then sat R74 down in his wheelchair. The wheelchair seat was observed to still be wet with urine.
Per interview with E23, E23 stated that she had worked at the facility for almost a year and has had training in pericare. When asked about how she had been trained to clean BM and urine from the wheelchair, she stated she should have used the pericare wash, then stated she wasnt sure but could ask.
As R74 was put in his wheelchair, BM was observed to be on the floor between his feet. At that time, E22 came into the room asking if E23 had cleaned R74's chair. E23 replied, not very well. E22 stated she would get you the stuff. E22 left and returned and proceeded to sanitize R74's chair with sanitizing solution. E22 proceeded to pick up R74's soiled clothing with bare hands and continued to sanitize R74's chair using bare hands and also cleaned the BM from the floor around R74's feet.
An additional example was observed for R74 on 11/4/99 at the facility at approximately 9:02 a.m. when E3 and E11 were observed to be attending to R74's personal care. R74's soiled clothing was observed lying on the floor by his bed. E11 was dressing R74 while he was in his wheelchair. E3 and E11 then assisted R74 to the bed to assist pulling his orthotics on. When R74 was moved to the bed, the surveyor noted a small area of fresh BM (approximately 1 inch in diameter) on R74's wheelchair seat. The surveyor noted same to E#s 3 and 11 who stated he was only incontinent of urine.
R74 was placed in his wheelchair and was wheeled to the dining room by E11 at approximately 9:20 a.m. Per interview with E11 on 11/4/99, E11 confirmed that R74 did not receive any pericare during the above incontinence care.
At approximately 9:22 a.m., the surveyor requested to see R74's perianal area due to the earlier suspected BM incontinence. Per observation at approximately 9:28 accompanied by E11, R74 had a large dried soft BM between his legs and in the crease between his buttocks and on his underwear.
Per review of staffing and confirmed per E22 on 11/5/99, there were 11 staff on duty on 6:00 a.m., 12 at 7:00 a.m. and 15 at 8:00 a.m., one of which was the morning supervisor. Per interview with E1 on 11/5/99, she stated that the direct care staff from day training are supposed to come to the facility in the mornings to help with a.m. care. E1 stated that day training is short of staff right now which makes the facility short on staff.
Per interview with E20 on 11/13/99 at 3:30 p.m., he stated that day training staff numbers are supposed to be 25 every morning but E20 confirmed that they were currently short staffed. E20 and E1 were notified of a Serious and Immediate Threat on 11/5/99 at 10:30 a.m. regarding lack of weekday staff to meet the needs of individuals.
6) The facility neglected to ensure that R11 did not sexually aggress R47.
R11 is a 29 year old male with Profound Mental Retardation, is ambulatory, non- verbal and displays PICA behaviors. Per an 8/3/98 psychological, R11 has a history of suspected, abuse... and he demonstrates several symptoms suggestive of sexual abuse. His current behavior management plan notes that R11 has been found engaged in, pseudo sexual behaviors, and there is a documented 6/13/96 incident of, performing fellatio on another client.
R47 (R11's roommate) is a 21 year old male with Profound Mental Retardation, is non-ambulatory and non-verbal. Per a nursing note dated 10/26/99, at 12:00 a.m., it states that R11 was observed, bumping against, R47. R47 was lying on his side facing the wall with R11 behind him.
Per interview with E1 on 11/16/99, she states that she was on duty at the facility when the incident occurred, that a new staff person was the actual witness to the incident. E1 further stated that the new staff was upset and when asked if R11 had an erection, the staff was not certain. The nurses notes state that an erection was not noted. However, the writer of the nursing note was not the witness to the incident.
Per file verification, there is no evidence that an emergency IDT was held after the incident. At the time of the current survey, R11 and R47 continue to be roommates.
The facility failed to ensure that R47 is protected.
7) The governing body failed to ensure that nursing provided safe and proper bowel management potentially affecting R#s 1 thru 85 (as of 10/15/99).
The facility has history of having at least two deaths which occurred as a result of bowel obstructions in the last year (Z1 and Z2). R10 had an emergency surgery on 7/99 to remove a bowel obstruction.
Per interview with E1, Director of Nursing and the Assistant Administrator on 10/4/99, following the 9/24/99 survey, E1 instructed the nursing staff to give Milk of Magnesia (MOM) to all residents in wheelchairs on Mondays and Thursdays, who had no bowel movements for 3 days. She further stated that direct care staff were complaining about some residents having many BMs but she stated they needed to document better.
Per interview with E2 on 10/14/99, E2 stated that she gives MOM to all residents in wheelchairs on Mondays and Thursdays with no BMs for 3-4 days, including ambulatory residents.
Upon request for review of 9/99 and 10/99 BM documentation, E1, 2, and 3 were unable to locate 9/99's records on 10/14/99. Per review of 10/99 BM records, R82 and R49 (residents in wheelchairs) and R36 were not listed on the documents. Confirmed per E3 when pointed out by the surveyor.
BM records for 10/10/99-10/14/99 shows no documentation for R#s 11, 13, 15, 17, 20, 5, 22, 26, 24, 25, 29, 30, 32, 33, 34, 1, 37, 42, 43, 44, 51, 52, 54, 55, 56, 8, 3, 57, 59, 60, 61, 62, 65, 66, 67, 68, 71, 72, 74, 75, 78, 81, 83, 84, 85, 80 and 69.
