LAKESIDE BOARDING HOME
Facility I.D. Number: 0038927
6330 North Sheridan Road
Chicago, Illinois 60660
Survey Date: 8/6/99
Complaint Investigation
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;
Who has serious mental or emotional problems based on medical diagnosis.
Sufficient staff in numbers and qualification shall be on duty all hours of each day to provide services that meet the total needs of the residents. As a minimum, there shall be at least one staff member awake, dressed, and on duty at all times.
The facility shall notify the physician of any accident, injury, or unusual change in a resident’s condition.
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.
These requirements were not met as evidenced by:
Based on chart review, staff and resident interview, review of the facility policy, it was evident that the facility staff allowed R16 to reside in the facility when his psychiatric illness was not controlled on medication, and while he was making threats (both verbal and physical) towards the other residents in the building who admitted to Surveyors that they were afraid of R16. R-16 injured R35 and R36 with a knife on 7/30/99. Per interview, review of records, the facility has failed to have staff on duty at all times.
R16 had not been taking his medication regularly because he spent large amounts of time out of the facility wandering the street and panhandling for drugs per staff interview with E3. Per staff interview with E2, E3, E6 on 8/3/99, all stated the R16 had not taken meds regularly “for about four weeks now.” E2, E3, E6 also admitted that they were aware the R16 had started to carry a brown handled knife approximately 12" to 14" long in his pants waist line with the brown handle visible “for about two weeks.” In fact, the staff were concerned enough about this treat that they wanted to initiate an emergency transfer to Vencor Hospital on 7/9/99, noting on the transfer sheet the R16 was “harmful to self and others, non compliant with meds/adl’s/meals”. This transfer never occurred because R16 went out into street and couldn’t be located. There is no evidence that the facility ever followed up or acted on their fears after this date–even though the resident was in and out several times between 7/9/99 and 7/30/99. Staff admitted telling E1 their concerns. E1 stated nothing was done because R16 was not found with knife or was absent from facility.
When R16 then left the building as was his usual behavior, the facility failed to follow up and take further necessary action to safeguard the 32 residents as well as safeguard R16 who was documented as non-compliant with his medication of Seroquel 200 mg 8:00 a.m., 100 mg at noon and 4:00 p.m., as well as Lithium 600 mg twice per day. Previous psych history shows that when he becomes non-compliant, he becomes manic and delusional.
There was evidence that R16 had a significant change in his condition and was impulsive and threatening both to residents and staff. There were no provisions or plan on how to deal with R16 when he returned to the building which he did often, thus putting everyone at risk, since it was known that he carried a weapon.
Z1 was not notified for input while this was going on.
On 7/30/99, R16 cut two residents with this knife in an unprovoked manner in the facility. R35 was cut across face and lips. R35 was sent to Edgewater Hospital for suturing per the paramedics. R35 complained to surveyors on 8/4/99 that it still is very difficult for him to eat and swallow with the swollen mouth. R36 was sleeping in his bed when R16 cut him across the left shoulder. The cut required 10 sutures at the hospital. R36 admitted to Surveyors he is still very frightened and never had any words with R16 who he ignored generally. R36 has some difficulty in sleeping because of the attack.
R16 did finally return to facility 8/1/99 and continued to be delusional and threatening. Surveyors were told that when residents saw R16 enter the building, they were told by other residents such as R36 and R3 to “get behind your door and get out of the way” because “he’s gone crazy”. Residents R3 and R37 called 911 and police who attempted to calm R16 and get his weapon also and became injured by cutting which led to the unfortunate shooting death of R16.
R16 got into an altercation with police and was shot and killed when he wounded police and refused to give up his weapon.
There is evidence that at time of resident injury on Friday night approximately 9-10 p.m., there was no staff in building and both R37 and R3 told Surveyors that they were the ones that called paramedics for the emergency. E1 admitted that he left the facility before the evening staff arrived on 7/30/99. There are no staff schedules or time cards.
Facility failed to identify and act upon the change in R16's condition thus exposing all 32 residents and staff to possible threat of harm. Actual harm did occur to two residents who remain fearful several days after the unprovoked attack.
Surveyor reviewed facility policy that states no person shall live in the facility who is destructive, disturbs others, manifests hostility, has serious mental problems, or who is a narcotic addict- characteristic that R16 exhibited, and facility staff were well aware of R16 had numerous psych admissions while at the sheltered care home. R16 also known to have been in jail for crack cocaine possession. R16 documented to have returned to facility intoxicated at times per nursing progress note. Finally, there is a note from the social service staff indicating on 6/8/99 that R16 needs “a more structured environment at this time” that was also not acted upon by the facility.
Surveyors interviewed residents who saw R16 with the knife and kept away from R16 fearful of what he would do as they also recognized that he was getting more “out of control” per R3, R36, R37.
Surveyors interviewed Z1 who last saw R16 on 7/16/99. Z1 denied that the facility staff had informed her of the fact that R16 was known to be carrying a knife and making threats. Z1 denied that facility called her on Friday 7/30/99 after R16 had cut the two residents. Z1 stated she did not know that facility staff were concerned enough about R16's behavior to be considering an admission on 7/9/99. Z1 stated that had she known about all these assessments and facts, she would not have stated on the progress notes that R16 was not a threat or behavior problem at this time. Z1 felt the facility should have called the police.
Finally, in conclusion, the facility continued to keep R16 in the facility thus failing to protect the other 32 residents in the facility from threat of physical and verbal harm. The facility also failed to seek prompt treatment for R16 when he began to exhibit change in his condition. The facility failed to notify the MD, or Public Health of the changes because for this resident, when he stops taking his meds, it is well documented that he then becomes psychotic mixed with mania. The facility failed to notify Public Health of the injury to the other two residents. Failure to recognize and act on R16's behavior led to injury not only for the two residents but to death for R16 when the police could not talk him into giving up the weapon.