PATTERSON HOUSE ID NUMBER 0037341 307 E. JEFFERSON SULLIVAN, IL 61951 As a result of an annual licensure survey conducted on August 18, 1998, by representative(s) of the Department, it has been determined the following violations occurred. "A" VIOLATION(S) The facility shall notify the Department of any incident or accident which has, or is likely to have, a significant effect on the health, safety, or welfare of a resident or residents. Incidents and accidents requiring the services of a physician, hospital police or fire department, coroner, or other service provider on an emergency basis shall be reported to the Department. A descriptive summary of each incident or accident shall be recorded in the progress notes or nurses' notes for each resident involved. The facility shall provide training and habilitation services to facilitate the intellectual, sensorimotor, and effective development of each resident in the facility. There shall be available sufficient, appropriately qualified training and habilitation personnel, and necessary supporting staff, to carry out the training and habilitation program. Supervision of delivery of training and habilitation services shall be the responsibility of a person who is a Qualified Mental Retardation Professional. Where appropriate, providers should cooperate with the Department of Mental Health and Developmental Disabilities and communities agencies in assisting individual residents to avail themselves of specialized work activity programs, prevocational and work adjustment training, or sheltered workshop programs. The facility shall notify the resident's physician of any accident, injury, or change in a resident's condition that threatens the health, safety or welfare of a resident, including, but not limited to, the presence of incipient or manifest decubitus ulcers or a weight loss or gain of five percent or more within a period of 30 days. If a resident becomes unmanageable, he shall be examined by a physician or psychiatrist. This medical examination shall be made promptly. A psychologist and members of other appropriate professional disciplines should be consulted, as necessary. An owner, licensee, administrator, employee or agent of a facility shall not abuse or neglect a resident. A facility administrator, employee or agent who becomes aware of allegations of abuse or neglect of a resident shall also report the matter to the Department of Public Health. When an investigation of a report of suspected abuse of a resident indicates, based on 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 the resident as well as the safety of other residents and employees of the facility. These regulations are not met as evidenced by: Based on observation, interview and file verification, the facility failed to implement their policies and procedures prohibiting abuse and neglect potentially affecting 16 of 16 individuals in the facility. Findings include: 1. The facility failed to ensure that R6 does not physically abuse other residents in the facility. Other residents in the facility include R's 1-5 and R's 7-16. In addition, the facility failed to ensure that R6 was not over-medicated (3/98-6/98). R6 is a 67 year old male with a diagnosis of severe mental retardation and Schizoaffective Disorder. On 7/13/98, a diagnosis of Dementia, Alzheimer's type (provisional) was added. R6 is ambulatory and verbal. Per review of R6's file, he has experienced multiple bouts of physical aggression towards staff and other residents over the past year. Per review of incident reports, from 1/98 through current, R6 has 25 reports completed which involve his physical aggression. Aggressive behaviors include hitting, shoving, grabbing, kicking, throwing objects, and knocking individuals out of chairs. On 1/9/98, R6 hit a female resident in the back of the head. On 1/10, R6 knocked R5 (profound MR) out of her chair and kicked her in the head twice while was down on the floor. On the same day, R6 hit a male resident three times between the legs. On 1/13, he again hit R5 in the head. On 1/30, R6 hit R11 in the face, knocked her out of her chair and kicked her. On 3/8, he threw a water pitcher at other residents. On 3/8, he threw a foot stool and hit another resident in the foot. On 3/12, R6 hit staff with a plate, then grabbed r5 by the throat and threw her to the floor. He then grabbed a chair and tried to throw it at her and threw two more plates (at other clients). On 3/13, R6 slapped R5 across the face. On the same date, he grabbed R3 by the neck and threw her to the floor. On 3/15, R6 threw a foot stool at a female resident and hit her in the face with his fist. On 3/16, he hit a female resident causing bleeding from her mouth. Other incidents of physical aggression towards other residents are noted in R6's file (and others) for the same types of behaviors for which no incident reports had been completed. Per interview with E3, she sated that R6 has had a "bad year" and that they "don't know what to do with him...." She stated that R6 seems to target people that he knows are not able to or will not defend themselves. Per review of R6's file, he was hospitalized in 11/97 because of his increase physical and verbal aggression at which time medication adjustments were made. No changes in R6's IPP were made at this time. E3 stated that following the 11/97 hospitalization, R6 "seemed better" for a few days but that within a week became aggressive again. The file indicated that R6 was hospitalized again in 3/98 for physical and verbal aggression. Medication were again adjusted. E3 stated