OAK PARK HEALTHCARE CENTER
Facility I.D. Number 0044602
625 North Harlem
Oak Park, IL 60302
Date of Survey: 08/30/01
Notice of Violation: 11/05/01
Sufficient staff in numbers and qualifications shall be on duty all hours of each day to provide services that meet the total needs of the residents. The number and categories of personnel to be provided shall be based on the number of residents, the amount and kind of personal care, nursing care, supervision, and program needed to meet the particular needs of the residents at all times, and size, physical condition, and the layout of the building including proximity of service areas to the residents rooms.
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 necessary precautions are taken to assure that the residents environment remains as free of accident hazards as possible.
On 08/28/01, R7 was observed by this surveyor in his room lying in bed with extensive gauze dressing on both lower extremities. R7 was alert and oriented to name only. R7 does respond to questions but seems to be confused, focused on going home as stated in mumbled words, " I want to go home." R7 was unable recall events related to the incident of 08/20/01 when the resident sustained 2nd and 3rd degree burns on both lower extremities from the knees to the ankle area.
R7 is a 51 year old resident originally admitted to the facility on 12/15/94 with the following diagnosis of seizure disorder, dementia, alcohol abuse, and depression. Clinical record review of R7 revealed the latest" Smoking Risk Assessment" was dated 07/19/01 with a total score of 17, which according to facility recommendation a total score of 10 - 18 indicates a potentially unsafe smoker and the resident needs a safe smoking care plan. The facility is to develop a safe smoking care plan. Assessment Form dated 08/08/01,"Cognitive Skills For Decision Making scored 2, which means: Moderately Impaired- decision poor; cues/ supervision required." Care plan dated 11/15/00, 2/15/01, 5/8/01/ and 8/8/01 on " Problem/ Need as written: Resident is at risk for injury and accidents D/T non-compliance to smoking policy." Below was the following notations as written, " 8/6- caught smoking 2x in the room. 8/19- caught smoking in the room."Goal as written, "Resident will smoke in designated areas at least 1x/day thru staff monitoring and interventions till next review." One of the Approaches as written, "Monitor and supervise resident while smoking. "Interdisciplinary notes dated 8/8/01- 11:58 under All Staff- Monitor resident for smoking in undesignated areas.
... Problem: Resident is non-compliant with the facility's smoking policy at times. Ashes and cigarette butts have been found on the floor under his bed. Resident is unaware of safety precautions."
Interview of R1, R2, R3, R5 and R6 on 8/28/01, denied that staff was present in the designated smoking areas. These residents are alert and oriented to time, place and person, and able to get around the facility.
Interview of E3 and R6 regarding incident of 8/20/01 revealed, R7 was in the basement smoking by himself at approximately 7:00PM, when his pants caught fire by unknown origin. According to R6, R7 can not speak, so she called for help by screaming very loud until E4 came and returned with a bucket of water to douse the flames. R4 stated crying, "I cried, can 't help him, he was on the floor after he had knocked off chairs and tables trying to remove his pants, he fell after hitting the walls." According to R6, she went to the basement to get a candy bar from the vending machine, and saw R7 seated in the chair by the table smoking. A few minutes later when she turned around R7 was in flame.
R7 was transported to the hospital trauma unit as a 'code yellow' on 8/20/01. Hospital history notations are as follows: " the patient arrived in the trauma bay with a blood pressure of 193/100 with bilateral lower extremity partial deep thickness and full thickness burns on the right and left respectively and will be transferred to the burn service." On 8/23/01 R7 underwent surgery for" Debridement and Skin Grafting" and returned to the facility on 8/27/01 with continued dressing orders.
Hospital Social Service assessment dated 8/22/01 states as follows: " the patient is oriented just times one. He is alert and does respond to questions but seems in general confused. According to the social worker at the facility, he does have a history of being a wanderer, and we have certainly seen that since his hospitalization here. He is otherwise somewhat pleasant and easy to manage, just very confused and somewhat nonverbal." Interview with Z1 on 8/30/01 at 1:35PM states that R7 was not able to relate what actually happened to him on 8/20/01.
Review of the facilities list of high risk smokers, ( non-compliant) revealed the following residents, R4, R7, R8, R9, and R10.