NORTH PLAZA NURSING CENTER

Facility I.D. Number 0045021
438 West North Street
Decatur, IL 62522

Date of Survey: 07/12/01

Notice of Violation: 09/20/01

Complaint Investigation

"A" VIOLATION(S):

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 residents’s medical record.

All necessary precautions shall be taken to assure that the residents’ environment remains as free of accident hazards as possible. All nursing personnel shall evaluate residents to see that each resident receives adequate supervision and assistance to prevent accidents.

Planning an up-to-date resident care plan for each resident based on the resident’s individual needs and goals to be accomplished, physician’s orders, and personal care and nursing needs. Personnel representing other services such as nursing, activities, dietary, and such other modalities as are ordered by the physician, shall be involved in the preparation of the resident care plan. 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 plan shall be reviewed at least every three months.

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 regulations are not met as evidenced by:

1. R1's record review revealed a social service progress note dated 5/24/01 documenting R1's admission. The note documents that R1 is "verbally and physically abusive to staff" and that R1 is "sexually socially inappropriate to staff". A physician progress note from the previous facility dated 4/24/01 documents that R-1 was "still having a lot of sexual behavior problems" and that R1 has "chronic psychological problems and schizophrenia and behavior problems". A Resident Assessment Protocol (RAP) for behavior problems dated 6/6/01 documents that "Resident is sexually aggressive to staff and confused residents. Resident is also verbally abusive to staff and peers at times".

Review of nurse's notes revealed documentation on 6/23/01 that R1 was exhibiting "inappropriate behavior" with a female resident. An entry dated 7/2/01 at 5:00 p.m. documents that a CNA (certified nursing assistant) had reported that R1 had "inappropriate sexual behavior towards several female residents" and that R1 was "attempting to place mouth in breast area". An entry dated 7/4/01 at 3:30 p.m. documents that R1 was "found fondling another female res. this a.m." 7/5/01 at 3:30 p.m. it is documented that another resident reported that R1 was in the hallway fondling a female resident's breasts. Behavior log includes an undated note documented by E6 that R6 was crying and claimed that R1 had touched her breast. Interview with E6 on 7/6/01 at 11:45 a.m. revealed that this incident occurred on 7/5/01. Review of R1's record on 7/6/01 revealed no documentation of physician notification of these incidents.

Review of R1's care plans on 7/6/01 revealed that R1 has a care plan dated 6/14/01 which states that R1 has a "long history of sexual aggression along with sexual abuse. Makes sexual advances and statements to staff". There is nothing in R1's care plan regarding sexually inappropriate behavior towards other residents. There is a "Behavioral Observation Monthly Flow Chart" for July 2001 which documents that the behavior to be tracked is "sexually inept w/staff and female res". It is documented that this behavior occurred daily from 7/1/01 to 7/5/01 and outcome is coded "2" indicating that the behavior continued. The area on the form where interventions are to be designated is blank. There are no behavior flow charts for prior to July 1, 2001 and this was confirmed in interviews with E1 and E3 on 7/10/01 at 1:25 p.m.

2. In interview on 7/6/01 at 12:25 p.m., E7 stated that R1 "has always been sexually aggressive with staff". E7 stated that prior to this week, R1's sexually inappropriate behaviors towards residents consisted of R1 reaching towards confused residents, attempting to grab or hug them and making inappropriate sexual comments. E7 stated that she was not aware of any special monitoring that had been put in place for R1.

In interview on 7/6/01 at 11:10 a.m., E5 stated that on 6/30/01 E5 observed R1 with his hands around R3 and hugging from the back, R3's shirt down. E5 stated that she "stopped him before he could put his hand on [R3's] breast".E5 also stated that on 7/1/01 she observed R1 kissing and hugging R4. E5 stated that "yesterday they had me chart this - just got these notes in the book yesterday", as E5 indicated her documentation in the behavior log. Regarding monitoring of R1, E5 stated that staff "haven't really been instructed per se, other than monitor and try to redirect". E5 stated that there is no specific monitoring regarding R1. E5 stated that the facility had an inservice regarding abuse a couple of months ago, but "did not cover sexual abuse per se". E5 stated that she would only call the physician regarding behaviors "if it was something we could not control".

E8 was interviewed on 7/6/01 at 1:20 p.m. and stated that on 7/2/01, E8 found R1 in the activity room with R3 up against the wall with R3's shirt up and R1's mouth on R3's breast. E8 stated that R3 had her hands out "as if to push him off her". E8 stated that she removed R3 from the area and when she returned to the area, R1 was doing the same thing with R4. E8 stated that she removed R4 from the activity room and then upon return found that R1 was doing the same thing to R5. E8 stated that R5 was stating "Get him. Get him" to staff. E8 stated that the incident was reported to E14.

E14 was interviewed on 7/10/01 at 11:20 a.m. and stated that on 7/2/01 E8 had reported to her that she had to redirect R1, who for three female residents was found "going up their blouses and trying to suck their breasts". E14 stated that R3 was one of the residents and E14 did not recall who the other two female residents were. E14 stated that she did not notify the physician, the Administrator, or any families of the residents involved.

