MARTIN LUTHER HOMES
Facility I.D. Number 0040329
510 E. Water St.
Pontiac, Illinois 61764
Date of Survey 03/30/2000
Special Licensure Survey
The facility shall provide all services necessary to maintain each resident in good physical health. These services include, but are not limited to, the following:
Nursing services to provide immediate supervision of the health needs of each resident by a registered professional nurse or a licensed practical nurse, or the equivalent.
Residents shall be provided with nursing services, in accordance with their needs, which shall include, but are not limited to, the following: The DON shall participate in:
Sufficient, appropriately qualified nursing staff shall be available, which may include licensed practical nurses and other supporting personnel, to carry out the various nursing service activities.
Direct care personnel shall be trained in, but are not limited to, the following:
Basic skills required to meet the health needs and problems of the residents.
In addition to the information that is specified above, each resident's medical record shall contain the following:
An ongoing record of notations describing significant observations or developments regarding each resident's condition and response to treatments and programs.
Any laboratory and x-ray reports ordered by the resident's physician.
An owner, licensee, administrator, employee or agent of a facility shall not abuse or neglect a resident.
Residents needing nursing care shall be admitted to an ICF/DD for 16 Beds or Less only if the facility has adequate professional nursing services to meet the resident's needs. Arrangements shall be made through formal contract for the services of a licensed nurse. A responsible staff member shall be on duty at all times who is immediately accessible, and to whom residents can report injuries, symptoms of illness, and emergencies (see Section 350.810(a)). The consultant nurse shall provide consultation on the health aspects of the individual plan of care and shall be in the facility not less than two hours per month.
These regulations are not met as evidenced by the following:
1. The facility failed to ensure that staff monitor and assist R4 in maintaining his health, hygiene, and safety.
R4 is a 29 year old male with Profound Mental Retardation, Legal Blindness, Constipation, Seizure Disorder, is non-verbal and is ambulatory, but prefers to scoot across the floor on his buttocks.
Additionally, R4 has a long history of scooting across the floor of the facility and placing his fingers in door hinges. R4 has a partial finger missing on each index finger of both hands due to this behavior.
Per file verification, R4 has a formal stand and move program which states that, "R4 will not be left by any doorways!"
On 03/21/2000, R4 was observed at the facility after his return from his day training site. From approximately 3:30 p.m. - 4:30 p.m., R4 was observed to be in the downstairs bathroom that contains a sink and stool only. When surveyor tried to enter the bathroom from the hallway, the door would only open a few inches, as R4 was positioned inside the bathroom door, sitting on the floor (apparently by a doorway and/or door hinge). The lights were off in the bathroom. When surveyor pushed slightly on the door, R4 scooted away from the door a few inches, allowing the surveyor to enter the bathroom. Surveyor turned the lights on and observed 3 plungers on the floor and a scrub brush (covered, but accessible and wet). The waste can was full of used paper towels and the floor was observed to be wet in various places around the toilet stool.
Per the 10/21/1999 annual survey by IDPH, R4 was observed in the same bathroom and on 2 separate occasions was observed to be chewing on the toilet seat.
2. The facility failed to ensure that staff of the facility practice health maintenance with regards to safe mobility and also failed to train R3 in safe mobility.
R3 is a 38 year old male with Severe Mental Retardation, Chronic Constipation, Dandy-Walker Cyst, Hydrocephalus, Uncontrolled Seizure Disorder, is verbal, but has significant intelligibility deficits. Over the past 6 months, R3 has experienced increased unsteadiness in independent ambulation, resulting in numerous falls. R3 requires a helmet and was observed to wear a gait belt throughout the survey.
On 03/22/2000, R3 was observed at the facility at approximately 9:00 a.m., sitting on a couch in the television room. R3 was observed to stand up and ambulate with a very unsteady gait to the dining room table. E4 was in the dining room and was damp mopping the linoleum floor. E4 had her back to R3 and did not observe R3 enter the area. As R3 approached the dining room chair, he was observed to almost lose his balance and fall. E4 turned around in time to catch R3 and assist him to the dining room chair. E4 was then observed to continue to damp mop the floor, all around R3's chair and feet, the mop coming into contact with the sides of R3's shoes. E4 then left the room without saying anything to R3 about the wet floor, or providing for R3's safety in her absence. R3 than stood up again, and left the dining room, ambulating with a very unsteady gait returning to the living room couch.