that following discharge from the hospital, R6's aggression was diminished. However, he experienced increased incontinence, an ability to walk, talk and care for his adl's and was unresponsive at times. No changes in R6's IPP objectives were made during this time. Z2 voiced concern regarding R6 during this time stating that he was no longer involved in any day training activities and that he was unable to do even the smallest of tasks unassisted. Confirmed per file verification that R6 remained in this state from 3/98 through 6/98. Z2 stated the R6's aggressive behaviors were reduced during this time due to his unresponsiveness. The file indicated that R6 was hospitalized again in 6/98 due to the unresponsiveness. He was then taken off of all his medication. Upon discharge to home, R6 initially experienced few bouts of aggression. However, over the past month, aggression towards others had increased and medication have been increased. Confirmed per E3. No changes in R6's IPP objectives have taken place regarding R6's behaviors. Z2 stated that she is worried that R6's physical aggression will get as bad as it was prior to the 3/98 hospitalization. Per review of physician orders, R6 currently receives Klonopin 0.5 mg, 1 tab three times per day, Cogetin 2mg, 1 tab twice daily, Depakote 125 mg, 4 tabs in the a.m. and 6 tabs at noon and bedtime and Seroquel 75 mg, 1 tab twice daily. Per observation at day training on 8/4/98, R6 was observed to begin pacing; when redirected, R6 became verbally aggressive and then shoved a chair forcefully into the table. Per interview with Z's 1 and 2, they have major concerns regarding R6's extreme agitation. They stated that he is now starting back to hitting, kicking and shoving others and that he is having a severe problem with masturbation. Per observation of R6 while in the home, it was noted that he was left unsupervised by staff while in the company of individuals for whom he has aggressively targeted in the past. Per review of R6's IPP, there has been no update to R6's behavior management program over the past year. Confirmed per E3. Per review of R6's assessments, there is a checklist-type behavior assessment which was completed by E3. However, there is no behavior assessment completed which offers recommendation for behavior programming. Per interview with Z7, he states that he has had concern regarding R6's behavior over the past year. He states that he has recommended on more than one occasion that the facility seek technical assistance for behavior management through the Department of Human Services but that it had not been done. Confirmed per file verification. Per review of the facility policy regarding abuse and neglect, it states that, "all residents are to live free of abuse and neglect.... Abuse mistreatment or neglect of residents will not be tolerated...by...other residents...." The facility failed to implement its policy regarding abuse and neglect. The facility shall notify the resident's physician of any accident, injury, or change in a resident's condition that threatens the health, safety or welfare of a resident, including, but not limited to, the presence of incipient or manifest decubitus ulcers or a weight loss or gain of five percent or more within a period of 30 days. A registered nurse shall participate, as appropriate, in the planning and implementation of training of facility personnel. Direct care personnel shall be training in, but are not limited to, the following: 1) Detecting signs of illness, dysfunction of maladaptive behavior that warrant medical, nursing or psychosocial intervention. 2) Basic skills required to meet the health needs and problems of the residents. There shall be available sufficient, appropriately qualified nursing staff, which may include currently licensed practical nurses and other supporting personnel, to carry out the various nursing service activities. Each facility shall have a medical record system that facilitates the retrieval of information regarding individual residents as demonstrated by the facility. The facility shall keep an active medical record for each resident. This resident record shall be kept current, completed, legible and available at all times to those personnel authorized by the facility's policies, and to the Department's representatives. An ongoing resident record including progression toward and regression from established resident goals shall be maintained. The progress record shall indicate significant changes in the resident's condition. Any significant change shall be recorded upon occurrence by the staff person observing the change. Medical history and physical examination form that includes conditions for which medications have been prescribed, physician findings, all known diagnoses and restoration potential. This shall describe those known conditions that the medical and resident care staff should be apprized of regarding the resident. Examples of diagnoses and conditions that are to be included are allergies, epilepsy, diabetes and asthma. Nurse's notes that describe the nursing care provided, observations and assessment of symptoms, reactions to treatments medications, progression toward or regression from each resident's established goals, and change in the resident's physical or emotional condition. An owner, licensee, administrator, employee or agent of a facility shall not abuse or neglect a resident. A facility administrator who becomes aware of abuse or neglect of a resident shall immediately report the matter by telephone and in writing to the resident's