OAK LAWN PAVILION
Facility I.D. Number 0038091
9525 S. Mayfield
Oak Lawn, Illinois 60453
Date of Survey 03/17/00
Complaint Investigation
An owner, licensee, administrator, employer 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.
Employee as perpetrator of abuse. When an investigation of a report of suspected abuse of a resident indicates, based upon credible evidence, that an employee of a long-term care facility is the perpetrator of the abuse, that employee shall immediately be barred from any further contact with residents of the facility, pending the outcome of any further investigation, prosecution or disciplinary action against the employee.
These regulations are not met as evidenced by:
Upon presentation of Nature of Complaint, E#1 and E#2 were interviewed. Both stated that "E#4 told them that E#4 had heard E#3 cursing at R#1," that both E#4 and E#5 left the room after providing care to R#2 who was R#1's roommate.
E#2 stated that on 3/14/00, E#2 was assigned to care for R#1 on the 7-3 shift. R#1 was observed to have a bruised nose, blood in her mouth, nose leaning to the side, and having respiratory distress after having been cared for by E#3.
When interviewed on the afternoon of 3/15/00 by phone, E#4 stated that on 3/14/00 at approximately 9:00a.m. she "had just finished administering medications to R#1 through her g-tube and that the resident did not have any facial bruising or bleeding at that time."
When E#3 entered the room, E#4 was administering medications to R#1's roommate, R#2, who was in the room also. E#4 stated "that E#3 came into the room cursing, saying that she was tired of this shit and, you're going to help me this time." E#3 then told R#1 "You're going to help me this time, I'm tired of your ass." E#3 then "snatched" (handled R#1 roughly as described by E#4). E#4 stated that she "was facing R#1 and saw E#3 jerking on the resident and moving her roughly and that the privacy curtains were open."
E#4 stated that she told E#3 "You're too rough with her", and that E#3 said, "It's not me, it's her." E#3 then pulled the privacy curtains closed.
As stated by E#4, after she finished giving meds to R#1's roommate, R#2, she "went to the nursing station and paged E#2 to the floor to tell her about E#3's behavior." E#4 left R#1 alone with E#3 even though she was aware of E#3's verbal abuse and rough handling of the resident. E#4 did not attempt to remove E#3 from the room.
According to E#4, she entered Room 219 and saw "R#1 bleeding from nose and mouth, and with her nose bruised." E#4 and E#6 suctioned R#1 and got between 100 and 150 cc bright red blood from the resident's mouth. Oxygen was started at that time. Afterwards E#4 asked R#1 what had happened, but all R#1 could say was "she, she, she. . ." and point to the door to the room.
At the end of the interview, surveyor read back to E#4 the statements made by that employee; E#4 verified that the statements given by her to the surveyor were complete and accurate.
As documented by E#4 in R#1's nursing note of 3/14/00 at 9:00a.m., R#1 was not in any distress. The next entry by E#4 on 3/14/00 at 9:30a.m., documents that the nurse "noticed resident (R#1) to be in acute distress with lots of bright red blood coming from mouth & nose with rapid breathing, resident nose seemed to be crooked and pushed to one side." E#4 noted that R#1 "continued to gurgle blood and could not speak."
Nursing entry by E#4 documented that as of 9:45a.m. 3/14/00, R#1 continued to cough up bright red blood and required continued suctioning.
Nursing entry of 3/14/00 at 2:40p.m. by E#4 documents R#1's admission to the hospital with the diagnosis of fracture to nose and hematoma.
On 3/21/00 at 11:45a.m., during phone interview of E#6, it was verified that on 3/14/00 after R#1 was noted to be bruised and bleeding, E#3, who cared for R#1 that day, continued working and caring for other residents and was not sent home until 12:30p.m. 3/14/00.
E#5 was interviewed by surveyor on 3/15/00 and stated that "on 3/14/00 between 8:30a.m. and 9:00a.m., she had put splints on R#1." "At that time, the resident did not have any facial bleeding or bruises." E#5 stated that "R#1 did not have any history of falls, and did not thrash around in bed." E#5 also stated that "E#3 had been rough with patients before and named R#3 and R#4 as two such residents.
While E#5 admits to having knowledge of E#3's abusive behavior towards residents, the employee also admits that she did not inform E#1 or any supervisor. The facility's policy requires employees to report any occurrences of potential mistreatment that they observe, hear about, or suspect to a supervisor or the Administrator.
Employees E#7 and E#8 when interviewed, stated that they had knowledge of E#3 having been abusive to residents in the past. E#7 named R#2, R#4, and R#5 as residents who had been abused by E#3 in the past. E#8 stated that she had seen E#3 as she put her hands over residents' mouths and shoved residents into rooms, but when questioned, would not identify the residents.
Both E#7 and E#8 stated that they had informed E#1 and E#8 stated that she had informed E#11, but that neither had acted upon the information. When interviewed, E#1 denied having been previously informed of the allegations against E#3.
E#5 continued to state that between 9:00a.m. and 9:30a.m. she was in R#1's room providing Passive Range of Motion (PROM) to R#2, and was talking to E#4 who was also present in the room. E#3 entered the room and asked E#5 if she wanted R#1 out of bed and E#5 replied no. E#3 was observed to pull the privacy curtain closed around R#1's bed in a rapid manner. E#5 states that afterwards, "she couldn't see anything," but could hear "rough movements." As E#4 and E#5 continued on talking, E#5 stated that "she could hear R#1 gurgling."
When surveyor reread the statements made by E#5 back to the employee, the employee verified that the statements given to surveyor were correct.
E#6 stated that after she was notified by E#3 of R#1's bleeding, she "entered the room to observe R#1 sitting in a wheelchair slouched over." "The resident was gurgling and cyanotic as well as looking scared." E#6 returned the resident to bed and placed her on her side. At that time, E#6 observed the resident to have 3 small purple bruises on the bridge of her nose and was bleeding from the mouth and nose; that when R#1 was suctioned by E#6 and E#4, they obtained 100-150 cc bright red blood, E#6 also noticed that R#1's nose was crooked and painful when touched. E#6 stated that "when she observed R#1 earlier that morning, there had not been any bruising or bleeding from the resident's nose or face."
Employees E#7 and E#8 both verified that statements given by them to the surveyor and read back to them were complete and accurate.
On 3/15/00, E#11 was interviewed. As stated by E#11, E#8 did speak to her about E#3's behavior, "but that she thought that the allegation came about because E#3 and E#8 did not really get along, and based upon that assumption did not investigate the allegation." When asked again by surveyor, E#11 reiterated that she "did not conduct an investigation."
E#11 stated that she "did speak to E#3, but no actual investigation or follow-up was done."
On 3/17/00 at 12:30p.m., E#11 contacted this surveyor by phone and stated that E#8 had informed her that E#3 was being "mean" to residents and that she had spoken with both E#3 and E#8 at that time, but no other investigation was done.
The facility's abuse policy requires that employees accused of mistreatment be removed from resident contact immediately until the results of the investigation are reviewed by the administrator or designee. In the case of E#3, this was not done. E#11 admits to having been informed by E#8 of E#3's abusive behavior, but not following up on the information received.
On 3/20/00, IDPH received a copy of the Oak Lawn Police Department Report in which E#3 made both an oral and written confession to "being rough with R#1" and admitted to striking R#1 in the nose with her right hand. Felony charges for Aggravated Battery were made against E#3.