Review of R3's most recent IPP (individual program plan) of 03/24/1999 and review of R3's records and incident reports since 11/1999, revealed at least 26 falls. Two of these falls were down the stairs of the facility. Per documentation and interview with E1, and E2, R3's gait has been steadily declining and he has had at least 25 seizures since 11/1999 with medication changes necessary.
Review of facility records and confirmed per interview with E1, a physical therapy assessment was not completed until 02/17/2000. Confirmed per interview with E1, she did not request a copy of the assessment until 03/20/2000 and did not review the assessment until 03/22/2000. As of 03/23/2000 nursing has not assessed R3's mobility needs. Review of the physical therapy assessment for R3 revealed no programs were in place as recommended by the physical therapist. Confirmed per interview with E1.
As of 03/23/2000 nursing has not assessed R3's needs related to his frequent falls or seizures. Per review of this client's record and confirmed per interview, there is inconsistent assessment of this client's vital signs by nursing staff after R3 experienced a seizure or a fall. Per E1, revealed only some of the direct care staff in the facility are trained to take vital signs.
Confirmed per E1 the last assessment by the nurse for this client was completed in September, 1999. There is no evidence of any vital signs completed by nursing at the facility since this date.
Per observation of this client and confirmed per interview with E1 and E2, R3's bedroom is located on the upstairs level of which there are 2 landings. Per review of incident reports this client's recent falls included falling from the top of the stairs to the 1st landing (approximately 6-8 steps) on 12/06/1999. R3 also fell down the lower landing stairs (2 steps) on 01/08/2000. Per review of these incidents and all others since 01/09/2000, there is no evidence that this client was assessed for any injuries by nursing. Per review of further incident reports, they state on 01/07/2000, R3 almost fell down the stairs. On 01/23/2000, R3 was noted to be unsteady on the stairs. On 01/11/2000 R3 was noted to nearly fall on the outside stairs and was caught by staff. Per observation R3 was observed to get up from a sitting position independently and to ambulate at a forward rapid gait in which he was observed to fall into things. Per observation R3's bedroom is located on the upper level directly next to the stairway. Confirmed per interview with E3 that staff are not on the upper level at all times to monitor his physical safety.
Interview with E2 on 03/23/2000, revealed she would prefer that R3's bedroom not be located on the second floor, however she did not feel she could trade rooms due to a request by a family member of another client. Interview with E2, stated she was not aware that R3 had fallen.
The facility failed to monitor R3's status to identify conditions or changes in conditions which potentially could lead to R3's harm and/or deterioration.
Additional example for lack of nursing assessment and recommendations to the facility include lack of monitoring R3's fluid and food intake to prevent further weight loss.
Per file verification, R3's weight documented in March, 1999 as 150 pounds. R3's weight in February, 2000 is 134 pounds. Review of the dietician's record dated 02/29/2000, R3 has not been receiving adequate fluid intake or food intake and states, "we need to make every effort to keep him hydrated and help him to gain weight." The dietician notes state that by assessing the food and fluid intake sheets the facility has completed, that R3 is receiving 51% of his fluid needs and 67% of his calorie needs. Per review of this client's record, it states that there are numerous meals not documented for meal intake and R3's fluid intake is inconsistent and often low. Per recommendation of the dietician, the staff are to offer R3 fluids hourly to ensure adequate fluid intake and to provide a Sustacal pudding to this client at his 2:00 p.m. snack. Per observation of R3 on 03/20/2000, R3 was not offered fluids from 2:00 p.m., until 3:52 p.m. R3 was not provided a Sustacal pudding on 03/20/2000 at 2:00 p.m. R3 was also not offered fluids from 3:52 p.m. until his evening meal at 6:15 p.m. Per observation of R3 on 03/21/2000, R3 was only offered fluids at meal time for breakfast and lunch and at his 2:00 p.m. snack. On 03/22/2000, per observation from 8:15 a.m., until 10:00 a.m. R3 was only offered fluids with his lunch.
Per review of R3's physician's notes dated 03/09/2000, the physician recommends to increase R3's appetite with either IM or PO medication. "Weight loss must be addressed if not helpful G-tube may be needed."
E1 stated these options were discussed with the family, however there is no documentation which states the family's preference, nor does it include an assessment by the nurse as to recommendations for this client's weight loss.
The facility failed to ensure nursing services meets R3's nutritional and hydration needs.
