RIVER BLUFF OF CAHOKIA NURSING
Facility I.D. Number 0045005
3354 Jerome Lane
Cahokia, IL. 62206
Date of Survey: 04/06/01
Noted of Violation:08/08/01
Annual Licensure survey, Incident Investigation of 2/13/01, Complaint Investigation 0141807
All persons seeking admission to a nursing facility must be screened to determine the need for nursing facility services prior to being admitted, regardless of income, assets, or funding source.
No resident shall be admitted to or kept in the facility: Who is mentally ill, in need of mental treatment, and at risk because the person is reasonably expected to self-inflict serious physical harm or to inflict serious physical harm on another person in the near future as a result of the mental illness, as determined by professional evaluation.
No resident shall be admitted to the facility who is developmentally disabled and who needs programming for such conditions.
The facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of the resident, in accordance with each resident’s comprehensive assessment and plan of care. Adequate and properly supervised nursing care and personal care shall be provided to each resident to meet the total nursing and personal care needs of the resident.
Objective observations of changes in a resident’s condition, including mental and emotional changes, as a means for analyzing and determining care required and the need for further medical evaluation and treatment shall be made by nursing staff and recorded in the resident’s medical record.
All necessary precautions shall be taken to assure that the residents’ environment remains as free of accident hazards as possible. All nursing personnel shall evaluate residents to see that each resident receives adequate supervision and assistance to prevent accidents.
Each resident shall have a comprehensive assessment of the residents’ needs, which include medically defined conditions and medical functional status, sensory and physical impairments, nutritional status and requirements, psychosocial status, discharge potential, dental condition, activities potential, rehabilitation potential, cognitive status, and drug therapy.
Each resident shall have an up-to-date resident care plan for each resident based on the resident’scomprehensive assessment, individual needs and goals to be accomplished, physician’s orders, and personal care and nursing needs. The plan shall be in writing and shall be reviewed and modified in keeping with the care needed as indicated by the resident’s condition.
The record shall include medically defined conditions and prior medical history, medical status, physical and mental functional status, sensory and physical impairments, nutritional status, discharge potential, rehabilitation potential, cognitive status and drug therapy.
Each resident’s medical record shall contain nurse’s notes that describe the nursing care provided, observations and assessment of symptoms, reactions to treatments and medications, progression toward or regression from each resident’s established goals, and changes in the resident’s physical or emotional condition.
Each resident’s medical record shall contain an ongoing record of notations describing significant observations or developments regarding each resident’s condition and response to treatments and programs.
These requirements are not met as evidenced by:
1) In a written statement dated 12/3/00, E20 wrote that on 12/3/00 at approximately 8:15 p.m. E20 heard a woman's scream on West 1 Hall in room 55. E20 stated that she "busted" in the room and found R80 on top of R19. E20 wrote that R80 had R19's "legs raised in the air" and R80 "was lying between them." R80 was partially naked with a white T- shirt on and no underwear. E20 stated that she screamed and "went to go get help". Two staff, E21 and E11, came to assist E20. E20 wrote that E11 asked R19, "Are you hurt? Did he do anything to you?”. Female resident replied and said, “Yes, he put that thing between my legs."
Interview with E20 on 12/14/00 at 3:25 p.m. in the front admission office reveals that she was working on West I Hallway on 12/3/00. E20 stated that she was coming out of a resident’s room that she had just taken care of at approximately quarter of eight when she heard a scream from room 55. She stated that it sounded like a frantic type scream. E20 stated that she busted through the door of room 55 and saw R80 on top of R19 in bed 1. E20 stated that R80 was on top of R19 and R19's legs were up in the air with her gown up to her hips. E20 stated that R80 was between R19's legs and only had a T-shirt on, no bottoms, and no underwear. E20 stated that she was shocked and she screamed for help. Two nurses came, E11 and E21. When E20 returned to the room R19 was standing up by the bed near the night stand "shaking like a leaf". R80 was on his back in bed and E11 asked R80 what he was doing with this woman in his room. R80 said,"Nothing. She came into my room", and pointed to R19 and R80 dropped R19's underwear on the floor. E11 asked R19 what happened and she stated that he stuck that old thing between my legs. E20 stated that the nurses took R19 out of the room and R80 put his clothes on and went to the smoke room to smoke.
The medical record for R80 notes that R80 is 5'9" tall and weighs 290 pounds. R19 is 5'0" tall and weighs 105 pounds.
In a written statement, with a time of 8:15 p.m. and a date of 12/3/00, E21 wrote that a CNA yelled for help on West I hall and E20 and another nurse came to investigate. E21 wrote that she found R80, of room 55, in "sims position, naked with only a white T shirt on, with his butt in the air". E21 wrote that R19 was standing near the night stand with her gown on backward and/or inside out. E21 wrote R80 jumped up and said that R19 had come into his room and he threw her panties toward the
foot of the bed. E21 wrote that she spoke to R19 and R19 stated that "he put that thing between my legs and it hurt". E21 wrote that as she was walking R19 back to her room E21 asked R19 what happened again and she said, "I haven't been touched that way since I was married."
Interview with E21 on 12/14/00 at 3:00 p.m., at the back nurses station, confirmed the above statements. E21 stated that when she entered the room R19 was standing by the night stand and her clothes were in disarray and she was shaking. E21 stated that she was told that R80 had aggressive behavior to staff. E21 stated that she told E23 and E20 not to shower R19 as that would get rid of the evidence.
In a written statement dated 12/3/00 by E11 she wrote that she heard E20 calling out for help and went to the room and observed R80 in bed in "knee chest position with buttock exposed wearing a white T-shirt." E11 wrote that R19 was standing by the night stand with her gown on "wrong side and on one arm." E11 wrote that R19 stated, "He tried to get me." E11 stated that R19 was asked if he did anything and she stated, "He put that thing between my legs." E11 wrote that R80 stated that R19 tried to get in his bed and pointed to R19's pink panties on the floor.
Interview with E11 on 12/14/00 at 5:10 p.m., in the bookkeeper’s office, confirmed the above statements. E11 stated that R80 had no clothes on from the waist down. E11 stated that E20 stated that R80 had thrown the pink panties on the floor. E11 stated that she called E2, who was Assistant Director of Nursing at the time and on call. E2 stated to send R80 out for possible assault of a femaleresident. E11 stated that R80 got dressed and went to the smoke room. E11 informed R80 that he was going to the hospital and R80 asked if he would be back. E11 stated that it would depend on his physician. R80 stated, "I will be good".
R80 was sent to St. Mary's Emergency Room.
The nurses notes in R19's medical record dated 12/3/00 at 8:15 p.m. were written by E23. The nurses notes state, "Pt in male room, CNA heard pt yelling." The note states that E20 "busted into room finding Black male on top of pt with pt's legs up in air with male between pt. Male had no pants on, T-shirt only on. Gown on pt twist with one arm in. Pt panties were in males hand when (E20) busted in the closed door male threw them on the floor stating ?get this women out of here’.” CNA report room was dark, “all she seen was buttocks in air". The nurses note dated 12/3/00 at 8:20 p.m. stated that R19 was ambulated to her own room and appeared shaken up and stated, "I'm scarred". E23 wrote in the nurses notes that R19's vagina was visually examined for any external trauma and none was noted. The nurses notes dated 12/3/00 at 9:00 p.m. state that R19 was transported to St. Mary's Hospital Emergency Room. The "Patient Transfer Form" signed by E23 and dated 12/3/00 states that R19's primary diagnosis is "Possibly Sexually Attacked".