representative. A facility administrator, employee or agent who becomes aware of allegations of abuse or neglect of a resident shall also report the matter to the Illinois Department of Public Health. When an investigation of a report of suspected abuse of a resident indicates, based on 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. The standards and regulations stated in other divisions of this publication shall apply to this type of facility unless indicated otherwise in this Subpart P, by substitutions or additions. These requirements are not met as evidenced by: Based on observation, interview and file verification, the facility failed to ensure nursing services according to client needs affecting 1 of 4 individuals in the sample plus 5 additional individuals in the facility. Findings include: 1. Nursing failed to provide nursing care to meet R13's health needs. R13 has a shunt placed in her left forearm for her renal dialysis. Per review of direct care staff documentation, R13 complained of pain to the left hand on 1/11/98. There are not nurses notes to indicate follow up to R13's complaints or to assess or made recommendations regarding care of the hand or the shunted area. On 1/23/98, the dialysis physician ordered Hydrocortisone Cream 1% to be applied to the "open areas" on the left hand twice daily as needed. Per review of medication administration records, the Hydrocortisone Cream was applied on time on 1/26 and 1/27. It was applied on time on 2/5, 2/7, 2/12, 2/13, and 2/25. It was applied on time on 3/7. Direct care staff notes on 2/7 states, "...small open sores on the left hand..." There are no further notes regarding the open areas on the left hand. There are not nurses notes regarding assessment or follow up with recommendations regarding the application of they Hydrocortisone Cream. There are no nurses notes regarding assessment of the "open areas" on R13's hand or of the shunt area in R13's left forearm. On 3/29, a nurse note states, "L hand swollen. Noted several small red areas on L hand and lower arm. Hand warm to touch." No measurement of edema (ie Pitting or measurement of hand/arm circumference) was made for a baseline. No evaluation of pain was documented. On 3/31, R13 was transferred to the emergency room or a consult regarding blisters on her left index finger. A vascular surgeon was consulted and surgery was scheduled for ligation of a fistula on 4/9/98. On 4/9/98, R13 had the fistula surgery and returned to home on 4/10. She was seen post- op on 4/14 at which time records indicate the large blisters and edema remained. The physician chose to leave blisters intact vs. debriding due to possible infection. Silvadene Cream was ordered. R13 was to keep the arm elevated and wrapped. On 4/15, another doctor ordered the blisters to be drained due to their size. There are no nurses notes in R13's file from 4/3 until 4/17 to indicated at home nursing follow up. The note on 4/17 states, "...Blister L hand popper per MD...Top L hand red and slightly swollen. Dressing changed per RSD. Arm remains edematous...Not using arm a lot..." There is no assessment of pain, no circulatory assessment, no assessment of edema and no recommendation regarding what direct care staff should do or watch for regarding increased edema, pain, infection, etc. No temperature was taken. On 4/21, R13 was admitted to the hospital for a fistulogram and was transferred to the burn unit for debridement of the left hand blisters. She returned home on 4/23/98. Nurses note 4/23 indicated R13's medical activities but no assessments were done regarding edema, site appearance or pain control. No recommendation for nursing care was made. No nursing notes are in R13's file until 5/2 at which time the nurse indicated the top of the left hand is pink and remains slightly swollen. The next nursing notes is on 5/24 and states, "...L arm remains edamatous...Color remains pale..." The next note on 6/5 state, "L hand slightly swollen/discolored..." R13 was not seen again by the nurse until 6/13 and note states, "...L hand remains slightly swollen..." On 6/26, nursing note states, "L hand/arm only slightly swollen..." No further nursing notes are listed in R13's file. No assessment of the fistula site and not recommendations to staff are noted. Medical notes on 4/21 state, "some problems with increased edema and subsequent development of blister over dorsal L hand. Edema significantly worsened after most recent dialysis. Has worsened L hand blister..." L arm moderate edema throughout...moderate swelling into distal extremities...need to r/o venous obstruction causing edema." Nursing failed to provide consistent in-home assessment of the left forearm fistula, edema and blisters tot he left hand. Nursing failed to provide instruction to staff regarding wound care and bandage application. Nursing failed to ensure medications were administered as needed (Hydrocortisone Cream order). 