An additional example for lack of nursing services includes R3's history of constipation.
R3 has a history of constipation per record review. R3's medication includes Docusate NA with Casant taken one time daily. Per review of records, R3 has sporadic problems with nausea and vomiting without apparent cause. Progress notes written by the non-nursing staff on 03/10/2000 at 9:35 p.m. state, "Staff has been concerned for R3 this p.m. He has been very sleepy and when awake all he would do is grunt and double over like his stomach hurt. Staff assisted him to the restroom several times but he couldn't seem to go...Home manager was called and suggested more fluids and less solids he may be constipated. Home manager also approved for him to have Tylenol...Staff tried to push more fluids but he refused...". On 03/11/2000 at 1:40 p.m., documentation states, "Staff was concerned about R3 again this a.m. for the same reasons as last p.m. He was taken to E.R.... He has refused to eat or drink."
Progress notes subsequent to the emergency room visit state he was very constipated and was given 1500cc enema and attempted to give him a fleets enema but he refused. Per notes they state he is to receive 1 teaspoon of Metamucil daily and to be placed on a BM list. Per progress notes dated 03/15/2000 they document that R3's physician stated he is, "to go no more than 3 days without a BM...Dr. will phone w/more info if more than 3 days w/o BM."
Review of the BM chart, reveals from 03/11/2000 when he received the enema at the emergency room, R3 had only a small BM on 03/15/2000 until he had a BM on 03/18/2000 which was so large that, "the toilet would not flush". Per BM chart as of 03/22/2000 R3 has no further bowel movements documented and there is no evidence of any action by the facility. Interview with E1 reveals if R3 does not have a bowel movement every 3 days he is to have Milk of Magnesia on the third day.
Per documentation and confirmed per interview with E1, R3 has received no Milk of Magnesia as of 03/22/2000. Per E1, she showed the surveyor a Post-It note that she had just found in the medication closet which stated: Milk of Magnesia on the third day if no BM and also a stool softener medication which was to be taken 2 times per day, which had not been initiated.
Per review of records and confirmed per interview with E1, there has been no nursing assessment of this client's constipation as of 03/22/2000 since 09/1999.
Per interview with E1 regarding nursing's recommendation to the (interdisciplinary team), E1 stated they do not have a nursing consultant at this time to assess this client. Per E2, she states the facility has not had a nurse consultant since 02/07/2000. However, per review of R3's nursing documentation, it states there has been no nursing assessment of this client since 09/1999.
The facility failed to ensure this clients health care needs are assessed with recommendation by nursing.
4. The facility neglected to ensure that R2, R3 and R6 (all of who have uncontrolled seizures) receive nursing services in accordance with their needs.
R2 is a 28 year old male with moderate mental retardation, uncontrolled Seizure Disorder, Hypertension and had a vagus nerve stimulator implanted on 06/23/1999 (to assist in lessening the frequency and intensity of R2's seizures).
Per review of R2's Individual Program Plan (IPP), R2's level of functioning data, dated 09/30/1999 document that R2's seizures, "are not controlled." R2's 03/2000 physician order sheet document that R2 receives Lamictal, Depakote and Tegretol for his seizures and Atenolol for his Hypertension.
Per review of an incident report dated 09/20/1999, R2 experienced a seizure while in the bathtub. "R2 was in the bathtub. Staff in the dining room....last(ed) ll min (minutes)...".
Per file verification, R2's level of functioning document dated 09/30/1999 states that, "Due to seizure activity, R2 is monitored when showering." Per interview with E2 (03/27/2000) and E4 (03/22/2000), both confirm that all individuals in the facility with seizure diagnoses are not constantly monitored while in the bath/shower. Both E1 and E4 concurred that individuals are checked on periodically. E4 specifically stated that they (staff), "check on them every once in a while."
On 03/20/2000 staff were not observed to check on R2 during his p.m. shower/bath. Per review of the 09/20/1999 incident report and nursing notes, there are no recommendations from the nursing consultant with regards to ensuring the safety of R2 or other individuals with uncontrolled seizures during bath/shower time, nor is there reproducible documentation that R2's vitals were checked after his 11 minute seizure or any other seizures experienced by R2.
Additional example for R6 (47 year old male with a diagnosis of uncontrolled seizures) with regards to only periodic checking of R6 during bath/shower time.