In interview on 7/6/01 at 10:40 a.m., E2, the Director of Nursing, stated that on 7/2/01 when she was getting ready to leave work, E8 informed her that she had found R1 in the activity room with R3's breast in his mouth. E2 was not aware of any other residents involved on 7/2/01. E2 stated that staff were instructed to keep R1 and R3 separated and to "monitor" R1. E2 confirmed that no specific monitoring guidelines were put in place for R1. E2 stated that on the morning of 7/3/01 E2 started the investigation, and that the investigation was still continuing as of 7/6/01. During interview on 7/12/01 at 9:30 a.m., E2 stated that on 7/2/01, when E8 informed her of the incident with R1, E2 instructed E8, the certified nursing assistant, to "keep an eye on them, or monitor them closely....don't remember exactly what I said". E2 stated that she did not speak with the nurse on duty regarding the incident.

E3, the Assistant Director of Nursing, stated in interview on 7/6/01 at 3:30 p.m. that on 7/3/01 E3 was speaking with R1's physician regarding another resident, and did mention to him regarding R1's behaviors, but did not inform the physician of the specifics of the incidents. E3 stated "We didn't have all the facts then". E3 stated that the physician was planning on coming in to see R1 on 7/6/01.

In interview on 7/6/01 at 11:45 a.m., E6 stated that on 7/4/01 E6 found R1 with R3's breast in his mouth. E6 stated that R3 "looked confused". E6 stated that E9 also witnessed this and the incident was reported to E15. E6 stated that the following day, 7/5/01, E6 witnessed R6 crying and holding her breast while pointing at R1. E6 stated that R6 was saying that she "didn't want no man". E6 stated that she had not witnessed R1 touching R6. E6 stated that since admission, R1 has been "grabbing" at staff and talking about staff's breasts. E6 stated that R1 has been seen kissing R4 in the past. E6 stated that staff are "just told to chart it". When questioned regarding monitoring of R1, E6 stated "nothing specific really", that staff check if they see R3 or R4 go down the hallway where R1's room is.

E9 stated in interview on 7/6/01 at 2:00 p.m. that on 7/4/01 E9 witnessed R1 with R3 at the end of the hallway, and that R3's shirt was up and R1 was sucking on R3's breast. E9 stated that R3 looked "frantic". E9 stated that when R1 was first admitted his inappropriate sexual behavior was directed towards staff. E9 stated that staff are instructed to chart his behavior and redirect him. E9 stated that there have been no instructions regarding specific monitoring.

E15 was interviewed on 7/10/01 at 10:45 a.m. and stated that E8 and E9 reported to her on 7/4/01 that R1 had been observed sucking on R3's breast. E15 stated that she did not notify the physician, the Administrator, or any families of the residents involved. E15 stated, "I didn't know I needed to do anything other than chart it."

In interviews on 7/6/01 at 3:30 p.m. and on 7/10/01, E1, the Administrator, confirmed that E1 was not aware until 7/6/01 of the incidents involving R4, R5 and R6 and was not aware of an additional incident with R3 on 7/4/01. E1 confirmed in interview on 7/6/01 at 3:30 p.m. that the families of the residents involved in these incidents had not been notified.

Z1 was interviewed at the facility on 7/6/01 at 2:15 p.m. and stated that E3 did notify Z1 on 7/3/01 regarding R1 having behaviors, however Z1 was not aware of the specific incidents until after speaking with facility staff and surveyor on 7/6/01. Z1 stated that Z1 had adjusted R1's medications on 7/6/01, prior to interview with surveyor, and stated that R1 should be monitored closely by staff.

On 7/6/01 at 3:50 p.m., E12 approached E1, the Administrator, and surveyor, and stated that R1 had just been found holding R3 up against the wall and "he was forcibly fondling [R3's] breast."E12 stated that the same thing occurred on 7/2/01, when E12 witnessed that R1 had R3 "up against the wall by the west nursing station". E12 stated that the 7/2/01 occurred around 4:30 p.m. while R1 was waiting for his ride to go out on pass. E12 stated that the nurse was informed, who then stated to R1, "This is the fourth time we've told you".

3. R3's record review revealed a diagnosis on the face sheet of Alzheimers and Organic Brain Syndrome. The most recent Resident Assessment Instrument dated 5/4/01 indicates that R3 is cognitively impaired. Review of nurse's notes on 7/6/01 revealed no documentation regarding any incidents of sexual aggression by another resident.

R4's record review revealed a diagnosis of dementia, confusion, agitation and Alzheimers on the face sheet. Review of the record on 7/6/01 revealed no documentation of any incidents of sexual aggression by another resident.

R5's record was reviewed on 7/10/01 and revealed a diagnosis of delusional disorder, agitation and hallucinations per the face sheet. The nurse's notes were reviewed and there was an entry on 7/701 at 1:52 p.m. documenting that the physician was notified of an "incident which occurred with resident and male resident". There is no documentation of the specifics of the incident or the date occurred.

R6's record review on 7/6/01 revealed a diagnoses on the face sheet of confusion and hallucinations and there was no documentation of any incidents of sexual aggression by another resident.

4. Facility policy titled "Abuse Prevention/Investigation Policy" was reviewed and the policy indicates that Employees are required to report any occurrences of potential mistreatment they observe, hear about, or suspect to a departmental supervisor, the director of nursing or the administrator. Supervisors shall immediately inform the administrator or designee of all reports of potential mistreatment. Upon learning of the report, the administrator or designee shall initiate an incident investigation. The policy indicates that the administrator or designee will inform the resident or resident's representative of the report of an occurrence of potential mistreatment and that an investigation is being conducted. The policy further states that residents who allegedly mistreated another resident will be removed from contact with that resident during the course of the investigation, and the accused resident's condition shall be immediately evaluated to determine the most suitable therapy, care approaches, and placement, considering his or her safety, as well as the safety of other residents and employees of the facility.