The St. Mary's Hospital Emergency Room "ER DISCHARGE" report, dated 12/3/00, for R19 states the diagnosis "Alleged Sexual Assualt". The "ER Discharge" initial nurses note states: "C/O pain R hip. Denies sexual assault. States nobody touched her. Denies vag pain. States ?Everything is fine’. Per Riverbluff nursing home employee (E20), CNA, states, ?About 2015 I was doing my work and I heard a lady scream. I opened (R80's) door up and the room was kind of dark. But I saw another resident (R80) His bare butt facing me and he was laying on top of (R19) with her legs up in the air. I screamed. Ran out. Got LPN (E23). Went back in asked him what he was doing. He threw her underwear on the floor from his hand. And was trying to pull his pants up and (R19) had her gown pulled up to her waist’.” The report also stated, "SW: Refer to victim services".
The St. Mary's Hospital physician "Emergency Report" dated 12/3/00, by Z9, states that R19 was brought to the emergency room with a report that the patient possibly had sexual assault. The "Physical Examination" states in the "General Exam", "The patient is conscious. She is disoriented to time, person and place. The patient denies any gastrointestinal, genitourinary or respiratory symptoms. She had inconsistent complaint of right hip pain . She is in no acute distress." The "Genitalia” states, “ There are no gross injuries or lesions to the genitalia." The "Medical Decision Making" states "Emergency Department Course: The patient was observed in the emergency department. The physical examination was unremarkable. The patient was repeatedly asked about any incident related to sexual assault or sexual encounter and the patient seems to be emphatically denying anything related to such activity. The nursing home was notified and the patient was returned to the nursing home by ambulance." The final diagnosis was "Alleged Sexual Assault".
The facility nurses notes dated 12/3/00 at 10:20 p.m. by E23 states that she received a report from St. Mary's ER nurse who informed E23 "when she asked pt what had happened pt replied I just sucked on her breast then swung out at ER nurse."
The nurses notes at 10:55 p.m. states that the ER nurse called the facility to inform her that the ER physician felt that there was no need to perform a rape exam and no x-rays were taken. The note stated “If pt experiences any vag discharge return her to ER." The ER nurse was noted to say in the nurses notes that she had informed the physician that the patient had stated that he only sucked on her breast. The nurses notes dated 12/3/00 at 11:20 p.m. and 12:15 a.m. on 12/4/00, state that the emergency room at St. Mary's was contacted and verified that there was no vaginal exam or x-rays done. The St. Mary's physician stated that "his exam of resident’s vagina showed no evidence of trauma (laceration, abrasions or contusions). Dr. stated that resident told him she was in no pain and no rape had occurred and based on the above assessment no rape kit exam or x-rays were done." R19 was returned to the facility and at 5:20 a.m. on 12/4/00 was noted in the nurses notes as "wandering through the halls andmumbling, pt is (increased) confused at this time".
According to the Cahokia police report they were called on 12/3/00 at 2141 hours by the nursing home. An officer, Z10, was dispatched at 2141 and arrived at the nursing home at 2145. The incident occurred at 2015. The police report stated that the reporting officer was dispatched to River Bluffs Nursing and Rehabilitation Center in reference to a criminal sexual assault complaint. According to the police report dated 12/3/00, Z10 arrived at the facility and spoke to E11. The report stated that one of the residents of the facility sexually assaulted another resident of the facility.
The police report stated that E11 stated that R80 was "observed possibly having intercourse with" R19 in R80's assigned room. The report stated that both residents had been transported to St. Mary's Hospital prior to Z10's arrival. Z10 spoke to E20 and according to the police report E20 stated that "at approximately 2015 hrs, she was cleaning room to room when she heard a female screaming from room #55. (E20) stated the door to the room was closed shut. (E20) said, ?I heard a frightening scream. I busted in the door. I saw (R80) on top of (R19) with her legs in the air. His tee shirt was still on, but he was not wearing any pants. His butt was up in the air. She had her gown on, but it was pushed up. I screamed and left the room. I went to go get some nurses. When I came back, she stood up and started shaking. He said he wasn't doing anything. He had her underwear in his hands.’ (E20) stated (R19) said, ?He stuck his thing between my legs’." The police report states that both subjects were lying on R80's bed.
According to the police report Z10 went to St. Mary's Emergency Room, where he spoke to Z11, who stated that R19 did not remember anything. Z11 stated that R19 stated, "No one touched me". Z11 stated that the doctor did not feel a sexual assault evaluation would be conducted at this time. Z11 stated that she had questioned R80 about the incident and R80 stated that he just sucked her breast. He stated he didn't penetrate her. He states she said "no". He stated that she told him she has been raped in the past.
The police report states that Z10 could not get a statement from R19 due to her medical condition. Z10 spoke to R80 and R80 stated, "A girl came into my room and woke me up. She fell on top of me. I didn't fuck her". R80 would not give any more information. The police report ended by saying that Z11 stated that R80 would be admitted to the hospital and R19 would be transported back to the nursing home.
An interview with R19 was conducted 12/14/00 at 1:25 p.m. in her room. R19 stated that she couldn't remember things like she used to. R19 was questioned about the incident about 2 weeks ago when a man was on top of her. R19 replied that she did remember but that she did not know who that man was. R19 stated that he was brown skinned but could not remember his name. R19 stated that she did not have anything to hit him with. R19 was asked if she remembered what he did to her and she replied, "He tried to have me. I told him I was going to get the house authority after him. He went out that door running. I said they coming to get you." R19 was asked if the man put his penis in her and she replied that he got it in a little bit and that she hollered and tried to wake up the whole house. R19 stated that no one came to help her but then stated someone that looked like a nurse came in. R19 stated, "I don't want no man". R19 was asked if she remembered going to the hospital and stated she couldn't remember but thought that she did and that nothing was wrong.
The "Final Incident Investigation Report" was sent to the Illinois Dept. of Public Health office on 12/11/00 by E18. The form states R19 as the "Name of the Resident Abused or Neglected". The form states that R19 was in male resident’s room on 12/3/00 with a male resident on top of her. The form states that the following conclusions were determined: "Even though penetration or trauma to vaginal area could not be established by ER physician, male resident was observed by staff to be in a compromising position and male resident did tell ER nurse that he "sucked her breast"; therefore allegation was found by facility to be valid". E18 wrote on the form that the following actions were taken based on the conclusion of the investigation as "male resident along with family and public health received a 30 day discharge. Female resident was placed on 15 min checks x 24 hours upon return from hospital and remains on hourly checks with no further incident". The facility did not send IDPH a copy of the police report.
R19 is a 78 year old female admitted to the facility on 11/15/00 from the hospital. Her diagnoses, in part, are dementia, schizophrenia, alzheimers, psychosis, late paraphrenia, and hypertension. The history and physical of 11/16/00 reveals that her family found her confused and unable to care for self.