On 02/09/2000, an incident report states that at approximately 3:55 p.m., R7 came downstairs (at the time of the survey, R2's room was on the second floor of the facility. There are two landings on the staircase) and notified staff that R2, "was having a seizure." The report states that when the staff arrived upstairs, R2 "had a glassy look in his eyes and appeared to be dazed...there was evidence in (R11 and R7's) room of a broken lamp. R7 stated that R2 had been in her room." Per interview with E4 (on 03/21/2000), E4 stated that she had to look for R2 when she first went upstairs, after having been notified by R7 of R2's seizure.
Review of the 02/09/2000 incident report for R2's seizure does not indicate that nursing reviewed the report, and there are no nursing notes for R2 from 11/09/1999. Additionally, there is no reproducible documentation that R2's vital signs were checked after his seizures. Nursing did not make any recommendations for R2 or other individuals who have uncontrolled seizures with regards to their safety and second floor living area, nor for their care after a seizure.
Per review of R2's monthly summaries and medical communication goals, R2 saw his physician on 06/22/1999 for increased blood pressure concerns. August 10, 1999 notes state that R2's blood pressure readings were faxed to R2's physician for 06/01-08/1999; and readings were again faxed on 10/05/1999. On 10/19/1999, nursing notes state that R2 will need to see his physician again for his increased blood pressure.
On 11/04/1999, the physician increased R2's blood pressure medication to 50mg. daily (Atenolol) The medical communication sheet states on the same date, "we are to keep checking his blood pressure weekly to monitor." The 11/09/1999 notes signed by the consulting nurse states, "R2 needs to have his BP (blood pressure) monitored (at) least 1X week. Document B/P reading - fax results to (physician) 1X month." BP results for R2 are documented for 11/17, 11/23, 11/30 and 12/08. No further documented blood pressure readings are noted for R2 after 12/08/1999 and no further assessments/recommendations by nursing are found with regards to R2's blood pressure.
Per interview with E1 on 03/22/2000, E1 confirmed that vital signs are not completed for individuals after they experience a seizure and per file verification, there are no recommendations from nursing to direct care staff as to monitoring the vitals of individuals after seizures.
Facility nursing neglected to ensure that individuals with uncontrolled seizures receive nursing services in accordance with their needs.
Additional example for physician ordered labs not completed for R4 (29 year old male with profound mental retardation, Legal Blindness, Seizure Disorder and who is non-verbal) who has a current physician order for Dilantin and Tegretol levels to be drawn every 12 months. Per file verification and confirmed per E1 on 03/22/2000, R4's last Dilantin level was drawn on 01/12/1999 (R4's Dilantin level was 5, with 10-20 being in the normal range). R4's last Tegretol was drawn on 03/01/1999. E1 revealed the facility nurse is responsible for blood draws and due to lack of a facility nurse, the labs were not obtained.
5. R's 1, 2, 3 and 4 have not received quarterly health status assessments in a timely manner.
R4 is a 29 year old male with Profound Mental Retardation, Legal Blindness, Seizure Disorder, Constipation, Incontinence and is non-verbal. Additionally, R4 is under his ideal body weight (119 lbs, with ideal body weight of 148, plus or minus 10%), and has dietary recommendations to push fluids and record fluid consumption.
R4 receives daily medication for constipation and receives an enema when he does not have a bowel movement within 5 days.
R4 also utilizes incontinence briefs and has a prn order for Carafate/Silvadene Cream when his buttocks area becomes excoriated.
Per file verification and confirmed per E1 on 03/22/2000, R4 has not received a quarterly nursing assessment since 08/17/1999.
Additional example for lack of quarterly health status assessment as follows:
a) R2 (28 year old male with Moderate Mental Retardation, Hypertension (R2's last blood pressure range since 05/26/1999 was 120/84 -160/100), Seizure Disorder that is not controlled (R2 has a neuro cybernetic prothesis system implant to assist in seizure control), whose last quarterly nursing assessment was 08/26/1999.
b) R1's (58 year old male with Mild Mental Retardation and Chronic Prostatitus) last quarterly nursing assessment was 09/21/1999.
c) R3 (38 year old male with Severe Mental Retardation, Chronic Constipation, Dandy-Walker Cyst, Hydrocephalus, uncontrolled Seizure Disorder) has experienced increased unsteadiness in independent ambulation and numerous falls in the last 6 months. R3 currently wears a helmet and was observed to wear a gait belt throughout the survey. R3's last quarterly nursing assessment was 09/21/1999.