ELMHURST HEALTHCARE & REHAB CENTRE

Facility I.D. Number 0044818
127 W. Diversey
Elmhurst, IL 60126

Date of Survey 8/03/00

Incident Investigation of 06/25/00

"A" VIOLATION(S):

No resident shall be admitted to or kept in the facility who is mentally ill, in need of mental treatment, and at risk because the person is reasonably expected to self-inflict serious physical harm or to inflict serious physical harm on another person in the near future as a result of the mental illness, as determined by professional evaluation.

The resident's overall plan of care shall be individualized, written in terms of short and long-range goals, understandable and utilized, and their needs met through appropriate staff interventions and community resources.

The facility shall notify the resident's physician of any accident, injury, or significant change in a resident's condition that threatens the health, safety or welfare of a resident.

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.

Objective observations of changes in a resident's condition, including mental and emotional changes, as a means for analyzing and determining care required and the need for further medical evaluation and treatment shall be made by nursing staff and recorded in the resident's medical record.

All nursing personnel shall evaluate residents to see that each resident receives adequate supervision and assistance to prevent accidents.

Each resident shall have an up-to-date care plan based on the resident's comprehensive assessment, individual needs and goals to be accomplished, physician's orders, and personal care and nursing needs. 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 facility shall not neglect a resident.

These requirements are not met as evidenced by:

Based on medical record review, facility staff and resident interview, review of the police report, interview with the Coroner's Office, and review of the facility's staff written statements, the facility failed to:

1. adequately supervise R1, who committed suicide on 06/25/00;
2. complete an accurate/comprehensive assessment for R1, who had a clinical history of depression and had a history of attempted suicide;
3. provide crisis intervention services for R1 when the family made the facility aware of R1's suicidal ideations; and
4. have available individual or group psychotherapy programs to assist R1 with history of depression and attempted suicide and an immunocompromised diagnosis.

Examples include:

Interview on 7/12/00 revealed that R1 was found by his roommate, R5, on 6/25/00 lying on the bathroom floor in room 217 at 11 p.m. with linen strips tied around his neck. These linen strips were observed to be tied around the grab bars of the toilet. Interview with Z4 of the DuPage County Coroner's Office on 7/5/00 revealed the preliminary report documented the cause of death was from strangulation. R1 had committed suicide by strangulation on 6/25/00.

Review of the Elmhurst Police report dated 6/25/00 at 2328 noted upon arriving to room 217 the paramedics leaving, Z6 and z7, said, "there were no vital signs found" for R1. "It appeared he had been dead for some time." The report continued to read that entered the bathroom accompanied by E12, the nursing supervisor. R1 "was laying on the floor to the left side of the toilet". R1 "had white strips of material tied around his neck and the other end of this material around a railing by the toilet." R1's "head was off the floor. The bathroom sink was off the wall and there was water on the floor." Z9 "took R1's bed sheet from the bed. That is where the make shift rope came from."

Interviews with facility staff on 7/12/00 and 7/13/00 in the facility's conference room reflected the following:

1. E7 stated, "I went to his room because he usually comes to the nurses station to get his medicine. This was between 10 and 10:30 p.m. I found R5, his roommate, and asked if he had seen him. R5 stated no, so I began a search for him. I told E12, the evening supervisor, and we began to do a building search. We checked all the floors and outside the building. Upon reentering the building after the search I overheard a page for staff to come to room 217. I found him slouched over the toilet, white linen cloth tied around his neck and to the toilet railing. P.M. supervisor was on the unit as she responded to the overhead page and called 911." E7 stated seeing R1 at 5 or 5:30 p.m. at dinner. E7 admitted not checking the bathroom when she went to look for R1 at 10 or 10:30 p.m. This was also verified through a written statement by E7 on 6/26/00.
2. E1 presented written and typed statements from staff on duty the night of 6/26/00. E12's typed statement dated 6/25/00 and written statements dated 6/25/00 verify that R1 was found by R5, who was yelling in the hallway of room 217. E1 stated E12 did not search the bathroom once when R1 was found missing.
3. E15 stated on 7/13/00 via phone interview that 6/25/00 was the first time working on that unit. E15 admitted never seeing R1 until 8 p.m. E15 said R1 was in room 217 looking out the window and his back was to her. E15 asked R1 if he needed help and he nodded his head no. When questioned E15 stated she would not have been able to identify R1 as she never saw his face. E15 stated when given report was told by the nurse, E7, that R1 was self care. E15 stated that went to room 217 on 2 occasions to look for R1. This was at the beginning of the shift and again around 10 p.m. E15 stated she "did not search the bathroom."