The Minimum Data Set, (MDS), dated 11/27/00, notes that R19 has modified independence withcognitive skills with long and was assessed as having the behavior of wandering. This behavior occurred daily. The social service history and initial assessment dated 11/16/00 noted that R19 "needs assist & supervision for all her care. She is confused, oriented x 1." The assessment also stated that R19 was able to ambulate in the facility and is a high risk for elopement. R19 was assessed on 11/15/00 on the "Wandering Risk Assessment" as "at risk for wandering.”
The care plan dated 11/16/00 states "Problems" for R19 as: "has dx of dementia, wanders throughout facility, may be physically & verbally abusive at times. Receives antianxiety & antipsychotic"; "has little time spent in activities, has poor cognition, may be aggressive toward staff"; "has decreased cognition, has poor memory recall, difficulty with locating room"; "at risk for falls r/t (related to) wandering, unsteady gait, independent with ambulation, psychotropic med use, decreased cognition, incont"; "has dementia, may be verbal, physical, socially inappropriate, sits in the day room, will tear couch apart, takes shoes off et (and) sticks in the couch"; "At risk for injuries r/t wandering throughout facility without any regards of safety. Will wander into other rooms-lay in other resident’s beds besides her own, has poor cognition, dx of, schizophrenia,dementia. Is an elopement risk"; "Needs supervision and verbal cueing with ADL's".
Pertinent approaches listed on the care plan to address the problems listed are: "Name tag on door/room identified as hers; Direct res (resident) to her hall, room, and room #; Monitor res whereabouts; assist res to find her own room to lay down in; Redirect away from others rooms and doors; Remove from others room immediately to avoid any harm ".
Further review of clinical record reveals that on 12/3/00, R19's family was concerned about her "falling while in church today, she's overly medicated". R19 had a physician’s order dated 11/15/00 for Haldol 4 mgs TID and Ativan 1 mg TID. The physician discontinued both medications on 12/3/00 at 5 p.m., which is just prior to the sexual assault incident. Nurses notes reveal that R19's behaviors escalated over the next month, with numerous episodes of behaviors noted. Nurses notes reveal on 1/9/01 at 8:05 p.m., "Resident extremely agitated, pulling at other residents, threatening staff-behaviors has been escalating since approximately 1 month prior to when Ativan and Haldol ordered routinely tid were discontinued per family's request due to resident appearing to them to be too "blah"." On 12/10/00, at 1:45 p.m., nurses notes reveal, "R19 stayed in bed today. Took meals in room. Res. R. leg rotating outward et res c/o pain in femur area. PROM (passive range of motion) to res lower extrem reveal L ext to 30% et R ext not able to move. Res not able to bear wt on R leg". The physician was contacted and R19 was sent to the hospital for x-rays. 12/10/00 nurses notes reveal, "6:35 p.m., Resident returned via (ambulance) no acute distress-to order Vioxx 25 mg po qd for DX of DJD of right hip...."
Nurses notes further reveal on 12/13/00, at 3:00 p.m., "Resident c/o burning when urinating". The physician was contacted and a urine specimen was ordered. The urinalysis results, dated 12/14/00, were within normal limits. The physician prescribed Pyridium 200 mg 3x for 3 days, on 12/13/00.
R80 was admitted to the facility on 10/11/00 with diagnoses, in part, of schizophrenia and early hypertension. Medication order was Haldol Concentrate, 5mg, 4 times a day; Ativan 1 mg in the morning and at bedtime; Mellaril 100 mg at bedtime. R80 was 44 years old. The medical records face sheet from River Bluffs Nursing and Rehabilitation states that R80 was admitted from St. Mary's Hospital, however, the Social Service History and Initial Assessment dated 10/13/00 states that R80 was admitted from Royal Heights Nursing and Rehabilitation Center, a sister facility. The "Post-Discharge Plan of Care" states that R80 did come from Royal Heights Nursing and Rehab.
The "Post Discharge Plan of Care" dated 10/11/00 was available in the chart at River Bluffs. It did not address any behaviors that R80 exhibited while at Royal Heights Nursing Home. Record review of R80's closed record at Royal Heights Nursing and Rehab revealed that R80 was admitted to that nursing home on 4/28/00. The Social Service History dated 4/27/00 notes that R80 can become hostile and abusive toward staff. The care plan dated 9/18/00 states that R80 becomes verbally aggressive with peers and staff . The care plan dated 5/16/00 stated there was a potential for harm to self and others due to a past history of physical aggression. The Long Term Specialized Rehabilitation Services Goal identified on 9/15/00 note the problem area for R80 is "Anger, agitation when he doesn't get his way, Poor coping, aggression towards others when he feels threatened by others, cursing, arguing, (with staff and peers), poor insight into illness, believes he is doing nothing wrong."
Incidents reviewed in chart included: 4/28/00 attempted to kick staff in the head; 5/8/00 attempted to hit staff; 9/18/00 R80 struck a female resident in the face; 5/7/00 asking female residents if they needed to "pee-pee". The chart indicates R80 was discharged from the facility due to smoking cigarettes in unapproved areas.
The Social Service History dated 10/13/00 at River Bluffs Nursing Home states that R80 stated when asked why he was placed in River Bluffs Nursing Home that "I got Auntie pregnant".
On 10/24/00, R80 attacked E25 and was admitted to a hospital Psychiatric Unit for “extremely agitated with flightiness, loosening, inappropriate striking out at others, not responding to advisories, and generally created quite a behavioral and management problem to the point where they could not handle him on Haldol 10 mg twice a day and Ativan 1 mg twice a day”, per History and Physical dated 10/24/00, written by Z12. Review of Haldol dosage in Physician Desk Reference 2001 reveals, “For severe symptomatology give 3.0 mg to 5.0 mg twice a day or three times a day”.
R80 was readmitted to facility on 11/02/00. Review of facility incident investigation dated 12/3/00, on 11/5/00 R80 threatened a female resident by telling her he would go inside her bra to search her for a cigarette.
Review of R80's Minimum Data Set (MDS) dated 10/26/2000, reveals R80 had all “0"s under Section E, Mood and Behavior Patterns, including #4, Behavioral Symptoms. The physician progress note dated 11/17/00 states R80 has a history of aggressive behavior in the past with multiple hospital admission because of that. The Minimum Data Set states that R80 is independent in cognitive function with no long or short term memory problems. The MDS does not identify any behavior symptoms such as verbal or physically abusive behavior. The MDS assessed R80 as independent with ambulation. The care plan did not address any verbal or physical abusive behavior until 11/3/00 after R80 attacked a staff from behind and hit him in the head on 10/24/00. R80 was sent to the hospital due to that incident.
The History and Physical from St. Mary's Hospital, dated 4/13/00, stated that R80 was admitted to the hospital from a Boarding Home due to the fact that R80 was angry and threatening violence. The history and physical stated that R80 had a history of abusing alcohol. A consultation record dated 4/15/00 noted a complaint of penile lesion. It states that R80 was admitted for acute sarcosis. R80 reportedly had been repeatedly masturbating according to the nurses. This history and physical was in the chart at River Bluffs.
