MEADOW MANOR ID NUMBER 0011528 800 MCADAM DRIVE TAYLORVILLE, IL 62568 As a result of a annual survey and a complaint investigation conducted on December 8, 1998, by representative(s) of the Department, it has been determined the following violations occurred. "A" VIOLATION(S) 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. These requirements are not met as evidenced by: Based on clinical record review, incident report review, facility investigation report, review of the facility policy/procedure on abuse and staff interview it was revealed an aide was allowed to continue working after it had been reported the aide was abusive to a resident. Findings include: Review of R24's clinical record revealed documentation, 11/16/98, at 2140 a CNA reported another CNA was rough with R24 when putting R24 to bed. CNA stated CNA has picked R24 up under arms and flopped him in bed over the siderails; No injury. Record review revealed R24 has a diagnosis, in-part, of cerebral palsy, mental retardation due to cerebral palsy, seizure disorder and muscular incoordination due to contractures. R24 is 46 years of age, weighs 61 lbs. and is dependent for all needs. Review of R24's incident report, for 11/16/98, revealed incident happened 2030 and was mentioned to the writer (E8) of the incident report at about 2140; CNA mentioned that he felt another CNA was "too ruff" when he put resident to bed. Stated CNA picked resident up under the arms and just flopped him in bed over the siderails. Review of the facility investigation, done by E1, revealed on 11/17/98 E1 was notified by the Director of Nurses of statement by E6 CNA; stated the previous evening he had seen E7 pick up an invalid resident (R24) up under the arms and toss him over the bedrails and into bed; stated he thought R24 had bounced when he hit the bed; stated he reported to the LPN (E8) that evening and she stated to tell the Director of Nurses the next day. Facility investigation report revealed E7 admitted picking R24 up under the arms, lifting him over the bedrails but denied throwing or tossing R24 in any matter. E1 reminded CNA picking up under the arms is not proper procedure. CNA's employment was terminated. Facility investigation report revealed E1 spoke to the LPN (E8), 11/17/98, as E8 was the nurse in charge 11/16/98; she did not think of incident, with R24, as abuse at the time; nurse was suspended without pay for 3 days. Review of the facility policy and procedure for abuse revealed any allegation of abuse results in the person accused to be removed from working until an investigation is completed and the alleged abuse is to be reported immediately to administration. Facility failed to immediately remove the CNA from working when the allegation of abuse was brought to the charge nurses attention as he was allowed to work the remainder of his shift (2-10p.m.) and did not report the abuse immediately to administration. The facility shall provide a Resident Services Director who is assigned responsibility for the coordination and monitoring of the resident's overall plan of care. The director of nurses or an individual on the professional staff of the facility may fill this assignment to assure that residents' plans of care are individualized, written in terms of short and long-range goals, understandable and utilized, their needs are met through appropriate staff interventions and community resources; and residents are involved, whenever possible, in the preparation of their 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. Personal care, as defined in Section 300.330, shall be provided on a 24-hour, seven day a week basis. Based on observations, record review, review of incident reports, and staff interviews it was determined that the facility does not ensure adequate supervision to prevent accidents. Findings include: R23 is a 78 year old individual admitted to this facility on 10-27-98 with diagnoses that include: Alzheimer's Disease, Depression, Gastroenteritis, Polymyalgia, Cerebral Infarction, Dehydration, hypokalemia, and history of urinary sepsis. Based on R23's 11-06-98 MDS, R23 has short and long term memory problems and is moderately impaired with her cognitive skills for daily decision making. R23 had behaviors present in each category of MDS (Minimum Data Set) section B.5. with a noted deterioration of R23's cognitive status. R23 was noted to have "Indicators of Depression, Anxiety, Sad Mood" in 12 of 16 available categories per her Minimum Data Set (MDS). Review of R23's nurse's notes revealed that on 10-28-98 R23 was attempting to elope...that R23 "...very confused, insisting on standing in highway...." On 10-30-98, nurse's notes indicate that an appointment was made for a mental health evaluation due to R23 being on "suicide watch". R23's guardian refused the