HERITAGE HOUSE OF CHARLESTON

Facility I.D. Number 0031047
738 18th St.
Charleston, Illinois 61920

Date of Survey 4/05/2000

Complaint Investigation

"A" VIOLATION(S):

The facility shall provide all services necessary to maintain each resident in good physical health. These services include, but are not limited to, the following:

A registered nurse shall participate, as appropriate, in planning and implementing the training of facility personnel.

An ongoing resident record including progression toward and regression from established resident goals shall be maintained.

The progress record shall indicate significant changes in the resident's condition. Any significant change shall be recorded upon occurrence by the staff person observing the change.

An owner, licensee, administrator, employee or agent of a facility shall not abuse or neglect a resident. (Section 2-107 of the Act)

A facility administrator, employee, or agent who becomes aware of abuse or neglect of a resident shall also report the matter to the department. (Section 3-610 of the Act)

1. The facility failed to notify IDPH of a bruise of unknown origin for Z1.

Z1 is a 47 year old female with a diagnosis of severe mental retardation, Autism, Behavior Disorder and Depression. She is ambulatory and nonverbal.

Per review of nurses notes for 05/02/1997 at 8:00 a.m., Z1's right eye, "upper and lower blue/purple with some edema...unable to tell nurse how occurred..."There is no evidence that the incident of unknown origin was reported to IDPH.

Additional examples are as follows:

a. On 05/28/1997, Z1 was found sitting on the floor with "blood on her hands and left side of face... 3/4/cm laceration left side of head...entire left side of face was reddened...left shoulder reddened.

b. On 02/19/1998, Z1 was found with a "3cm knot with hematoma...on left forehead."

c. On 04/29/1998, Z1 had a "purple bruise...lower right eye...unable to tell how this occurred..."

For examples a-c, there is no evidence in Z1's file that IDPH was notified of these incidents of unknown origin.

Confirmed per E2 that she did not notify IDPH of these incidents during this time frame.

2. Nursing neglected to seek medical/physical therapy/occupational therapy services for Z1's contracted hands. Nursing neglected to assess, document and provide continuous treatments for Z1's hands.

Z1 is a 47 year old female with a diagnosis of severe mental retardation, Autism, Behavior Disorder and Depression.

Upon admission the facility in 06/1995, documentation revealed that Z1 had an ICAP score of 4-0. She is noted to be independent with supervision for eating, tooth brushing, bathing, dressing and hair care. Her fine and gross upper extremity (UE) motor skills were intact and her dentition was in good repair.

Upon discharge from the facility in 02/1999, Z1's ICAP score is listed at 2-3. Notes reveal Z1 required staff to feed her, brush her teeth, bath and dress her and provide hair care. Z1's fine and gross UE motor skills were drastically reduced due to bilateral hand contractures. Notes indicate an increase in falls. Z1's last dental evaluation was 03/1998 which diagnosed Z1 as having gingivitis and periodontal disease.

Review of physician, ER and nurses notes revealed: following an injury of unknown origin in 12/1995, Z1's left forearm, hand and three of her four fingers were placed in a cast. On 01/22/1996, the cast was found to have created an ulceration between Z1's pointer finger and thumb. The cast was therefore prematurely removed.

Throughout the time when Z1's forearm, hand and fingers were casted, there are no nurse's notes indicating assessment by nurses of the areas at the immediate openings of the cast to ensure that cast was adequately padded and was not causing ulcerations until 01/22/1996.

Nurse's notes following cast removal indicate that Z1 moved left fingers until 01/25/1996 at which time, notes indicate, "she wouldn't move fingers..." On 01/26 nurse's note indicates that Z1 "continues to keep ring finger bent..." Nurse's notes indicate a follow up visit to the doctor on 02/06/1996. Nursing failed to have a copy of the physician note in the file. Z1 saw the doctor again on 03/05/1996 at which time he planned to schedule surgery on the left ring finger for 03/15/1996. However on 03/15/1996, nurse's notes reveal that the physician called the facility and canceled the surgery. Z1 then returned to see the physician on 03/27/1996 and was subsequently referred to a hand specialist.

