Facility I.D. Number0037895
7050 Madison St.
Willowbrook, IL 60521
Date of Survey:7/24/01
Notice of Violation:9/6/01
The facility shall have written policies and procedures, governing all services provided by the facility which shall be formulated by a Resident Care Policy Committee consisting of at least the
administrator, the advisory physician or the medical advisory committee and representatives of nursing and other services in the facility. These policies shall be in compliance with the Act and all rules promulgated thereunder. These written policies shall be followed in operating the facility.
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 nursing personnel shall assist residents with safe transfer activities.
An owner, licensee, administrator, employee or agent of a facility shall not abuse or neglect a resident.
A facility employee or agent who becomes aware of abuse or neglect of a resident shall immediately report the matter to the facility administrator.
Employee as perpetrator of abuse. When an investigation of a report of suspected abuse of a resident indicates, based upon credible evidence, that an employee of a long-term care facility is the perpetrator of the abuse, that employee shall immediately be barred from any further contact with residents of the facility, pending the outcome of any further investigation, prosecution or disciplinary action against the employee.
These requirements are not met as evidenced by:
Based on interviews, observations and record review, the facility failed to prevent one of 21 residents (R3) on the Medicare Unit from being handled roughly by 2 employees (E12 and E13).
The facility also failed to:
a) investigate an alleged abuse incident reported to have occurred on July 11, 2001;
b) suspend two employees, the alleged perpetrators;
c) remove the employees from having further direct care contact with residents after the allegations were brought to the attention of the Administrator; and
d) follow its policy and procedures on abuse.
R3 was admitted to the facility on April 5, 2001, with diagnoses of brain damage due to lack of oxygen, Cerebral Vascular Accident, Diabetes, Dysphasia, Dementia with Associated Agitation and Depression, Tracheostomy, and Anoxic Encephalopathy according to R3's Physician Order Sheet of July, 2001, and R3's Admission Record.
On July 14, 2001, R3 was observed between the hours of 10:00 a.m. and 4:00 p.m. intermittently in R3's room. Z3 was also present in R3's room during these times. R3 was up in a wheelchair at 10:30 a.m. and was observed to be clean, dry and alert. There were 2 scabbed areas on R3's knees. According to R3's July 12, 2001, Minimum Data Set, R3 has no range of motion limitations and requires extensive assistance of at least two persons when transferring.
On July, 18, 2001, at 10:45 a.m. in R3's room an interview was conducted with Z3. Z3 demonstrated how E12 and E13 roughly handled R3 while transferring R3 from the bed to the wheelchair. Z3 demonstrated how, at about 1:30 p.m. on July 11, 2001 E12 and E13 put their hands under R3's arm pits and how E12 and E13 grabbed R3 by the side of the neck when R3 began to fall forward. E12 then pulled R3 up. E12 pulled R3's legs to get R3 into a sitting position. E12 and E13 took R3 by the shorts and "plopped" R3 into the wheelchair. E12 shoved R3 back into the wheelchair using her fingers.
On July, 18, 2001, at approximately 12 noon a telephone interview was conducted with Z1. Z1 stated, "I arrived in (R3's) room with (Z2) on July, 11, 2001, about 1:30 p.m. (E12) and (E13) were there and I witnessed the rough handling of (R3) during a transfer by these 2 employees. In my opinion it was abuse."
On July, 18, 2001, at 11:40 a.m. telephone interview was conducted with Z2. Z2 observed a transfer of R3 on July 11, 2001, about 1pm in R3's room. Z2 stated, "Staff pushed (R3) to wall. Bed has no brakes. (E12) pulled (R3) by shoulder. (R3) started to fall forward and then (E12) took (R3) by the neck and pulled him up and tried to get (R3's) legs so (R3) would be sitting. (E12) helped and took (R3) by outer shorts and plopped (R3) into the chair. I was near tears. (R3) started to fall forward. (E12) took her hand and shoved (R3) in the chest to push (R3) back in the chair. Staff left without saying anything. The next day I found black and blue marks on (R3's) right rib and left shoulder. (Z1) informed (E9) approximately 5 minutes after this occurred."
On July 17, 2001, at 10:57 a.m. per telephone conversation Z1 stated, "(E2) yelled at (Z1) and (Z2) to quit Calling IDPH."
R3's care plan dated July 11, 2001, failed to address specific and individualized approaches on how to transfer R3.
E9 was interviewed on July 18, 2001, at 11:30 a.m. in the conference room. E9 confirmed that she had been informed of the rough transfers of R3 on July, 11, 2001. E9 indicated the transfer issues would be addressed with E1 at the scheduled family meeting. The Care Plan Conference was scheduled at or about 1:45 p.m. on July 11, 2001, and the family meeting would be about 3:00 p.m. that day. Review of E1's notes from the family meeting confirmed the incident was discussed and say, "CNA sometimes rough when transferring (R3)."
On July 16, 2001, at 4:30 p.m. in the conference room E2, E10 , E16 and E5 all denied having been made aware of any alleged abuse regarding R3. These facility employees confirmed there had been no investigation regarding any alleged abuse of R3. They also confirmed that E12 and E13 had not been suspended and had continued to work with residents after the alleged incident. Staffing sheets provided by the facility also confirm E12 and E13 had been working on the day of the alleged abuse and had continued to work with residents after that day.
A facility incident report dated on July 15, 2001, revealed that E12 had allegedly hit R1 on her right arm three times during morning care. This alleged incident regarding E12 occurred 4 days after the alleged rough transfer of R3. E12 had not been suspended between these 2 incidents.
The facility's abuse policy says when an employee is suspected of abuse, that employee will be suspended immediately, pending investigation which is to be conducted within three working days of the occurrence.