psych. eval being completed. Per review of nurse's notes, R23 would make elopement attempts from the A and West wing doors. On 11-10-98, when resident was attempting to leave, resident indicated "I don't want to be here." Thirty minutes later, at 1500, R23 was again attempting to leave the facility. At 15:30, R23 again tried to leave--thru the dining room door this time. At 17:30, R23 tried to leave thru the front door became combative with increased agitation and stated "Let me go, I want to throw myself in front of the truck"--per nurse's notes the resident was pointing at train across highway. Nurse's notes indicate that on 11-17-98 at 1800 "Notified by visitor that resident was outside of facility. Resident found by YMCA building. Resident brought back into facility without incident. Res [checked] for injuries, none noted at this time. Res denies discomfort." Resident's POA(Power of Attorney) was notified of the above occurrence. This facility is located very near a busy highway to the front of the building(Old Route 48 N). Just on the other side of the highway is a set of functional and used train tracks. The speed limit for this highway is 45mph. Just behind the facility is Route 48. The YMCA is located at least 150 yards from the back of the facility. Per interview of E2, E1 was working the evening of this occurrence. E1 had heard the door alarm go off and it was the west door alarm. Per E2, she was told that E1 checked the west door, saw no one and then re-set the door alarm. Per interview of E1, E1 was working the night of this occurrence. E1 indicated that he heard the alarm go off, but before he could get from behind his desk to go check, it had been re-set, so he figured that either an employee or a visitor had set it off and re-set it. He then indicated that it was approximately five minutes later that an individual that apparently had been at the YMCA drove to the facility, parked, came in, and told staff that there was a resident over at the YMCA. On 11-18-98 R23 indicated at 12:30 that all her family was dead. Then later R23 indicated that she wanted some string so she could "hang herself". Then later R23 indicated "Just let me die please just let me die." R23's MD was notified at that time(1425). POA(Power of Attorney) was notified and gave permission for R23 to receive Chlorpromazine 50mg IM(intramuscular); POA also agreed that R23 should have a psychiatric evaluation, but wanted to discuss it with the physician first. At 16:15 R23 was again trying to leave the facility. By 17:30 R23 was indicating --when she refused to eat her evening meal "No, I said I leaving I will kill myself by mid-noc. Do you hear me" POA was at facility by 17:40 and inquired if R23 was still on "Paxil". R23 was not (apparently resident had been on this medication for about two years--since her husband died; this medication was discontinued while R23 was in the hospital --the physician had tried to discontinue as many medications as possible due to R23's confusion). Resident indicated that "I'm going to make a thousand slits on my wrist. I'm gonna die I have no purpose in life. I don't want to be a bother I'll slice my wrist and be gone. There will be plenty of money for the rest of them." Periodically, R23 was placed on "suicide watch" which means her whereabouts were checked every 15 minutes. The facility failed to consistently have R23 on a suicide watch; nor did facility aggressively seek a mental health evaluation for R23. Per staff and other interviews, there were indicators that R23 was to be involved in activities that she had used to enjoy--such as crocheting and knitting. Per interview of Activity Director on 12-04-98, these things had not yet been implemented with R23 because the activity director had been busy with other items in preparation for the Holiday Season. 2) On 12-03-98 at approx. 12:40p.m. while pericare was being provided to R37, staff left the siderail of R37's bed down and walked away to the bathroom. Per review of R37's record, R37's diagnoses include: Senile and Presenile Organic Psychotic, Alzheimer's Disease, and Psychomotor Agitation. R37's care plan indicates that R37 is at risk for falls and has poor balance. She has decreased mobility, decreased vision, and poor judgement. M.D. orders include to "always practice safety" and "side rails up as needed". 