PARK HAVEN CARE CENTER
107 S. Lincoln
Smithton, IL 62285
Date of Survey 5/23/00
Complaint Investigation 0042082
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.
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 requirements are not met as evidenced by:
1. R4's clinical record review revealed diagnoses to include Schizoaffective Disorder and Moderate Mental Retardation.
E8's (nurse aide) interview, on 5/11/00 per phone from the facility, revealed that on the 3-11 shift on 4/28/00 E3 and E4 (nurse aides) antagonized R4. E3 initially offered a soda to R4, but instead gave soda to R7. E8's interview revealed this is what got R4 started. E8 stated E3 and E4 took R4 down to R4's room. E8 stated she went down the hall to R4's room because she heard E3 and E4 screaming and yelling at R4. E8 stated she told E3 and E4 to get out of R4's room, and E8 calmed R4 down.
E9's (nurse aide) interview, on 5/09/00 in the break room of the facility, revealed that on the 3-11 shift on 4/28/00 E9 was in R4's room with R4 calming down when E4 entered R4's room. R4 stood up from the side of her bed and called E4 a "nigger". E9 stated E4 pushed R4 back onto R4's bed "just enough to get her onto her ass". E9 stated E4 pushed with a hand in front of each of R4's shoulder areas. E9 stated that E4 stated to R4, "I'm not a nigger." E9 stated E4 laughed as E4 pushed R4 down onto R4's bed, and then E4 ran to R4's bedroom door. E9 stated as E4 was running to R4's bedroom door, R4 began hitting E9. E9 stated a nurse came in and gave R4 a shot. E9's interview revealed R4 would not have had to get a shot as R4 was calming down, until E4 pushed R4 onto R4's bed.
Clinical record review revealed that on 4/28/00 at 8:30p.m., R4 received Ativan 1mg intramuscular/injection for severe agitation.
E8's interview revealed R4 was not getting that many shots before E3 and E4 came. E8 stated R4 has to get shots most of time when E3 and E4 are on.
Personnel files of E3 and E4 revealed hire dates of 3/23/00 and 3/14/00, respectively.
R4's clinical record review revealed R4 to receive the following
01/25/00, 6:30 a.m., Ativan 2mg
02/06/00, 3 p.m., Ativan 1mg
3/01/00, 8 a.m., Ativan 1mg
4/01/00, 7:40 a.m., Ativan 1mg
4/28/00, 8:30 p.m., Ativan 1mg (E3 and E4 were on duty on the 300 hall where R4 lives)
4/29/00, 12:15 a.m., Ativan 1mg
4/30/00, 7:45 a.m., Ativan 1mg
5/01/00, 8:45 p.m., Ativan 1mg (E3 was on duty on the 300 hall where R4 lives)
5/03/00, 7:34 a.m., Ativan 1mg
5/04/00, 7 p.m., Ativan 1mg (E3 and E4 were on duty on the 300 hall where R4 lives)
5/07/00, 5:50p.m., Ativan 1mg (E3 was on duty on the 300 hall where R4 lives).
2. R2's clinical record review revealed diagnoses to include Affective Psychoses and Major Depressive Disorder. Nursing notes reflect that on 4/01/00, during 11p.m.-7 a.m. shift, R2 fell trying to go to bathroom. R2 was sent to area Emergency Room and returned with internal and external sutures to left eyebrow area. R2 was given call light and instructed to use same so staff could help R2 with R2 stating, "Okay, I will use it." Nursing notes reflected swelling of R2's left eye area remained through 4/08/00, and bruising remained through 4/10/00. R2 was also moved from room 107b to 306a. E12's (licensed nurse) interview, on 5/11/00 per phone from the facility, revealed this was done for staff to keep closer observation on R2 due to R2's falls.
Nursing note of 4/29/00 at 7:03 p.m. revealed R2 was found with a large purplish-yellow bruise to the inner right forearm. Nursing note reflected R2 to state, "I fell in the BR a couple of days ago, I was going to the BR one morning by myself et lost my balance. I fell onto toilet." Nursing note reflected nurse asked R2 why R2 had not told anyone R2 had fallen until today with R2 stating, "I was afraid to. I got up et used the bathroom by myself et I know I'm supposed to get help." Nursing note reflected that R2 was told to use the call light anytime she needed help and R2 agreed.
Nursing note of 4/30/00 at 12:57 p.m. reflected R2 to state, "I didn't want to get anyone in trouble so I didn't tell anybody." This was documentation related to R2's earlier fall as related to another nurse.