There was no documentation of sexual behavior in R80's chart except on 11/5/00 when he stated he would go inside a female residents bra to search for cigarettes. Interview with E 7 on 1/16/01 at 12:47 revealed that E7 stated that R80 would strip and masturbate with the door open. This was found often.
Interview with E23 on 4/05/01 confirmed that R80 did not return to the facility after he was discharged to the hospital on 12/03/00.
To clarify the term "Boarding Home", Z8 was interviewed by telephone on 4/5/01 at 1:19 p.m.. Z8 revealed a "Boarding Home" is a private shelter care home. People who want to provide shelter care for residents, this includes meals, housing and sometimes laundry and personal 24 hour care, have "Boarding Homes”. Z8 refers residents to them and also Comprehensive Mental Health Agency will assess residents and place them in Boarding Homes. Z8 stated these residents in Boarding Homes are homeless and pay $325.00 to $350.00 per month from their Social Security Income. Z8 stated due to not wanting to be under State Regulations, these Shelter Care Homes are called Boarding Homes. Z8 stated she is the liaison between St. Mary's
Hospital Psychiatric Unit and River Bluffs. She places residents and then follows their progress. She also places residents in Boarding Homes. Z8 named 5 Boarding Homes in East St. Louis and stated that was all she could think of, but there were more. Due to confidentiality, Z8 could not talk about R80 specifically. Interview ended with verification that homeless residents live in the Boarding Homes.
Interview with E17 on 4/5/01 at 1:35 p.m. reveals she did not know anything about Boarding Homes. Interview with E9, 4/5/01 at 1:36 p.m. reveals, "they call the places Boarding Homes, but they are really assisted living places".
2) Based on observations, clinical record review and resident, staff and other interviews, it was 1) determined that facility failed to determine need for and provide adequate supervision of residents (R15, 38, 6,17,22,16,80). The facility admits residents who have been screened on the "Illinois Department of Public Aid Interagency Certification of Screening Results" as not appropriate for nursing facility (R15, 6, 17, 38,) Physician Certification does not address level of care which 2 residents require (R51, 16). Due to being Homeless and coming from Illinois Department of Corrections (IDOC), residents have not been assessed for level of supervision needed (R15, 38, 6, 17, 22,16,80). No additional supervision has been added for residents from IDOC. One was assessed as not needing care (R15), and the others, even though screened appropriately, record review and observations revealed that these residents did not need nursing home care at this time (R55, 22).
Homeless residents were pre-screened with no need for nursing home care noted on the form (6, 17, 38,58, 18). One resident (R6) has a history of alcohol and drug abuse with no rehabilitation. One resident (R51), has a history of inappropriate/violent behavior and knocked an elderly resident from her wheelchair and had one resident with an MR/MI diagnosis, in his room, with that resident's pants down. One homeless resident had a history of inappropriate/violent behavior (R80) and sexually assaulted an elderly female resident.
Inquiry of E12 on 3/20/01 at 1:50 p.m. in her office revealed that there were residents at the facility (R15, 22, 55) that had been admitted to the facility from the Department of Corrections(IDOC). E 12 stated the residents from IDOC were at the facility finishing their time before they went home and that they were on probation. E12 stated there was no plan for discharge and there was no special programs in place for these residents. E12 stated the residents from IDOC attended activities at the facility as well as activities outside the facility. Once a month, the residents from IDOC went to an IDOC meeting outside the facility. E12 stated that IDOC checks on the residents on a regular basis and she could call the parole officer if there was a problem. E12 stated there had not been any problems with the residents from IDOC. E12 stated there was no social history available to her regarding why the residents from IDOC were in prison, and she did not know why they were in prison and did not want to know.
Interview with E1, on 3/21/01, at 2:35 p.m., in the far corner of the dining room, confirmed there were residents from IDOC at the facility. E1 stated that all were directly admitted from a correctional facility and that all were paroled. E1 stated she was not sure if she should tell the surveyor why the residents had been in prison. E1 stated the information on each resident from IDOC was kept in her office and this information was private. E1 stated that she did not know why the residents had been in prison. E1 stated she would check with the parole officer to see if it was all right to tell the surveyor why the residents had been in prison.
On 3/21/01 at 4:15 p.m. in the hallway by the copy machine, E1 stated she had called the parole officer and she could not tell the surveyor why the residents had been in prison, per the parole officer, and the surveyor could call him if there was any questions. On 3/21/01 at 5:00 p.m. E1 was informed by the Illinois Department of Public Health that the information on the residents from IDOC would need to be provided to the surveyors, according to the licensure regulation requirements. E1 complied and folders on R15 and R22 were given to the surveyors, which contained information as to why the residents had been in prison. E1 stated there was no information on R 55.
Interview with the Director of Nursing (E2) on 3/21/01 at 5:09 p.m. in the Admissions Coordinator’s office revealed the IDOC residents mainly keep to themselves in their room. E2 stated Facility had not been lulled into a sense of security. E2 stated there was a young child in the facility on the afternoon of 3/21/01 and they were watching the child to make sure the child was in view at all times. R55 and R22 cannot be alone with young children and/or have a restraining order that protects a young child from contact with them due to their previous convictions. E2 confirmed there was no care plan in place that addressed the supervision of the residents from the IDOC, nor had the staff at the nursing home been told by administration why the residents had been in prison, due to confidentiality. E2 stated the residents had told the staff themselves why they were in prison and felt staff knew the reason for their incarceration. E2 confirmed the residents from IDOC could leave the facility to go shopping, unsupervised, to places such as to Walmart, however, there were some restrictions.
On 4/2/01 the facility was asked to provide copies of the facility policy on signing in and out of the facility and the "Sign Out" sheets for R6, 15, 51, 55, and 22. The facility provided the policy "Leave of Absence (Out on Pass)". The policy states that a Leave of Absence will be granted upon the order of the attending physician. E1 noted R15, 51 and 22 did not sign out of the facility and there were no sheets for them. Review of R6's sign out sheet revealed multiple sign-outs but he did not sign every day that he was actually gone. Not all of the days signed-out had return times posted for the actual times when R6 returned to the facility. On the days R6 did sign back into the facility, it was after 8:00 p.m. Review of R55's sign-out sheet had a sign-out listed for 11/23/00 and 3/4/01. Both times were with R55 listed as the responsible party.
Interview with E12 on 3/20/01 at 1:50 p.m., in her office, revealed there were several residents at the facility that had been homeless. E12 stated there was no plans for discharge for any of the residents and there was no special programs provided to enable the residents to return to the community.
Interview with E15 on 3/28/01 at 11:00 a.m. in her office revealed that she would go to the homeless shelters in St. Louis and East St. Louis to see if there was any homeless people that could be admitted to the facility. E15 stated that the homeless person would be taken to the emergency room at St. Mary's Hospital or other hospitals where a physician would evaluate them prior to them being admitted to the facility. The homeless person would be admitted to the facility after the evaluation. E15 stated that they had to be older, with a medical diagnosis.