2. Additional examples regarding lack of nursing care as per client needs for R13 are as follows: a. R13 has expressed delusional thoughts of being fat and has repeatedly refused foods over the past year. R13 was placed on a dietary supplement by dialysis physician on 6/1/98. A physician note of 5/21/98 states that R13 will need to be seen by a psychiatrist if she continues not to eat. There are not nurses notes until 6/26 which states, "...discussed weight loss of 8 pounds in one month with RSD...will monitor. Per review of R13's file and confirmed per E's 3 and 4, she has continued to refuse meals and/or to eat only scant amounts of food. Her current weight is 104 (IBW 108-120). Per observation of the am mal on 8/5, R13 ate only 3-4 small bites of her meal then refused to eat any more. There are no nurses notes after the 6/1 note regarding R13's weight loss/refusal to eat. No weights are on the nursing quarterlies. No recommendations were made and no psychiatric consultation has been sought. Nursing failed to monitor and provide nursing care for R13's weight loss concerns. b. Per review of direct care staff notes, multiple notes indicated R13's complaints of dizziness and nausea and vomiting. R13's Vasotec was increased by the dialysis physician on 6/1/98. Per review of blood pressure readings taken by direct care staff twice daily, R13 has multiple high readings. For instance in 6/98, blood pressure was up to 222/121 on 6/5, 206/130 on 6/7 and 210/106 on 6/22. Similar elevations are noted for 7/98 and 8/98. There are no nurses notes indicating review of these elevations with physician notification. There are no recommendations made to direct care staff to indicate at what level the nurse or physician should be notified. Confirmed per E4. c. Direct care staff notes indicated that on 2/6/98 R13 had difficulty with bleeding following dialysis. Upon late arrival home, the left arm was wrapped and R13 felt weak and tired. There are no follow up notes to indicate further direct care staff observation and no nursing follow up to the episode. d. During a 5/98 hospitalization a tetanus shot was given to R13 (per review of physician hospital notes). Per review of nurses notes and facility immunization records, the nurse failed to transfer the tetanus shot over to facility documentation. e. During a 5/98 hospitalization, the physician documented that R13 is allergic to Keflex. The nurse noted same in her notes. It was later ascertained that the physician had erroneously documented the allergy. Confirmed per E4. The nurse failed to investigate and properly document the error in the facility records for R13. Nursing failed to follow up on lack of urinalysis for R13. Per review of physician orders, R13 has an order for annual urinalysis. No results were in R13's file. Per interview with E3, she stated that she doesn't think R13 urinates so they have not been able to get a u/a. Per review of nurses notes and quarterlies, there is not mention of the lack or urination and/or the inability to get the urinalysis as per physician order. No notification of the physician is apparent. f. R13 has a physician order to receive Amoxicillin 1000 mg on hour prior to dental appointments and 500 mg 6 hours after the first dose. Per review of dental records, R13 had a scheduled dental appointment on 6/12/98 to which she was taken by facility staff. Per review of medication administration records, no Amoxicillin was administered prior to the dental appointment. There are not nursing notes to indicate review of the medication and recommendations to staff for future dental appointments. Nursing failed to ensure administration of R13's prophylactic antibiotics as per physician order. g. Additional examples regarding the nurse failure to ensure complete documentation of fluid intake records as shifts/days are missing in facility records. Per interview with Z7 on 8/11, he voiced concern regarding the lack of nursing follow up and care for R13. He acknowledged the importance of in-home assessment and for consistent nursing recommendations to the direct care staff due to R13's high medical needs. 3. Additional examples regarding nursing failure to ensure completion of lab work as per physician orders are as follows: a. R12 has a diagnosis of severe mental retardation and seizure disorder. Per review of R12's physician orders, she has an order to have GGT level drawn every 3 months until 5/98 at which time it was changed to every 6 months. Per review of labs, R12 has a GGT drawn on 4/24/98 with results elevated at 58 (normal 7-51). No further GGT results are in R12's file and none were provided when requested by the surveyor. R12 has a physician order for a liver profile every 3 months through 5/98 at which time it was changed to annually. Per review of labs, R12 had a liver profile drawn in 1/98 but it did not include integral liver function tests such the SGOT, SGPT and GGT. Additional examples regarding lack of lab work as per physician orders for R12 include lack of Tegretol level results after 1/98 when ordered every 6 months. b. R16 has a physician order dated 7/22/98 for a Chem Profile, u/a, Phenobarbital level and a Tegretol level. These are admitting labs and there are no baseline labs with admission documentation. As of 8/7/98, the labs have not been completed. Confirmed per E4. 4. Nursing failed to identify a medication allergy for R2. R2 is a 72 year old female with a diagnosis of moderate mental retardation and old right mastectomy. Per record review, it indicates that R2 was treated in 5/98 with oral Amoxicillin. Within a short time of starting the medication, R2 developed hives and shortness of breath and was treated by the physician with Benadryl. Per review of current medication records and physician orders, there is not indication that nursing has updated the records to include the Amoxicillin allergy. Records indicate no known allergies. Per interview with E4, she confirms that she is unsure that R2 has an allergy. It was noted that there was an alert on the inside of the client file which was approximately « by 1 inch in size. However, there were no updates made in documentation or in the IPP. Nursing failed to update R2's file with her allergic reaction information.