Per review of a note sent to the facility by Z2 (guardian) on 03/04/1996, it states that they were "devastated when they saw Z1's hand...very concerned about treatment which surely has been a failure so far..." The note goes on that Z2 had made an appointment for Z1 to see a specialist on 03/13/1996.

In another note from Z2 to the facility dated 03/15/1996, it indicates that Z2 had been very concerned regarding the condition of Z1's left hand and had taken her to her local physician. The note states, "...doctor said it could have been fixed but too much time had gone by...recommended second opinion." Z2 explains in the note her frustration regarding being forced to return Z1 to the facility before the scheduled second opinion could have been obtained. She stated, "...This should be done before any more time is wasted and more damage done." Confirmed per Z2 that she had written the notes. Z2 explained that she had written many such notes to the facility.

Upon return visit to the physician on 03/27/1996 (the one who canceled the 03/15/1996 surgery), he referred Z1 to a hand specialist.

After 02/11/1996, there were no nurses notes indicating assessment planning or appropriate treatment for Z1's.

There is no evidence in Z1's file of nursing requesting a follow up for the left hand to ensure proper healing. There also is no evidence that nursing requested a physical therapy or occupational therapy evaluation for the documented lack of movement.

There is no documentation in Z1's file regarding any hand exercises and no nurses notes assessing Z1's ability to move her fingers and/or use the left hand. Nursing also failed to implement an updated nursing care plan.

Z1 was seen by the hand specialist on 05/09/1996 at which time he recommended QMRP and mother be at a rescheduled appointment on 05/14/1996. At this appointment he recommended Z1 wear a splint on the left ring finger for 24 hours with every two hours off with a 2 minute massage.

Per review of Z1's file, there is no documentation that this Dr. order was implemented. No evidence was found that the nursing care plan was revised to include the splint and hand care. Also, no evidence was found that a nursing assessment for the status of Z1's left fingers was implemented. O 05/19/1996 a nurse noted, "...continues to keep left ring finger bent..."

Z1's nursing care plan in her IPP had not been updated and no PT/OT evaluations had been requested.

Per review of Z1's file, there was no more discussion by the IDT to seek hand specialist recommendations through the point to which Z2 chose not to continue Z1's stay in the facility in 12/1998.

From 06/1996 - 05/1997, there are no assessment of Z1's hands. Note on 05/28/1997 states, "...Hand grasp hard to assess related to contractures..." From 05/29/1997 through 09/1998, there are no nurses notes assessing Z1's left hand condition and her functioning ability.

Per review of Z1's 01/1997 and 12/1997 IPP's, there is no mention of a need for OT/PT services for Z1's hand. In addition, Z1's nursing care plan does not assess Z1's left hand deficits and does not make recommendations for care.

Per review of a 04/03/1998 nurses note, it states, "Right hand-back and fingers-slightly swollen, warm to touch..." On 04/04/1998, a note states, "...less swelling and warmth..." No notes regarding Z1's right hand are noted on 04/05 - 04/08. A 04/09 note indicates no edema and full ROM. A 04/21/1998 nurses note indicates that following a home visit, "...mom complains of client's fingers. PT notified, nurse noted PT attempted to examine hand but client refused to allow treatment." No further nurse's notes regarding the right hand are written until 05/03/1998 which states, "...Right hand +1 edema. Warm to touch..." Notes on 05/04 indicate ongoing edema and state, "...Bruising noted to outer side of hand...holds hand in a half clenched position all the time. Notes indicate improved edema through 05/11/1998 and no further notes regarding the right hand are made. There is no mention of a physician referral or a recommendation for an x-ray noted in the nurse's notes.

Per review of a 04/21/1998 note written by Z2 to the facility, it states, "I can't believe anyone can say her (Z1's) damaged fingers don't need therapy. As I've written before, a minute or two manipulating the fingers...would help flexibility. No one seems to care enough to do this. Do people think she arrived... with these maimed fingers? The latest problem, clenched and what seems to be very painful fingers on her right hand should not be neglected. I worked on them but could not undo in 10 days what happened 38 days ago. Placing a folded washcloth to hold the fingers open helped and she gradually accepted the treatment. Because it seems to hurt badly one has to be gentle-but firm. The knuckles seem less swollen now."