3) Record review of R38 revealed she was admitted from a homeless shelter on 2/07/01 with a diagnosis of Uncontrollable Hypertension, Degenerative Joint Disease, Bronchitis, Tobacco Abuse and Obesity. On the front sheet of R38's clinical record under “Admitted From”, it stated R38 came from a homeless shelter. Review of clinical record reveals R38 is not referred to as homeless anywhere else in the record. R38 was taken to the hospital for evaluation prior to her admission to the facility. At the hospital, she was given a diagnosis of hypertension even though she did not exhibit any symptoms of hypertension at the facility. The admission note of 2/7/01 revealed her blood pressure was 130/70. The nurses notes revealed three other documentations of blood pressures which revealed to be all within normal limits. The physician's progress notes of 2/7/01 confirmed the above diagnosis, which did not include a psychiatric diagnosis.
Review of social history and initial assessment dated 2/13/01, revealed R38 had a residential address prior to admission, has a Doctorates Degree in Secondary Education, is a retired high school teacher, is alert and oriented, is able to make needs known and answer all questions adequately and has no noted behaviors. She’s quite normal, calm, and friendly, and she kept "talking about as soon as her apartment is ready she will be gone". Despite these comments by R38, this assessment identified there was no discharge plan at this time. The "Illinois Department of Public Aid Interagency of Screening Results" dated 2/12/01, states that R38 is not appropriate for nursing home placement. The circumstance for the pre-screen done after admission was that R38 was admitted from a hospital emergency service. Interview with Z3 revealed that R38 was cognitively and physically independent and did not need to be in a nursing home. Z3 stated that R38 wanted to get an apartment.
Interview with E12, on 3/8/01 at 9:00 a.m., confirmed E12 was not working on any discharge plan for R38, but did understand that R38 was looking for an apartment.
The assessment failed to identify why staff failed to plan for a discharge for R38. The behavior symptoms assessment dated 2/6/01, revealed R38 was noted to be alert and oriented, that she refuses to take medications, and that she comes and goes out to appointments independently. The Minimum Data Set dated 2/19/01, revealed R38 is independent cognitively and for all activities of daily living and has no behaviors noted. Facility failed to assist R38 in looking for housing or monitoring/tracking behaviors. Review R38's Plan of Care, dated 2/23/01, revealed the only care plan for R38 was an approach for R38 to take medications, as ordered, and for having a stable blood pressure. Interview with E2 reveals R38 had behaviors of barricading self in room and throwing all of roommates clothing out of room.
Review of R38's Physician's Orders revealed an order by attending physician dated 2/14/01, "Psych consult with Z4". On 3/20/01 it was noted Z4 saw R38 per Physician Order dated 2/14/01. Z4 wrote an order dated 3/20/01, to admit R38 to St. Mary's as soon as possible, with a diagnosis of Paranoid Psychosis. Review of the chart revealed hospital admission was not scheduled, nor attempted. On 3/28/01, interviews with two nurses who are in charge of R38's care, revealed this admission was not scheduled, and that R38 did not refuse to go to St. Mary's. Interview with E2, on 3/28/01 at 9:30 a.m., revealed someone told her the resident was refusing to go to the hospital, but after reviewing the chart E2 was unable to identify who, or when R38 refused to go the hospital.
The next telephone order from Z4 is on 3/27/01, and states, "Send to St. Mary's Hospital CM as direct admit, contact Call for Help or Comprehensive Mental Health for assist with transfer if needed". Interview with Z4, on 3/28/01 at 9:40 a.m., revealed facility staff called him and said R38 was locking out her roommate, and refusing to go to the hospital. Z4 further revealed that is why he ordered assistance to be obtained if needed. Z4 stated that he expected the facility to involve police/help if the resident refused or was uncooperative. Surveyor asked Z4 what paranoia R38 was exhibiting on 3/20/01 and Z4 stated R38 was kicking out her roommate, she felt people were plotting against her and not helping her get out into her own apartment. Z4 stated R38 voiced she was discouraged about not hearing about an apartment being available.
Review of the record revealed R38 blocked roommate's entrance one time on 3/12/01.The only behavior modification noted is staff charting their response as, "Pt. has been reprimanded several times on behavior toward roommate". Staff interviews confirm R38's beliefs that no one was helping her get into an apartment.
On 3/27/01, at 5:15 p.m., R38 was observed to be taken out of the facility escorted by 4 local police officers. Observation further revealed R38 screaming, "I don't want to go". Interview with E2 reveals that on 3/27/01 at 5:20 p.m., R38 went cooperatively with police and ambulance attendants and that it was policy that police are called when a resident is an voluntary admission to a locked psychiatric unit at a hospital. When E2 was interviewed 3/28/01 at 10:24 a.m., she stated that it was not the facility's policy to call the police, it was the Comprehensive Mental Health's (CM) policy to call the police for involuntary placement. Facility nursing staff is instructed to call CM if a resident has an escalated mental episode. CM will do a telephone assessment and determine if it's an emergency. If it is deemed an emergency, CM will call the police and ambulance and a CM staff member will meet them onsite. E2 stated that R38 was a different case as the physician order was to admit to locked mental health unit per the order on 3/20/01, and since R38 refused to go, the physician was called and told of her refusal. He then called CM and told them he wanted R38 directly admitted and to go and get her from the facility. This information was not consistent with interview with Z4 on 3/28/01.
According to staff interview and record review R38 did not exhibit any escalated mental episodes. Further review of R38's record revealed R38 put the bed up against the door one time on 3/12/01 and staff did not care plan this as being a problem and no interventions were tried. The record showed that on 3/27/01, R38's room was found to have a sign taped to the wall that read: "Do not close window, room being aired". It is noted in the nurses notes that R38 had previously complained of urine odors in the room. It was also noted that R38's roommate's bed was completely stripped, and clothing bagged in the room. The staff also chart that there is another sign outside the room stating, "Keep Door Closed". Staff do not record that R38 kicked roommate out of the room on 3/27/01 as reported to Z4. Interview with the nurse who did the charting of 3/27/01, confirmed what was charted were the behaviors exhibited by R38.
Interview with Z5, on 3/29/01 at 10:15 a.m., via phone conversation revealed Z5 had met with R38 and hospital staff at the locked unit and that R38 would be discharged from the unit to placement in the community as soon as arrangements could be made.
The facility staff failed to assist R38 in reaching her highest level of mental well being by not responding to her request to move out into the community, and by having her taken from the facility by 4 police officers to be involuntarily committed to a locked psychiatric unit level.
4) R15 was admitted to the facility on 2/9/01 from the Illinois Department of Corrections in Robinson, Il. R15 has diagnoses, in part, of diabetes, hypertension, bilateral leg edema, cellulitis and substance abuse. R15's date of birth is 9/6/41. The "Illinois Department of Public Aid Interagency Certification of Screening Results" was done 2/14/01 and stated that the "Screening indicated nursing facility or ICF/MR services are not appropriate". There was no circumstance checked on the form that indicated a reason for the screen to be performed after admission.
Upon surveyor inquiry, the correctional history of R15 was obtained through the administrator in her office on 3/21/01. This information was not in the facility medical record. This file revealed an Illinois Sex Offender Registration Act, Notification form. This form revealed R15 was convicted on 9/1/99 for "Aggravated Criminal Sex Abuse/Vic. U13." The form further revealed R15's sentencing was for 5 years and that on 2/9/01 he was given parole. R15 was then directly admitted to the facility on 2/9/01 from Robinson Correctional Center.