Of the BM records for 9/30/99 to 10/9/99, individuals with 3 or more days of no documented BMs are as follows:
R10 (who had surgery 7/99 for bowel obstruction); R#s 11, 12, 13, 14, 15, 9, 16, 18, 17, 19, 20, 5, 22, 26, 25, 27, 28, 29, 30, 2, 3, 1, 32, 33, 34, 35, 1, 37, 40, 41, 42, 43, 44, 47, 4, 5, 50, 51, 52, 53, 54, 55, 56, 8, 3, 6, 57, 58, 60, 61, 62, 63, 64, 65, 66, 67, 68, 70, 74, 78, 79, 81 and 46.
In addition, R#s 1, 56, 2, and 66 have a diagnosis of Megacolon. R#s 11, 9, 16, 17, 28, 29, 32, 47, 65 and 76 have a diagnosis of PICA. R70 has a history of inserting objects into her rectum.
Per review of medication administration records, there is no documentation in 9/99 or 10/1/99 to 10/13/99 of Milk of Magnesia administration on any resident, R#1 through 85. There are no nurses notes to indicate any BM results following MOM administration. Confirmed per E1.
E1 stated that she had been so busy with other things that she had not had an opportunity to review BM records. She also stated that the MOM should have been documented on the medication administration record as per the facility. E1 also acknowledged that it was impossible to know which R#s had or had not received MOM on what dates for R#s 1-85.
Per review of MARs for MOM administration on 10/14/99, 44 individuals received MOM at 9:00 p.m. Of these 44 individuals, the following individuals had at least 1 BM in the previous 3-day period. R70, who also received Kaopectate for loose stools at 2:00 p.m. on 10/4/99, had a BM on 10/12/99, 10/13/99 and 2 on 10/14/99.
8) Per review of MARs on 10/15/99 for 10/14/99 MOM administration, 44 individuals received the medication at 9:00 p.m. Of these 44 people, R#s 79, 64, 40, 4, 77, 73, 59, 3, 38, 26, and 10 had a BM within the last 3 days. R#s 39, 61 and 18 had more than 1 BM in the previous 3 days.
R70, who also received Kaopectate for loose stools at 2:00 a.m., on 10/14/99 had a BM on 10/12/99, 10/13/99 and 2 incidents on 10/14/99.
Per review of MARs and nurses notes as of 10/15/99, there is no reproducible documentation of any results of MOM being administered. Per review of facility policies, nurses are to document all medications given. Confirmed per E1 that nurses are to document medications given in the facility.
This facility failed to provide an organized system of medication administration. Nursing failed to implement an IPP nursing measure to elevate the head of R8's bed. R8 is a 62 year old male with a diagnosis of Histal hernia and Esophageal Reflux.
Per review of R8's 12/11/98 IPP, a nursing evaluation states that R8's bed should be elevated 6 inches because R8 refuses to cooperate with requests to stay in an upright position following meals. Per observation on 11/5/99, the head of R8's bed was flat. Also on 11/10/99, when accompanied by E18, the head of R8's bed was flat.
Nursing failed to keep R8's head of bed elevated as per his IPP.
Additional example regarding a recommendation in R8's IPP for him to be encouraged to use salt. Nursing failed to ensure that R8 utilized salt on 11/4/99 at the p.m. meal. Nursing also failed to ensure that R8 ate and drank slowly at the same meal.
9) Nursing failed to monitor R21's groin area for skin breakdown. Per observation on 11/4/99 at day training, at approximately 11:15 a.m., R21 was observed being toileted by E27. There were 4-5 small pimple like areas on R21's coccyx and her buttocks between the crack was reddened. E27 was observed applying an ointment she stated was, barrier cream. E27 also stated that about 2 weeks earlier, R21 had been very red in the groin area.
Per review of nurses notes, there are no nurses notes on R21 since 10/26/99 as of 11/19/99. There is no mention of any barrier cream application or any groin area skin excoriation from 9/99-11/19/99.
Per interview with E1, she stated that she would have expected direct care staff to report the redness and ointment application to nursing and for nursing to follow up.
10) Additional examples with regards to lack of nursing services in accordance with individual needs as follows:
a.) R5 is a 33 year old female with Profound Mental Retardation, is non- ambulatory, non-verbal, with Spastic quadriplegia, Contractures, Diabetes Mellitus and Epilepsy. R5 has a physicians order for weekly accuchecks, for which there are none for 9/7/99, 9/21/99 and 9/29/99. R5 has not had a pap smear since 9/27/98. Per her IPP she is to have a nursing schedule to trim her nails (as direct care staff are not to trim her nails due to her diagnosis of Diabetes). Per file verification and confirmed per E3 on 11/18/99, there is no reproducible documentation that nursing is trimming R5's toenails. Above confirmed per E3 on 11/18/99.
b.) R66 is an 81 year old male with Profound Mental Retardation, Congestive Heart Failure, Prostrate Cancer, Cerebral Palsy, Epilepsy, Hypertension and Hypothermia. He has a current physicians order for feet to be elevated when possible. R66 was observed on 11/11/99 in his room before leaving for the day training program and his feet and legs were hanging down and not elevated.
c.) R3 is a 27 year old female with Profound Mental Retardation, is non- verbal and has Autism. R3's last pap smear was completed 5/9/98. The facility failed to provide individuals with nursing services in accordance with their needs.