RACHUY HOUSE

Facility I.D. Number 0038695
605 N. Main St.
Stockton, Illinois 61085

Date of Survey 12/8/99

Incident Report Investigation

"A" VIOLATION(S):

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 evidence by the following:

1) Based on interview and file verification, the facility failed to provide clients with nursing services in accordance with their needs for 1 of 1 individual involved in the incident of 11/06/99 in which an individual was found face down in water in bathtub and later pronounced dead.

R1, a 23 year old moderately mentally retarded male diagnosed with Lennox-Gastaut Syndrome and Cerebral Palsy, with an unsteady gait, was admitted to the facility on 07/22/99. R1 had a long history (since the age of 4 years) of frequent seizure activity.In October, 1998, R1 had a vagal implant put in place to stimulate the vagal nerve behind his vocal cords to help aid with seizure control. In addition to the implant, R1 was on five different medicians for seizures (Mysoline, Laminotal, Dilantin, Zarontin and Klonopin).

According to R1's Medical notes: On 07/22/99, he was taken to the Freeport Memorial Hospital ER

where he received 5 sutures to his chin following a fall. Another entry reads that on 08/05/99, R1 was taken by ambulance to the Freeport Memorial Hospital ER due to seizure activity. At the ER, R1's Dilantin level was found to be low and 500 mg. of Dilantin was administrated IV push. R1's daily Lamictal was subsequently increased.

On 09/16/99, Z2 was contacted regarding R1 “having simple partial seizures for extended periods of time...She (Z2)stated to give (R1) 100 mg. of Lamictal and watch him for 45 mins. If (within) the 45 mins. he experienced another long seizure, staff was to transport him to the hospital.” (Documentation by E5, not a nurse).

On 09/22/99, and again on 11/01/99, R1 was seen by Z2 in Chicago.

R1 was transported to Freeport Memorial Hospital ER by ambulance on 10/20/99 after having had a grand mal seizure lasting 10 minutes. His Dilantin level was low and 400 mg. Dilantin IV push was given. According to his medical Notes, “He had refused to get up and take his medication that morning. A little later he went to the bathroom to shower as he had an accident in bed and staff heard him hit the wall as he fell, having a seizure.”

On 10/26/99, R1 was transported to Freeport Memorial Hospital ER “due to having a partial complex seizure lasting greater than 45 minutes. “On 11/01/99, per both a Medical Notes entry and by E4 a “Medication Error Form”, this individual received only 150 mg of Lamictal rather than the ordered 200 mg. as there were “no 25 mg. tabs in medication drawer.” The Medical Notes entry by E4 reads “call was placed..no call returned...” Per interview with E4 on 12/01/99, Z2 was not notified.

Per the facility’s Registered Nurse DON Job Description, the nurse is to:

1. Provide “periodic evaluations/reevaluations of the type, extent and quality of services and programming. No evaluations by a nurse regarding services and programming were noted to have been performed prior to 10/25/99 (3 months after admission). Confirmed on interview with E3 12/02/99, there is no documentation by a nurse prior to 10/25/99.
   
   
2. Develop “a written nursing services care plan for each resident as part of the total plan of care and habilitation program” and “modifies the...plan in terms of residents daily needs at least annually but more often as needs arise.” No nursing services care plan was found to have been developed prior to 10/25/99. No nursing documentation prior to 10/25/99 as confirmed on interview with E3 on 12/02/99.
   
   
3. Provide "training of staff personnel as required”, to include “detecting signs of illness or dysfunction that warrant medical or nursing intervention, basic skills required to meet the health needs and problems of the individuals...”No documentation of any training pertaining to R1 by a registered nurse was noted. Per interview with E4 on 12/01/99, she has not conducted any in-services (hire date 09/25/99). Prior to 10/25/99, there is no documentation by a nurse as confirmed by E3 on 12/02/99.
   
   
4. “supervises the health services.” Per interview with E2 and E3 on 12/01/99, there is currently no review by the nurse of Incident Reports including those of medical nature. Per interview with Z1 on 12/01/99, she stated. (I) “don’t believe I have (ever) been contacted by an R.N.” (regarding R1). An interview with E4 on 12/01/99 reveals that she never spoke with either Z1 or Z2 about R1.

According to the termination letter addressed to E1 by E2 dated September 20, 1999, it reads that the facility “ tried several times over the last few months to contact you.” Per interview with E2 on 12/06/99 at 4:05 p.m., the last documentation on a resident’s record appears to be that of May 16, 1999. Per E2, E1 “never showed up for work” after May 16 (1999). E4's hire date is that of 09/25/99. From June, 1999 to September 25, 1999 the facility failed to provide nursing consultation for all clients of the facility.

No nurse evaluated, made recommendations, trained direct care staff, supervised or co-ordinated the health care of R1 from his admission 07/22/99 to 10/25/99. In view of R1's history and health status while at the facility, (85 seizures of varying degrees are documented from 07/23/99 to 11/04/99 on R1's Seizure Record), R1 should have always been supervised while bathing.

R2-R5 have a diagnosis of seizure disorder. There was no policy in place at the time of the incident of 11/06/99 to provide supervision during bathing for R1-R5.

On November 6, 1999, at approximately 9a.m. , R1 was found in the bathtub in about 2 inches of water. R1 was kneeling with his face in the water; there had been a bowel movement in the water. At approximately 9:30 a.m., R1 was transported by ambulance to Freeport Memorial Hospital where he was pronounced dead.

The facility neglected to provide nursing services to R1 in accordance with his needs.