There is no social service history in the chart. Review of the current care plan revealed staff are not including sexual aggressive behaviors, or related problems, and no additional supervision is being identified as needed on the plan of care. Interview with the Social Service Director, (E12), on 3/20/01 at 1:50 p.m., in her office, revealed she knew R15 was on probation. E12 stated there are no plans for discharge for R15. E12 stated she is not aware why R15 was in prison. The facility failed to identify the need for additional supervision as evidenced by the problem not being identified in the care plan and by interview with Social Service staff.
Social Service provides one to one visits to R15. He does not attend any psychosocial groups. The Social Service History dated 2/13/01 states that R15 does not know the reason for nursing home placement. The discharge plan states that discharge is not anticipated at this time.
The Minimum Data Set (MDS), dated 2/22/01, assessed R15 as independent in cognitive skills and independent for activities of daily living. The MDS noted that R15 does not receive any behavior intervention programs and noted R15's discharge potential would not be a stay less than 90 days. The current care plan dated 3/2/01 for R15 states the only problems for R15 is he has concerns about schedules, diabetes, and he is at risk for dehydration due to diuretic medication.
The information that R15 had a conviction of sexual assault was not available for facility staff or the pre-admission screener. R15 was discharged from the facility on 3/27/01.
5) R55 was originally admitted to the facility on 10/13/00, with diagnoses of Post Coronary ArteryBypass and Cardiac Cath with Angioplasty with Stint. R55's facility "Social History and Initial Assessment", dated 10/19/00, states the following "Residents awareness of reason for nursing home placement and attitude about placement: Yes he knows why he is here and knows he is going to receive rehab to improve, has no c/o any type, very pleasant.” The facility "Social Service Quarterly and Care Plan Note", dated 1/22/01, states the following, "Resident is alert and oriented x 3, very cooperative, pleasant. He is active with all activity groups. He joins all groups for any type of activity, he doesn't c/o about too much. He gets along with all other residents. If he has any appointments to any Dr. office he goes without difficulty. His overall outlook with his placement is good. If he does have any questions regarding his condition he generally will ask his nurse or go through the proper channels. Discharge Plan: Discharge not anticipated at this time". R55's Plan of Care, dated 10/24/00, reveals "Resident is withdrawn from others and activities related to being a new admission and his age and just having a past coronary artery bypass, cardiac cath with angioplasty with stint. Risk for falls R/T post coronary bypass with cardiac cath angioplasty with pain.....High risk for decreased cardiac output R/T post coronary bypass....1/22/01, All goals met as of this date".
There is nothing in the clinical record related to behaviors. Interview of E16 reveals that R55 told them that he molested his daughter and was sent to prison. E16 further stated that R55's wife brought his children into the facility to visit him recently, a girl about 5 and a boy about 9. Interview further revealed that recently someone came to the facility, picked up R55, and took him to a birthday party in the community.
E1 verified that R55 came to the facility from the Department of Corrections, however she had no information of R55 regarding his incarceration. R55 was placed at the facility from the Department of Corrections. The pre-screen was conducted by SWVNA on 11/28/00 and stated that nursing facility placement was appropriate. R55 is 38 years old and has a conviction of sexual assault.
This information was not shared by administration to facility staff or the pre-admission screener. R55 was not receiving any additional supervision or rehabilitation services. R55 was discharged from the facility on 3/27/01.
6) R22 was originally admitted to the facility on 10/6/00, from Graham Correctional Center, in Hillsboro, Il. R22 has diagnoses, in part, of Diabetes, HTN and Bilateral Amputation. Facility records from the United States Department of Justice, Federal Bureau of Investigation, Division, indicates that R22 was arrested on 12/24/81, on 2 charges of aggravated sexual assault. R22 was sentenced on 9/10/82 to 18 years at Graham Correctional Center on charges of Aggravated Criminal Sexual Assault. An Order of Protection was filed in Madison County, Il., on 10/11/00, to keep R22 from seeing his children. The Order of Protection states "He was convicted of sexual abuse to my daughters. My youngest daughter is a minor. She is scared of him. He made threats before he was sent up the last time to come and get the kids. I don't know what he'll do. He is a two offender of sexual abuse".
Pre-admission screen was performed on 11/13/00 by SWVNA. The screen noted that R22 was appropriate for nursing home placement and did not have any mental illness or mental disability (MI/MR). There was no circumstance checked on the form that indicated the reason for the pre-screen to be performed after admission to the facility. The information that R22 had a conviction for sexual assault was not available to facility staff or the pre-admission screener. R22 was discharged from the facility on 3/27/01.
R22's facility "Social History and Initial Assessment", states the following: "Previous hospitalization, nursing home placement or psychiatric treatment: Healthcare Unit Big Muddy". Interview of numerous staff members reveal that they did not know why R22 was convicted. R22's facility Plan of Care, dated 1/20/01 and 2/10/01, lists the following problems: "decreased strength all ext, decreased amb. At risk for falls R/T Bilateral BKA. Requires total assist of staff for transfers. At risk for dehydration R/T diuretic med use secondary to HTN. Diabetes: receives insulin, LCS diet. Is noncompliant with diet-will eat only meals of choice." There is no mention of any type of behaviors or inappropriate sexual behaviors in R22's clinical record.
7) R6 was admitted to the facility on 2/8/01 with diagnoses, in part, of alcohol abuse, opioidal dependence, and drug depressive disorder. R6 was admitted to the facility from a homeless shelter in St. Louis, Mo. R6's date of birth is 10/25/45. The Illinois Department of Public Aid "Interagency Certification of Screening Results", performed 2/14/01, screened R6 as not appropriate for nursing facility or ICF/MR services. The circumstance checked was that R6 was admitted from out of state.
R6 has a history of substance and alcohol abuse but is not enrolled in any rehabilitation programs.
R6 has a physician order that states "outside privileges with medication." R6 receives Thiamine, B Vitamin with C, Naprosyn, Atarax, and Tylenol and Ambien as needed.
The MDS, dated 2/21/01, assessed R6 as modified independence with cognitive skills and independent with activities of daily living. Discharge is not anticipated in less than 90 days. The care plan dated 2/28/01 lists problems for R6 as: at risk for falls due to antianxiety medication use, drug abuse and alcohol abuse, dental problems and modified independence with decision making skills due to diagnosis of drug and alcohol abuse.
Interview with E12 on 3/20/01 at 1:50 p.m., in her office, reveals that R6 was homeless. R6 leaves the facility during the day, unsupervised, and goes to his sister's house or to the Veterans Administration Hospital where he visits friends. E12 stated there are no plans for discharge for R6. R6 does not attend any psychosocial programs or drug/alcohol rehab programs. E12 stated there was no physician order for R6 to attend any programs.
