Facility I.D. Number 0043364
2601 223rd St.
Sauk Village, IL 60411
Date of Survey 6/16/00
Complaint Investigation 0092596 and 0093054
Physician services including a complete physical examination at least annually and formal arrangements to provide for medical emergencies on a 24 hour, seven day-a-week basis.
Direct care personnel shall be trained in, but are not limited to, the following:
AN OWNER, LICENSEE, ADMINISTRATOR, EMPLOYEE OR AGENT OF A FACILITY SHALL NOT ABUSE OR NEGLECT A RESIDENT. (Section 2-107 of the Act)
These regulations are not met as evidenced by the following:
1.) R1 is a 48 year old, mobile, ambulatory male with a wide unsteady gait. Diagnoses includes: Seizure Disorder, Developmental Language Disorder and Visual Impairment.
On 5/4/00 at approximately 2:05 p.m. per Day Training (DT) Injury Report Form, R1 fell backwards off four steps while waiting in line to board his bus sustaining a 2 1/2" laceration to the left eyebrow, with 12 sutures.
While at the hospital's Emergency Department a Computerized Tomography (CT) Scan was completed, result was a normal brain study.
Interview with E3 via phone call on 6/20/00 at 11:50 a.m. stated, "no changes were noted in R1 between 5/4/00 until 5/30/00."
Per staff progress notes dated Saturday, 5/27/00, E4, p.m. shift hab aide wrote "R1 was noted to be not looking well at dinner time. R1 barely ate his food. R1 held his medications and food in his mouth."
Interview with E4 on 6/8/00 at 3:30 p.m. in the office stated, "called E3, the nurse, because R1 wouldn't swallow his medication. E3 instructed me to put the medication on a spoon with yogurt, which R1 took and swallowed. That was the first time R1 did not take his medications."
On Sunday, 5/28/00, E8 a.m. shift hab aide wrote on the progress notes stating, "R1 was very tired or real lethargic. He didn't barely touch his lunch, so I tried to help him hand over hand." Interview with E8 on 6/15/00 at 11:55 a.m. in the living room stated. "R1 was very lethargic, dozing off, eyes kept closing, he was unstable when he stood up, even when sitting he was leaning over, didn't call the nurse. We thought that because of the weather change, that's why he was sleepy."
Interview with Z11 confirmed that on 5/28/00 R1 was dozing off and on from approximately 2:00 p.m. to 4:30 p.m. and Z11 further stated, "staff did mention that they noticed R1 sleeping a lot that day which is unusual for him."
Z11 stated, "On 5/28/00 R1 was sitting dozing off and on practically all day. It hadn't been like that.
He didn't get up at all." Z11 further stated. "Staff did mention they noticed him sleeping a lot that day."
Interview with E5 and E8, staff on duty on 5/28/00 revealed they did not notify the nurse. E3 interview confirms she was not notified of R1 symptoms until 5/29/00.
"E3 further stated that staff informed her on 5/29/00 that R1 was slightly lethargic and instructed staff to take vital signs every hour. Z3 also stated she instructed E4 to keep him home the following day and to tell everyone that R1 needs to stay home on the 30th of May.
On Memorial Day, 5/29/00 E9 a.m. shift staff progress notes stated, "R1 needed assistance in walking, he was pulling staff, his gait was unsteady. He seemed out of it, real lethargic. E3 was paged and she instructed to take his vital signs every hour. "E4, per interview dated 6/8/00 at 3:30 p.m. in the office stated, "R1 looked tired on the 27th and I was off, R1 was worse when I came back the 29th. I know on the 29th when I came in I was told to take R1's vital signs." E5, per interview on 6/8/00 in the office at 4:05 p.m. stated, "R1 was lethargic, he was still sluggish. On Monday, 5/29, you know something was wrong because R1 was still lethargic. R1 was in bed when I came in. I got him up, gave him water and have him seated in the living room. R1 did not eat that day, from Sunday 5/28 to Monday 5/29 he was getting worse." E8 per interview of 6/15/00 at 11:55 a.m. in the dining room stated. "I don't recall if he ate, I know that Sunday (5/28) and Monday (5/29) we have to help him eat because he was keeping food in his mouth."
On 5/30/00 E9's progress notes states, "R1's gait was off and needed assistance in walking." E9 further stated. "I had no orders for him to stay at home so he went to workshop."
In a sworn statement completed by E6 on 6/20/00 she stated, "R1 seemed to be very ill and very weak. I was told by E9 that since there was no special instructions to keep R1 home that we would send him to workshop and that is exactly what we did."
On Tuesday, 5/30/00, E9 a.m. shift staff's progress notes stated, "R1's gait was off and needed assistance in walking. Still seemed lethargic. I had no orders for him to stay home, so he went to DT."
Staff sent R1 on a school bus to DT the morning of 5/30/00, knowing that he was evidencing signs of lethargy, and an inability to ambulate normally. As a result R1 went to DT and after disembarking the bus, he fell sustaining another head injury.