The facility failed to provide adequate supervision for R1.

Medical record review on 7/12/00 and 7/13/00 revealed R1 was a 39 year old resident admitted to the facility on 5/20/00 with the following diagnoses: Depression, Human Immunodeficiency Virus, Parkinson's Disease, Cerebral Vascular Disease, Pain, Hepatitis C and Seizure Disorder. Interview with nursing administration on 7/12/00 revealed R1 lived in California with a friend for 8 years independently in an apartment before being admitted on 5/20/00. R1's family was concerned of R1's deterioration and safety and was instrumental in getting R1 to return to Illinois, stated E1.

Review of R1's medical record on 7/12/00 revealed R1 had a former history of suicide attempts. This was documented in a progress noted dated 12/19/98 from GOOD SAMARITAN HOSPITAL that stated resident had attempted suicide many times in the past. Per interview with E1, Director of Nurses; E2 and E4, social service staff; and E3, administrator, on 7/12/00, they stated they did not have knowledge of R1's attempted suicide history upon admission to the facility on 5/20/00.

Per review of R1's nurse's notes of 6/10/00, R1's mom called the facility concerned about suicidal threats R1 made to a friend in California during repeated telephone conversations R1 had with his friend on 6/10/00. Record review and interview with the facility nursing and administrative staff revealed the facility failed to notify R1's physician of this.

R1's physician Z2, stated he was not told by the facility about the resident's psychiatric history or suicidal behavior until being informed on 6/26/00 after R1's death. Z2 stated he would have ordered an emergency psychiatric evaluation or emergency admission to the hospital on 6/10/00. Interview with E1 revealed on 6/10/00 E12 failed to notify administration about the family's concerns of suicide. E12 and E4, social services, stated became aware of the occurrences dated 6/10/00 on 6/12/00. E4 stated became aware on 6/12/00 when R1's mother called.

She was still worried about R1 because he had attempted suicide many times. E4 stated was not made aware of this by nursing staff even though the nurses notes dated 6/10/00 noted endorsement to the night nurse to contact social service about this.

The facility did not implement suicide precautions or suicide watch for R1. This was verified through interviews with E1, E2, E3, E4 and E5. These staff members stated the facility did not have suicide policies and procedures until after the suicide of R1. The facility was notified 15 days prior to the suicide occurring that R1 had a potential to commit suicide.

R1's medical record was reviewed on 7/12/00 with social service staff present. There was a cognitive loss Resident Assessment Protocol (RAP) dated 6/1/00 completed by the social service staff that documented R1 as having had a history of drug overdose, extensive history of drug and alcohol abuse, isolative behavior, prefers to stay to himself, rarely interacts with others and prefers to spend time in the smoking room and watching television. There was a check mark on the cognitive loss RAP dated 6/1/00 that indicated that R1 could benefit from participation in small group activities.

The mood assessment, page 1, indicated that R1 was in a behavior control program and that this was effective in reducing target behavior. Interview with E4 on 7/12/00 revealed that this only meant R1 would have a care plan developed. Review of the care plan with E4 and E2, social service staff, on 7/12/00 revealed there was no care plan developed for behavior control/suicide.

A psychotropic drug RAP dated 6/1/00 read resident has slurred speech, depression secondary to HIV status and no signs and symptoms of Parkinson's Disease, i.e. tremors, postural unsteadiness, muscle rigidity. This was noted to be an inaccurate statement found through interview of the nursing and social service staff. The record noted R1 to have a problem making self understood and understanding others.

The activity RAP completed on 6/14/00 by the activity staff documented "NO" to the following questions: has resident experienced loss of a close friend, was daily routine very different from prior pattern in the community, and use of psychoactive medications. These were inaccurate assessments. Interview with nursing staff revealed that R1 would spend time smoking and did not participate in activities. The activity Resident Assessment Protocol of 6/14/00 noted R1 to spend little or no time in activities.

Review of R1's mental and psychosocial assessment, progress notes, and care plan and interviews with E2 and E3 on 7/12/00 revealed the facility did not accurately assess R1 for mental/psychosocial difficulties and failed to provide services to meet this resident's psychosocial needs.

The facility staff (E1, E2, E3 and E5) stated on 7/12/00 and 7/13/00 per interviews that they did not have programs/groups to deal with a resident with this type of behavior and history.

The facility staff acknowledged that they did not have available the staff or have programs developed to meet this resident's needs and had not implemented crisis intervention services for R1 on 6/10/00. The administrative staff stated this type of resident should not have been admitted because the facility was not equipped to handle this type of resident.