3) On 12-03-98 at approximately 3p.m. R14 had been incontinent. R14 was placed on the stool in the bathroom. R14 was left on the stool alone while staff went into her room to acquire clothing. R14 uses a lap buddy when up in wheelchair and uses siderails and a personal alarm when in bed due to balance problems. R14's diagnoses include: Dementia, Generalized Osteoporosis, Left and Right hip fractures, seizures, and paranoid schizophrenia. Each facility shall: Maintain the building in good repair, safe and free of the following: cracks in floors, walls, or ceilings; peeling wallpaper or paint; warped or loose boards; warped, broken, loose, or cracked floor covering, such as tile or linoleum, loose handrails or railings; loose or broken window panes; and any other similar hazards. Maintain all electrical, signaling, mechanical, water supply, heating, fire protection, and sewage disposal systems in safe, clean and functioning condition. This shall include regular inspections of these systems. Every facility shall have an effective plan for housekeeping including sufficient staff, appropriate equipment and adequate supplies. Keep the building in a clean, safe, and orderly condition. This includes all rooms, corridors, attics, basements, and storage areas. Hot water available to residents at shower, bathing and handwashing facilities shall not exceed 110 degrees Fahrenheit. These regulations are not met as evidenced by: Based on observations, staff interviews and record review the facility failed to maintain areas of resident-use in a safe manner (i.e., hot water in excess of 110 degrees Fahrenheit (F), hallways having handrails blocked and a grab bar loose). Evidence includes: Excessively hot water was noted on 12-2-98 at the sink and tub hot water fixtures in the group toilet/tub room on C hall ("Bath C"). At 1:05 P.M. the hot water was measured to be 175 degrees (F) with thermometer number 406. The water temperature held to this maximum consistently during the temperature measurement period of at least 3 minutes time. This group toilet/tub room is located on a resident-use hall in the main building approximately 30 feet from the main entrance and the front nurses station. Six resident rooms are on this hall and 8 residents currently reside in these rooms. The door to the group toilet room was wide open at the time of the observation and there was no staff monitoring the area. No residents were in the area at the time of the observation. Administrative staff (E5) were notified right after the observation and within 20 minutes E5 drained all the hot water from the hot water heater and shut off the heating element. The situation was remedied in this manner at 1:25 P.M. The hot water heater has a capacity of 10 gallons, supplies the fixtures mentioned above only, and is located in this toilet/tub room. Other resident hot water fixtures were checked in various resident rooms and toilet/bathing facilities within the building and all but one were within the required range (100-110 degrees F). The toilet room between resident rooms' 20 and 21 had a sink hot water fixture with hot water measuring 117 degrees (F). E-5 indicated that he had been in "Bath C" first thing in the morning and noticed that the water was cold and not producing hot water at all. He indicated that he had made some adjustments to the heaters controls to try to get the heater to work. He indicated that he had just checked the water temperature before lunch and it was still producing cold water only. Maintenance personnel were not available for interview on the day of the observation. The facility's water temperature log was reviewed and showed that weekly checks are made on Mondays at hot water outlets. All the temperatures, as of Oct. 1998, were documented to be within the required range, or at least not more than two or three degrees above the 110 degree (F) maximum. For "Bath C" the temperature log showed the following recorded temperatures (in degrees F): Oct. 5th-110; Oct. 12th-104; Oct. 19th-110; Oct. 26-110; Nov. 2nd-100; Nov. 9th-110; Nov. 16th-105; Nov. 23rd-left blank; Nov. 30th- left blank. On 12-3-98 E-4 was interviewed and he indicated that the hot water heater had been worked on by plumbers, in the recent past, due to not producing any hot water at all. He indicated that the heater has never had problems with producing excessively hot water. He indicated that the reason for the blanks left in the temperature log, for "Bath C", was that the water was completely cold at first check on those days so he hit the reset button on the unit and checked the temperature later in the day. He indicated the temperatures were fine later but he neglected to go back and document in the log book. He indicated that he did not know what kind of work the plumbers did and that the billing paper work for those visits is handled by E1. E1 indicated that the facility's Springfield office would have that paper work. On 12-3-98 a plumber was noted to be working on the hot water heater in the late afternoon. On 12-4-98, at 10 A.M., a sign was observed taped to the hot water faucet on the sink in "Bath C" reading "Out of Order". No sign was observed at the tub faucet. The temperature of the water for the "Bath C" outlets was measured by surveyor, with Thermometer # 006. The temperature was 130 degrees (F). E1 was notified and he immediately drained the water. According to E1's above-mentioned written statement, the plumber said, on 12-3-98, that the water heater was O.K. as far as he could tell, but the mixing valve was plugged up on the cold side so he cleaned it. The statement goes on saying that he then turned the water heater on to let it warm up (it was at 105 degrees F) but due to the lateness of the day the facility decided to turn the unit off for the night. On 12-4-98 the water heater was turned on at 7:30 A.M. The statement says staff took temperatures at 8:00 A.M. (it was at 100 degrees F) and at 8:15 A.M. (it was at 130 degrees F). Maintenance was called at that time to make adjustments. Adjustments were made so the heater produced 110 degrees (F) water by 8:30 A.M. At 8:50 A.M. a recheck showed the temperature to be 120 degrees (F). The water heater was adjusted again by maintenance to 109 degrees (F). At 9:30 A.M. the temperature was 130 degrees (F), the unit was unplugged and plumbers were called by the facility. The statement indicates "all this time the faucet was covered by a sign marked Out of Order." At 10:00 A.M. (at the time of the surveyor observations and prompting to immediately remedy the excessive hot water) the statement reports that E1 drained the water heater of its hot water and shut off the valve supplying the hot water. At 1:00 P.M. E1 called the plumbers again. At 1:40 P.M. the plumbers called saying they were on their way. Finally, the statement indicates that once the water heater was fixed properly the water will be monitored 2 times per day and the unit would be shut down if it reaches temperatures above 110 degrees (F) until fixed. 2) There are 8 residents residing on C hall at this time. Their rooms are all 40 feet or less from the Group "Bath C." Five of the 8 have impaired cognitive abilities and have wandering behaviors. A) R39's room (28) is located across the hall from "Bath C." Her record shows diagnoses including Advanced Dementia (Alzheimers type) and Depression, with delusions. Her record indicates she hears voices at times and has poor vision. 1998 monthly Nurse notes indicate: "11/16- ambulates w/walker gait slightly unsteady needs standby assist"; "9/19- ambulates w/walker but needs hands on & constant direction"; "8/26- ambulation has gotten worse e.g., her running into walls as opposed to staying in mid hallway." Her quarterly Minimum Data Set (MDS) assessment of 11-20-98 reveals R39 to have cognitive skills for daily living that are "severely impaired", wandering behavior that "occurs daily", that she is awake "most of the time" (morning, afternoon, and evening), and that her level of activity involvement is at the "none" level. B) R56's room is located about 40 feet from Group "Bath C." She has diagnoses including Alzheimers, with agitation, Anxiety, and Diabetes. Nurses notes indicate, "11/27- Alert, w/confusion...ambulates independently but needs direction and physical assist at times." Social Service notes indicate, "10/15- continues to deteriorate cognitively...short term & long term memory has worsened." R56's MDS quarterly assessment of 10-16-98 reveals she is moderately impaired cognitively, that wandering occurs 4 to 6 days a week, and she is awake most of the time morning, afternoon, and evening. C) R4 and R14 are both assessed to have severe cognitive impairments and they have wandering behaviors 1 to 3 days a week (per their recent MDS). They both can ambulate independently by propelling their wheelchairs. R4's record indicates she wanders into other's rooms. D) R38 has a Diagnosis of Schizophrenia, with paranoid features. She is assessed to have moderate cognitive impairments. She has no wandering behaviors indicated but she has 4 of 6 indicators of delirium assessed as problematic on her recent MDS (Her schizophrenia causes periodic disordered thinking/awareness). 3) Nursing staff indicated that there are about 20 residents, residing in the main building (all having access to "Bath C"), who can independently ambulate, or propel themselves, and are confused. E2 indicated that at least 5 wander into other's rooms and have to be closely monitored for wandering behaviors within the building (R4, R21, R23, R26, & R27). On 11-12-98, in the main building in the group bath/toilet room (labeled "Bath B-2") the grab bar at the toilet site was not attached securely to the wall. The grab bar moved about one inch when weight was applied to it. E-1 indicated they have had to re-secure this wall grab bar before. He indicated the staff would find a way to secure it with a metal plate or something so it would stay secure and not loosen. No incidents or accidents were noted, per incident report review, resident record review, or per staff or resident interviews, which related to this loose grab bar. The facility staff re-secured the grab bar when the loose grab bar was pointed out to E-1 on 11-13-98. 