A note from Z2 to the facility dated 07/11/1998 states, "Z1 does not have arthritis. The fingers on her left hand were hurt in December of 1995. Something happened to her right hand earlier this year...it was very swollen and painful. I hoped therapy would help." The note goes on to say that on 06/30 the fingers were worse and had found cold compresses helpful. Confirmed per Z2 that she had written the two notes and many others regarding her concerns regarding Z1's hands.

After the dates of the notes, there remained no changes to Z1's nursing care plan. There is no evidence that the IDT discussed Z2's attempts at providing Z1 relief to her left hand contractures.

Nurse's notes in 09/1998 and 10/1998 indicate that Z1 was refusing to use her right hand for eating, would not dress herself and was intermittently cooperative with the ROM. "Client very anxious and shakes" and "will grimace and whine loudly...pull back from staff..." when they tried to touch the hand.

Z1 continued to refuse PROM through 11/1998 and 12/1998. A note on 11/11 indicated that Z1 pulled hands away and cried.

On 12/23/1998, Z2 took Z1 home and did not bring her back to the facility.

Per interview with Z2, she felt that the facility was not treating Z1 right.

Per interview with Z4, she stated that Z1 went into the facility healthy and came out a zombie with mutilated hands. She stated that Z1 had become skeletal and was prone to falls. Z4 stated that each time Z1 was taken back to the facility, Z2 always gave staff a memo but that nothing ever happened. Z4 stated that when they took Z1 to a neurologist, he informed them that the right hand contractures were a result of a syndrome that happens when a person loses muscle tone in the elbow area. Z2 stated that the contractures were a result of nerve damage from lack of use and being left laying on a hard surface too long. Z4 stated, "Both hands were contracted as a result of neglectful care in the home." Z4 stated that Z1 now has bilateral hand/arm splints with she wears daily and is receiving daily ROM exercises. Z4 stated that Z1's hands have improved.

Nursing neglected to seek medical care and treatment for Z1's hands. Nursing neglected to assess and document the hand deformities. Nursing neglected to seek aggressive and timely PT/OT services for Z1's hands. Nursing neglected to maintain treatment records for the hand treatments. Nursing neglected to update Z1's nursing care plan in her IPP to include the treatment needs for her hands. Nursing neglected to initiate with the IDT any kind of desensitization program for Z1's refusals and neglected to seek a behavioral specialist evaluation for refusals.

3. Nursing neglected to ensure that Z1 maintained good oral care.

Upon admission in 06/1995, Z1's dental evaluation indicates no problems. By 03/1997, the dentist indicates Z1 had "red gums" and needs to brush better. In 03/1998, the dentist diagnosed Z1 with gingivitis with periodontitis and recommended to improve hygiene.

Per review of Z1's IPP, nursing indicates the need for good oral hygiene. However nursing neglected to monitor and ensure oral hygiene measures were carried out. Z1 had no program for oral hygiene.

4. Nursing neglected to contact the physician when Z1 fell in 05/1997.

On 05/28/1997, Z1 was found in the hallway "with blood on her hands and left side of face." A laceration to the left side of head and redness to the entire left side of the face and left shoulder was noted. There is no evidence that the physician was called at the time to report the injuries on this date in the nurse's notes.

Nursing neglected to evaluate Z1's falls thoroughly.

Per review of Z1's file, her Mellaril was increased from 100mg to 200mg on 03/25/1997. Prior to the increase, only one bruise of unknown origin and one fall were documented. Following the increase in the Mellaril, nursing documentation shows 3 bruises of unknown origin, six falls with multiple episodes of suture placement in the scalp and head areas, and two days of unsteadiness where Z1 was hitting her head on walls.

Z1's file shows that Z1 had made repeated written requests to have Z1's medication reduced. In 01/1998, Z2 contacted the physician with her concerns but the IDT disagreed and the medication was continued.

There are no physical therapy evaluations in Z1's file addressing her multiple falls, injuries of unknown origin and bruises.

Nursing did not aggressively seek techniques to help keep Z1 from falling and did not assess reasons for Z1's falls.

Nursing neglected to actively assess reasons for Z1's falls and neglected to seek techniques to maintain Z1's safety.