R2's initial Minimum Data Set Assessment (MDS) of 3/09/00 revealed R2 to not have any memory impairment, nor any indicators of delirium. MDS did reflect R2 to have moderate impairment of cognitive skills for daily decision making.
E2's (Director of Nurses) interview, on 5/09/00 in the break room of the facility, revealed R2 to be interviewable. E2 stated, "Yes, on her good days." R2's interview, on 5/09/00 in the break room of the facility, revealed R2 to know E3, "Yes, not intimately, but pretty well." R2's interview revealed E3 did threaten to tie R2 down in a gerichair with R2 stating, "because I wouldn't leave light switch alone." When asked how this made R2 feel R2 stated, "I didn't feel good but I said, go ahead, go ahead." R2's interview revealed E3 threatened to take call light from R2 with R2 stating, "Well she has threatened. She said if I didn't lay off of it, she was going to put it up on light thing out of my reach." Surveyor asked R2 if R2 meant light above her bed and R2 stated, "Yeah." When asked how she felt about having call light taken away R2 stated, "I felt very bad cause I couldn't understand why she was going to do that."
E8's interview, on 5/11/00 per phone from the facility, revealed E8 heard E3 bragging in certified nurse aide (CNA) class that E3 had told R2 that E3 was going to strap R2 down in a gerichair so R2 couldn't use call light, as well as that E3 had taken R2's call light away from R2. E8 stated E3 and E4 take R2's call light and put it up on light above R2's bed. E8 has found R2's call light up on the light above R2's bed before. E9's interview, on 5/09/00 in the break room of the facility, revealed that on 5/01/00 on the 3-11 shift, E3 said E3 was going to take the call light away from R2 as E3 was going to R2's room to answer call light. E9's interview revealed E3 said this in a joking way and that E3 was laughing.
E12's interview, on 5/11/00 per by phone from the facility, revealed R2 had reported to E12 that E3 had been threatening to tie R2 in a gerichair if R2 used call light anymore, and that E3 had also threatened to take the call light away from R2.
Z1's (R2's psychiatrist) interview, on 5/11/00 in the break room of the facility, revealed R2 to be grossly oriented x3, long term memory definitely intact, and if R2's statements were corroborated by CNAs' statements, then R2's statements would be minimally paranoid delusional.
3. E12's interview, on 5/11/00 per phone from the facility, revealed E12 reported to E2 on 5/3/00 that on 5/01/00 on the 3-11 shift an incident of E3 threatening to tie R2 in a gerichair if R2 used call light anymore, and also of E3 threatening to take R2's call light from R2.
E2's interview, on 5/11/00 in the break room of the facility, revealed E2 was never notified of above incident and stated if she had been notified of incident she would have suspended E3 pending investigation. E2's interview revealed E1 to not have been notified of incident.
4. E9's interview, on 5/09/00 in the break room of the facility, revealed she reported to E12 on 4/29/00 on the 3-11 shift that on 4/28/00 on 3-11 an incident of E4 pushing R4 down onto R4's bed occurred.
E2's interview, on 5/11/00 in the break room of the facility, revealed E2 nor E1 knew anything about the incident.
5. On 5/09/00 at 3:35 p.m., surveyor informed E1 and E2 of probable validity of allegation of mental abuse of R2 and R4 by E3 and E4. Surveyor observed E3 and E4 in the facility on 5/09/00 for the 3-11 shift. E1 and E2 stated E3 and E4 were not on the floor yet for direct patient care. On 5/09/00 at 4:30 p.m., E1 and E2 stated E3 and E4 would continue to work the 3-11 shift on 5/09/00 because of "he say/she say" situation as per statement of Z3 (facility's Corporate Human Resource Person).
On 5/11/00 at 9 a.m., E1 and E2 reported to surveyor that E3 and E4 were suspended on 5/10/00 pending facility's investigation, and E1 stated E3 and E4 were suspended due to statement of Z2 (facility's Attorney). Additionally, interviews of E1 and E2, on 5/11/00, revealed E3 and E4 to have quit. On 5/15/00 at 1:20 p.m., E1 approached surveyor and stated E3 and E4 had been terminated per Company policy.
E2's interview and facility's above policy reflected that if suspected perpetrator is staff, the Executive Director, E1, shall place that staff person immediately on investigatory suspension while facility completes its investigation.