4) B and D halls in the main building were observed with items stored on both sides of the halls making the handrails inaccessible for resident use. On 12-2-98, during the noon meal, B hall was observed with 3 resident wheel chairs on one side of the hall and a laundry barrel and an isolation cabinet on the other. The handrails were inaccessible for this portion of the hall. Also on 12-2-98, in the afternoon, 3 portions of D hall were observed with similarly inaccessible handrails. Along the stretch of hall, between rooms 41, 42, 43, and 44, a storage cart was on one side of the hall and a laundry barrel was on the other side of the hall. Along the section of hall, with rooms 37, 38, 39, and 40, a Geri-chair was on one side of the hall and an isolation cabinet was on the other. Finally, along the section of hall where rooms 32, 34 are located, 2 isolation cabinets were observed on one side of the hall and a patient lift and a linen storage cart were observed on the other side. The total hall length, on these 2 halls where handrails were observed inaccessible, was measured to be approximately 50 feet. To use the handrails along the whole length of D hall and most of B hall a resident would have to maneuver around objects and/or traverse across the hall in an attempt to maintain contact with the handrails. On 12-3-98 the halls were in the same condition and the problem was pointed out to E1 and E2. The halls had one side clear for easy handrail use that afternoon. On 12-4-98 the halls were noted to have the handrails in an inaccessible condition, with items stored on both sides of the halls in a very similar pattern to the observations noted on 12-2-98. Residents in wheelchairs were observed to have to traverse back and forth across the sides of the halls to maintain contact with the handrails which they used to pull themselves along. The situation was again pointed out to facility staff with a prompting that the halls need to remain completely clear on one side at all times. "B" VIOLATION(S) 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. These requirements are not met as evidenced by: Based on clinical record review, incident report review, facility investigation report, review of the facility policy/procedure on abuse and staff interview it was revealed an aide was allowed to continue working after it had been reported the aide was abusive to a resident. Findings include: Review of R24's clinical record revealed documentation, 11/16/98, at 2140 a CNA reported another CNA was rough with R24 when putting R24 to bed. CNA stated CNA has picked R24 up under arms and flopped him in bed over the siderails; No injury. Record review revealed R24 has a diagnosis, in-part, of cerebral palsy, mental retardation due to cerebral palsy, seizure disorder and muscular incoordination due to contractures. R24 is 46 years of age, weighs 61 lbs. and is dependent for all needs. Review of R24's incident report, for 11/16/98, revealed incident happened 2030 and was mentioned to the writer (E8) of the incident report at about 2140; CNA mentioned that he felt another CNA was "too ruff" when he put resident to bed. Stated CNA picked resident up under the arms and just flopped him in bed over the siderails. Review of the facility investigation, done by E1, revealed on 11/17/98 E1 was notified by the Director of Nurses of statement by E6 CNA; stated the previous evening he had seen E7 pick up an invalid resident (R24) up under the arms and toss him over the bedrails and into bed; stated he thought R24 had bounced when he hit the bed; stated he reported to the LPN (E8) that evening and she stated to tell the Director of Nurses the next day. Facility investigation report revealed E7 admitted picking R24 up under the arms, lifting him over the bedrails but denied throwing or tossing R24 in any matter. E1 reminded CNA picking up under the arms is not proper procedure. CNA's employment was terminated. Facility investigation report revealed E1 spoke to the LPN (E8), 11/17/98, as E8 was the nurse in charge 11/16/98; she did not think of incident, with R24, as abuse at the time; nurse was suspended without pay for 3 days. Review of the facility policy and procedure for abuse revealed any allegation of abuse results in the person accused to be removed from working until an investigation is completed and the alleged abuse is to be reported immediately to administration. Facility failed to immediately remove the CNA from working when the allegation of abuse was brought to the charge nurses attention as he was allowed to work the remainder of his shift (2-10p.m.) and did not report the abuse immediately to administration.