R6 was gone from the facility on 3/19/01 and E9 stated that he was out on pass. Observation of R6, on 3/20/01 at 9:30 a.m., noted R6 was leaving the facility and walking in the direction of the convenience store. Interview with E9, on 3/20/01 at 9:30 a.m., at the nurses station, stated R6 was going to the VA hospital to visit his friends. E9 stated R6 catches the bus at the convenience store at the corner around 9:30 a.m., and does not return until evening supper. Interview with E13 stated she is not sure where R6 goes but he says he visits at the VA hospital. E13 stated R6 is a younger person and not one to sit around. E1 confirmed she was aware that R6 leaves the facility and is gone all day. E1 stated R6 does not receive any programs and R6 could be in a less restrictive situation.
8) R17 was admitted to the facility on 2/12/01 from a homeless shelter. R17 is 47 years old and has diagnoses, in part, of Peripheral Neuropathy of the Hands, Alcohol abuse and optic atrophy. R17 takes a Multivitamin and Naprosyn. The Minimum Data Set, dated 2/23/01, noted R17 has modified independence with cognitive skills and is independent with activities of daily living and ambulation.
The "Illinois Department of Public Aid Interagency Certification of Screening Results", completed on 2/14/01, states "nursing faccility or ICF/MR services are not appropriate", for R17. It was done by SWVNA and stated that R17 was screened after admission due to the fact that he was placed from out of state.
The Social History states R17's awareness for nursing home placement is "homeless". There is no discharge planned at this time. The care plan, dated 3/2/01, for R17 states that R17 is a cigarette smoker and smokes in his room , has a diagnosis of alcohol abuse and impaired vision. The goals set for R17 state that R17 will smoke only in designated areas and will maintain current level of visual field. R17 does not attend any alcohol rehabilitation programs.
9) R51 has diagnoses, in part, of Dementia Secondary to Brain Trauma with Severe Depression and Psychotic Symptoms and Sexually and Physically Aggressive Behavior, Obesity, Low Back Pain, High Blood Pressure, Schizophrenia, and Spastic Triplegia. R51 is 33 years old. R51 was admitted to the facility on 8/6/96 from another long term care facility. R51 was screened as not having a mental illness even though he has a diagnosis of schizophrenia. The MDS dated 2/13/01 assessed R51 as cognitively independent. The MDS states that R51 has socially inappropriate behaviors and resists care.
The quarterly social service assessment, dated 2/13/01, states that R51 can be very appropriate when he wants to be. The note states R51 is alert and oriented. R51 makes inappropriate sexual remarks to women and tries to touch staff in inappropriate places. R51 attended Psychiatric Day treatment at St. Mary's Hospital but refused to go since 1/14/00. The social service notes dated 1/27/00 states that R51 had been discharged from his outpatient program.
R51 sees the psychiatrist, however, there are no physician progress notes in the medical record. R51 is seen in individual therapy however, there is no coordination of that therapy in the care plan.
Paxil 20 mg twice a day, and Zyprexa 20 mg daily.
Phone interview with Z4 on 4/3/01 at 1:10 p.m., revealed that R51 receives the Depo Provera 300 mg intramuscularly every 4 weeks due to his "history of sexually acting out behavior." Z4 stated that R51 had been on 150 mg every 4 weeks about 6 months ago but that this dose was increased to 300 mg because the lower dose was "not helping". Z4 stated that R51 was fondling female staff and saying obnoxious things to them but he was not aware of R51 being a threat to other residents.
The History and Physical, dated 7/6/00, states that R51 has "serious management problems, including sexual behavior and physically aggressive as well as verbally aggressive behavior toward staff." The Minimum Data Set (MDS), dated 2/13/01, notes that R51 has socially inappropriate behavior. The MDS notes that R51 has full loss of voluntary movement in both legs and only partial loss of movement in both arms and hands.
The care plan, dated 11/24/00, states that R51 is sexually inappropriate. Additions to the care plan made on 2/19/01 states that R51 "likes to grab at female staff-grab at their breasts, in between their legs during ADL care."
The current care plan, dated 11/24/00, with an estimated resolve date of 5/19/01 states problems for R51 are: “Dx: schizoaffective disorder/severe depression/psychotic symptoms. Receives antidepressant and antipsychotic meds daily for medical dx.; situational low self-esteem R/T physical challenges of body, dx of spastic triplegia, quadriplegia multiple body injuries secondary to MVA AEB: verbilization of negative feeling of self et others as well as staff; Sexually inappropriate- makes remarks to female staff i.e.: “What turns you on?”, will grab at female staff making sexual comments to nurse. Likes to grab at female staff-grab at their breasts, in between their legs during ADL care; Inaffective coping: attention seeking, yells aloud when staff walking down the hall, sits at nurses station demanding to use the telephone at undesignated times. May become verbal toward staff if he doesn’t get his way; Risk for falls r/t decreased mobility, quadriplegia, will throw self on floor out of w/c resulting in fall; High risk for skin breakdown r/t decreased mobility, incontinence/quadriplegia/obesity requires assist of staff for mobility and transfers; has laceration to top of head from recent fall, sutures present.”; and, “Res has decreased function in all L joints with the exception of elbow flexion.” For these problems the goals are: “Will remain free of side effects from medications; Will identify existing strengths and view self as a capable person. AEB: will make at least 2 positive statements a week to staff et others; Will have a decrease in sexually inappropriate behavior to less than 2 x a day; Will identify ineffective coping behaviors AEB: Will use telephone in designated area when scheduled; will have decrease in yelling aloud at staff going down the hall x/weekly, less than 4 episodes a week of verbally aggression toward staff and peers; Will remain free of falls without injuries requiring hospitalizations; Will remain free of skin breakdown; area to remain free of s/s of infection; to maintain movement and prevent further contractures.” The care plan does not address behaviors toward other residents.
Record review of R51's nurses notes, dated 2/22/01, at 8:00 p.m. stated “Resident has crawled on floor again in sitting position. Told this nurse, ?You can't tell me what to do. I don't have to listen.’ Had been observed in rm 33 & resident in 33-2 had his pants down around ankles. Did not observe touching. Assisted back to bed by 2 CNAs". The resident in Room 33 is R16, who is mentally retarded and mentally ill. E1 confirmed that R16 was the only resident in that room when the incident occurred.
The nurses notes, dated 2/23/01, at 2:15 p.m. states that R51 was placed on one hour visual checks per facility policy due to increased falls. The "15/30 Minute Monitoring Sheet" reviewed for 2/22/01, 2/23/01, 2/25/01 and 2/26/01 states that R51 should be checked every 60 minutes; however, the sheets document observations of R51 every 2 hours.
On 1/21/01 at 4:00 p.m. the nurses notes state that R51 knocked R27 out of her wheelchair. The nurses notes state that R27 was found in R51's room on the floor with the wheelchair on top of her legs. R51 stated, "See, I knocked her out of the chair. She don't belong in here". Staff informed R51 of the inappropriate behavior and he stated, "I told you I'd knock her out of that chair." R27 propels herself around the facility in a wheelchair. R27 is cognitively impaired. R27 complained of pain when the left hip was touched; however, the physician ordered observation only. The "Supervisors Incident Investigation" states that R51 has a history of manipulative/aggressive behaviors. R51 was counseled to call staff for assistance with confused residents to prevent recurrence.