Interview with Z6 on 6/15/00 at 3:10 p.m. inside the bus stated, "On 5/30/00 R1 was groggy, not look good. It took 2 staff to assist him on the bus that morning which is not normal for him. I was able to get him off the bus once we got to DT. Before the worshop staff was able to reach him. R1 fell sideways. I just remembered blood on him. I'm not sure if he had a seizure."
Z6 called and said R1 fell and needed to go to the hospital. On 5/30/00 R1 received five sutures inside his mouth.
Review of hospital records revealed R1 on 5/30/00 was seen at 8:51 a.m. in the ER with diagnosis of Seizure Disorder and Laceration to Lips with Suture Repair. Tegretol level was 4.8 (normal level 8-12 mcg/ml). Hospital records do not mention the prior fall of 5/4/00 and head trauma sustained on 5/30/00. R1 was treated and released before noon the same day, 5/30/00.
Review of nurse E3's notes revealed that on 5/30/00 primary doctor was notified re: laceration with orders to monitor R1 and to take vital signs every shift.
Z13, the facility's neurologist was also informed the afternoon of 5/30/00 re:low tegretol blood level with orders to increase Tegretol to 600 mg BID and tegretol blood level in the morning.
Review of resident plan of care completed by E3 on 5/30/00 revealed the following orders:
Monitor vital signs every shift, Instructions given per telephone E3 evaluated R1 on 5/30/00 at 2:00 p.m. in the facility.
E4, p.m. shift staff's progress notes dated, Tuesday, 5/30/00 stated, "R1 looks very lethargic, heavy saliva still coming out of mouth. Can't stay awake, propped up in two chairs with pillow. Refused dinner (soft foods), and kept medications in mouth until they dissolved, takes two staff to move R1 any distance."
On Wednesday, 5/31/00, E9 a.m. shift staff's progress notes stated, "R1 could not even walk today, dragging his feet, it took two staff to walk him. He seemed like a walking zombie." Again, E9 sent R1 to workshop on 5/31/00. Interview with Z6 on 6/15/00 at 3:20 p.m. stated, "R1 was very lethargic on 5/31. It took 2 staff to get him on the bus again and since I couldn't get him off the bus, a guy from workshop came on the bus and lifted him off the bus."
Interview with Z1 on 6/9/00 at 10:30 a.m. in the office revealed, "R1 came in (to DT on Wednesday 5/31), seemed very weak, unsteady gait, not responding, eyes closed, could hardly walk. We called the facility right away and transported him home. "Z3 on interview dated 6/9/00 in the Common Area of DT at 10:50 a.m. stated, "I believed, he was that weak that if we left him stand and removed our hands off him, he would just slump to the floor, no doubt about it."
Interview with E1 on 6/8/00 at 11:00 a.m. in the facility's living room stated, "On 5/31/00, R1 was sent to DT by mistake."
Nurse E3's notes dated Wednesday, 5/31/00 stated, "R1 went to workshop this a.m., sent home, slightly lethargic, primary doctor notified, ordered to bring R1 for evaluation on 6/1/00. Tegretol level was 7.6."
Interview with E8 on 6/15/00 at 11:55 a.m. in the dining room stated, "R1 on 6/1/00 was very lethargic when I came in. Myself and another staff assisted him towards the van, we basically pushed him up to the van. I went to the clinic to tell the doctor that we can't move R1, he was dead weight, lethargic. The doctor told me to take him to the hospital. Once we reached the Emergency room (ER), the security guard lifted him off the van. He was still the same when they got him in the ER . The nurse said he had a fever of 101.3 F. We waited for an hour or so and no physician saw R1 yet. I called the facility and told E2, I was informed so I came back to the facility." R1 was admitted to the hospital and had brain surgery for a Chronic Subdural Hematoma.
Interview with R1's primary doctor, Z5, via phone call on 6/8/00 at 12:00 p.m. stated, "I don't remember the dates, I know they called me about R1 twice. Then I saw him in my office. Not really in my office. I went out to the car and when I saw him instructed to send him to the hospital. I just called the hospital that he is coming."
Review of E3's progress noes revealed that prior to the 5/30th note, the last documented entry was dated 5/23/00.
Interview with E2 on 6/15/00 at 11:30 a.m. in the dining room stated, "the staff progress notes are only written by staff if there is something important or unusual that occurs on a client like having a behavior or a sickness, it's not a daily thing."
R1 per review of hospital records was noted on 6/1/00 to have "a large right subacute subdural hemorrhage with evidence of an acute component" per CT scan. R1 had brain surgery within hours of the CT results on 6/2/00 for evacuation of Subdural Hematoma. R1's Post-operative Diagnosis, per hospital records, was "Chronic Sudral Hematoma, Right Craniectomy". R1 was discharged to the facility on 6/7/00 and is observed to be alert, ambulating with wide steady gait with staff assist and is eating by himself.
The facility neglected to ensure that R1 received the appropriate nursing services when he started exhibiting deteriorating changes in his mental status, ambulation and eating patterns after he had a history of a serious fall down 4 steps on 5/4/00 resulting in head trauma. By neglecting to address R1's deteriorating health, the facility sent him to workshop on 5/30/00 where he sustained another fall resulting in head trauma. The facility continued to neglect R1's health care needs and sent him to DT again on 5/31/00.