10) R5 is a 54 year old resident of the facility. R5 was admitted to the facility on 9/22/00, with diagnosis of Downs Syndrome, Alzheimer and Schizophrenia. R5 had resided in a 16 bed group home prior to his placement in the facility. The facility could not find a pre-admission screen for R5. R5 has not received any active treatment, day programs or workshops or specialized rehabilitation for MR since his admission to the facility.
11) R19 was originally admitted to the hospital on 11/15/00, with diagnoses, in part, of Psychosis, Schizophrenia and Dementia. Record review reveals that R19 was independent for ambulation and often wandered about the facility. Nurses notes dated 12/28/00 reveal that R19 had behaviors of "hitting and kicking at staff". There is a facility form entitled "Evaluation of Siderail Usage" in R19's clinical record. This form is not dated. The evaluation does not list the medical reason for the siderails, least restrictive measures tried or risk versus benefits of the siderails.
Nurses notes reveal the following: "1/3/01, 9 p.m., Pt to bed with assist of one.
Removed clothing with a lot of difficulty with full SR up....10:45 p.m., Heard someone screaming, another pt. When summoned this pt in other female residents bed. Pt removed et taken to own bed. Side Rails down for pt to get in bed. SR up upon positioning et instructed to go to sleep. ?I'm not tired.’ Staff informed to watch pt closely to prevent fall et injury to pt. 2/1/01, 1 a.m., Observed resident in rm 13 standing in doorway with sm. laceration over R browline with sm. amt of bright red blood draining from wound. Swelling noted around R eye. When asked what happened to your eye? Resident stated “nothing".
R19 was sent to the hospital for evaluation and returned to the facility with sutures over the right eye. 2/1/01, Rt eye remains swollen, sclera red, pupil reactive. Speech slurred. Sutures intact to rt orbit outer area. Pt ambulating ad lib in day-dining room with staggering gait. Needs a lot of attention to prevent fall et further injury..... 2/4/01, 9 p.m., F/U from incident. BP
124/80, P 80, R20. Pt ambulating ad lib around facility with shuffling gait, confused. Pt put to bed x 2 with pt crawling over full side rails up. And returned to day room. 2/11/01, 12:25 AM, observed resident lying across bed with lower body between siderails. Skin warm and dry to touch, unresponsive, assisted to bed, CPR initiated per staff and 911 emergency called".
Interview of R19's physician on 3/22/01 reveals cause of death on 2/11/01 to be Acute Subdural Hemorrhage. Review of "State of Illinois, Medical Certificate of Death", reveal R19's immediate cause of death as Subdural Hemorrhage.
Staff interview reveals that no investigation was done by the facility regarding finding R19 unresponsive on 2/11/01. Facility licensed staff stated that no investigation was done as they felt that what occurred was due to a medical problem and there was no reason to conduct an investigation.
12) Record review of R3 revealed R3 was assessed on 12/06/00 and on 01/27/01. On both assessments it was found R3 was at risk for falls. Review of the record revealed on 12/10/00 at 10:30 a.m., R3 fell onto the floor. Review of the incident report revealed that staff left blanks in several areas on the form, for example, were there any appliances, environmental hazards, any witnesses, and if not witnessed a description of what was observed and/or stated. The investigation did identify the resident's blood pressure was 80/40, pulse was 40, and respirations were 10. The investigation failed to identify when the resident was last seen, or if the resident was sleeping in the chair prior to the fall. The incident report does reveal the resident had fallen face first in the day room with no apparent injury.
The Nurses Notes revealed the resident's level of consciousness varied from being very alert and talkative, and at other times her eyes would roll back in her head. The physician gave the order for R3 to be sent to the emergency room stat. Transfer form revealed the resident had experienced a change in the level of consciousness. This resident was sent to the hospital.
Review of the hospital emergency department record revealed the resident was sent back with head injury instructions, and the CT scan showed no intracranial injury. This resident returned from the hospital on 12/10/00 at 2:40 p.m. with head injury protocol. The next entry in the chart is dated 12/11/00 at 2 PM. Interview with the Director of Nurses on 3/27/01, revealed no other monitoring was available as staff were more concerned about R3's blood pressure. There is no entry in the record prior to this entry regarding the head injury protocol, such as pupil reaction, and level of consciousness. Review of the care plan on 3/21/01, revealed there is no change in the Plan of Care in an attempt to prevent further falls.
13) R16 was admitted to the facility on 12/6/00 from the emergency room of a local hospital. R16 had been living at an unlicensed group home prior to the emergency room visit. R16 has diagnoses, in part, of mental retardation, schizophrenia, and Syndrome XYY. R16 was sent to the hospital due to aggressive and violent behaviors at the group home. R16 is 38 years old.
The pre-admission screen was performed by an agency identified as “CMA”. The screen identifies that R16 has both a MR and MI diagnosis. The screen states that R16 should then be referred to the “DD PAS” organization but the form indicates R16 is being referred to the “MH PAS” organization. The “Name of Organization to Which the Individual is being Referred” was filled in with “River Bluffs Nursing Home”. R16 has not received any specialized mental health rehabilitation services, does not attend day programs or receive any active treatment since admission to the facility. R16 was observed wandering about the facility, standing in the hall repeating himself and interacting inappropriately with residents and staff during the survey.
The "Identification of Individuals for Whom There is a Reasonable Basis to Suspect a Developmental Disability or Mental Illness" OBRA-1 form identifies that R16 has both developmental disability and a mental illness. The PAS/MH 1 form was filled out by the same individual that filled the OBRA-1 form. This form has marked that R16 requires inpatient psychiatric hospitalization, requires nursing facility level of care and requires psychiatric rehabilitation services. R16 does not receive any psychiatric rehabilitation services.
Interview with E12 at 1:50 p.m. on 3/20/01 revealed that R16 is at the nursing home to monitor his behaviors. E12 stated that R16 had an episode of aggressive behavior on December 31 where R16 struck another resident. R16 was in the smoke room and hit R60 on the back of the neck with a closed fist. This required a trip to the hospital for R16 where his medications were changed. E12 stated that since that time R16 has been doing fine. E12 stated that R16 does not attend any psychosocial programs, attend any facility or outside mental health or developmental disability day programs receive any active treatment in the facility. E12 stated that she visits one to one with R16 and that R16 attends activities. E12 stated that R16 has a hard time staying at the activities because he can't sit still. E12 stated that there are no discharge plans at this time and it is unclear if he will be returning to the previous living arrangements.
R16 was observed during the days of the survey wandering about the facility. R16 would stand in the hall and repeat sentences over and over. R16 was observed hugging staff and other residents for prolonged periods. On 3/19/01 at approximately 1:00 p.m. R16 was observed hugging a female housekeeping staff on the back. The staff attempted to walk away from R16 and R16 hung onto the staff as they walked around the television area and then into the dining room. On 3/20/01 at 3:40 p.m., R16 was observed in the front lobby area with R27. R16 was hugging R27 and touching her on the face. R16 attempted to kiss R27. R27 was in a wheelchair and did not return the affections. R16 pulled on R27's hand and arm. There was no staff in the television or lobby area or at the nurses station to supervise R16. The surveyor asked R16 to come with her in an attempt to get R16 to leave R27 alone.