Statement of Violation

THE ABBEY OF CARBONDALE - LITTLE WILLOW

Facility I.D. Number0041418
120 N. Tower Road
Carbondale, IL 62901

Date of Survey: 1/17/01

Incident Report Investigation

"A" VIOLATION(S):

Residents shall only be admitted who have had a comprehensive evaluation of their medical history and physical and psycho/social factors, conducted by an appropriately constituted interdisciplinary team. No resident determined by professional evaluation to be in need of services not readily available in a particular facility shall be admitted to or kept in that facility. Additionally, emotional and cognitive histories shall be evaluated when applicable and available.

Sufficient staff in numbers and qualifications shall be on duty all hours of each day to provide services that meet the total needs of the residents.

The responsibilities of the director of nursing shall include, at a minimum, the following:

Planning an up-to-date resident care plan for each resident in cooperation with the interdisciplinary team based on individual needs and goals to be accomplished, physician’s orders, and personal care and nursing needs. Services such as nursing, developmental, activities, dietary, and such other modalities as are ordered by the physician, shall be reflected in the preparation of the resident care plan. 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 plan shall be reviewed every three months.

Participating in the screening of prospective residents and their placement in terms of services they need and nursing competencies available.

In addition to the information that is specified above, each resident’s medical record shall contain the following:

A physician’s order sheet that includes orders for all medications, treatments, therapy and habilitation services, diet, activities and special procedures or orders required for the safety and well-being of the resident.

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.

An owner, licensee, administrator, employee or agent of facility shall not abuse or neglect a resident. (Section 2-107 of the act)

These regulations are not met as evidenced by:

Based on record verification, review of the facility's client file(s), the facility's investigation regarding the Incident of 9/13/00, review of the facility's policy and procedures, interviews, review of hospital records, and per review of the Coroner's Report (including the Autopsy Report, Police Report, and the Coroner's Inquest), the facility has neglected to ensure that clients admitted to the facility are provided services necessary to avoid physical harm for 1 of 1 client admitted to the facility during the month of September 2000 (R-1) who suffered a "fatal fall" within 48 hours of admission as a result of the facility's failure to:

1) Complete a comprehensive pre admission assessment to ensure that R-1's needs could be met by the facility;

2) Provide sufficient staff monitoring and supervision to R-1 to prevent injury as based on R-1's health status and history; and

3) Take effective and corrective action to prevent further injury from occurring after R-1 fell on 9/12/00 and received a laceration to his head which required emergency medical attention.

Findings Include:

A) Per record verification and per review of the facility's files on R-1, the Admission Nursing Assessment revealed that R-1 was a 6 year old male who was admitted to the facility on 9/12/00 at 2 p.m. with diagnosis of Sanfilippo Syndrome.

1) Comprehensive Pre admission assessment was not completed by the facility to ensure that R-1's needs could be met.

a) Comprehensive Pre admission assessment was not completed as per review of the facility's policy and procedures. Per review of the facility's Admissions Policy, the following is identified: "The following must be completed prior to admission:

I. Prior to admission

A PAS (Pre Admission Screening) must be completed.
Medical information must have been reviewed including:

a. Diagnosis
b. Past surgeries
c. Past medical history
d. Therapy needs and past reports
e. Special equipment needs
f. Nutritional assessments

3. Educational information must have been reviewed including:

a. Psychological within past three years
b. Individual Education Plan
c. Speech and Language Report
d. Physical Therapy Report
e. Occupation Therapy Report
f. Social History

No admission can be completed without the receipt and review of the above by the IDT (Interdisciplinary Team) (Director, Nursing Supervisor, Physician and QMRP representative)."

Per interview of the facility's administrator/director (E-1) and the facility's director of nursing (E-2) on 10/10/00 in the facility conference room at 3:45 p.m.verified that they (E-1 and E-2) did not participate in an interdisciplinary team meeting with the Physician and or QMRP to determine if R-1's needs could be met by the facility prior to R-1's admission on 9/12/00 as per the facility's policy on new admissions.

Per review of R-1's client files on 10/10/00 at the facility, no pre admission assessment was found.

Per interview with the facility's administrator (E-1) and the director of nursing (E-2) at 3:15 p.m. in the facility's conference room, E-2 stated that the facility's Public Relations person (E-12) or the administrator (E-1) does the pre screening for admissions. The administrator (E-1) gave the surveyor a copy of the pre admission screening completed by E-12. No completion date was noted on any pages of the form by the surveyor.

Per interview of E-12 on 01/05/01 in the facility's conference room at approximately 10 a.m., E-12 stated that she had faxed the pre screening packet to the facility about the time she did the prescreening. (A facsimile date of 7/24/00 is noted on the form.) E-12 verified that she had not seen R-1 at the time the Pre admission Screening form was completed, nor did E-12 secure information from R-1's guardian (Z-1) to assist in the completion of this pre admission form. E-12 stated that she had secured the pre screening information from R-1's "School Superintendent and the School's Social Worker".

Review of the Pre admission Screening form completed by E-12 revealed general information, reflected R-1 was losing mobility skills, had behaviors of eating "things he shouldn't (PICA) and that R-1 would "almost be impossible to program". Additional documentation is noted that he (R-1) "might tap his head" but the behavior was not self injurious.

Review of the Pre admission Screening form also revealed:

a) under the section marked Family Guardian Goals Intentions, E-12 documented "intends to place in L.W. (Little Willow)..."

b) under the Team Review section, E-12's signature is the only signature on the form to identify that R-1's admission to the facility was approved.

Per review of R-1's client records, R-1 was not admitted to the facility until 9/12/00.

Per interview with E-12 on 1/05/01, E-12 stated that "R-1 was an emergency admission to the facility". E-2 (Director of Nursing) was also present in the conference room at the time of the interview with E-12, stated that "they (the facility) did not even know R-1 was coming, until the hospital called the facility two hours before the ambulance arrived at the facility with R-1 on 9/12/00". (Per prior interview with E-2 on 10/10/00, E-2 had stated that R-1's was not an emergency admission to the facility.)

b) Review of medical and hospital records revealed pending transfer to the Little Willow prior to R-1's admission to the facility.

Per review of R-1's client records, R-1 was admitted to Memorial Hospital of Carbondale on 9/03/00 prior to his admission to the facility (on 9/12/00).

Review of the R-1's hospital records, R-1 was seen in the Emergency Room of Memorial Hospital of Carbondale on 9/03/00.

Per review of the Emergency Services Report completed by the physician (Z-5) the following was noted:

"History: This is a 6-year-old white male with a history of Sanfilippo syndrome brought to the

Emergency Room by his mother with a history of decreased intake over the past three days. The child reported he had broken a mirror three days ago and tried to eat some of the glass. He lacerated his buccal surface of the lower lip and now has two small ulcers that are present there. He has history of Sanfilippo syndrome, and mother states he is unable to swallow at this time..."

"Impression: Dehydration, Sanfilippo syndrome, anemia..."

"Plan: The plan is to place this child in long term care. The prognosis normally for people with Sanfilippo syndrome not to live beyond puberty."

Per review of R-1's hospital records including Integrated Progress Notes and Physician Orders completed during R-1's hospital stay, multiple entries were documented in regards to R-1's placement to the Little Willow facility. Examples include:

(from R-1's Integrated Progress Notes)

9/04/00 "...We have previously discussed placement at Little Willow and mom is now ready. I contacted Little Willow today..." Completed by R-1's attending physician (Z-2). 9/05/00: "...possible transfer to Little Willow; E-1 at facility - they need mom to come in and sign forms there, also need a stool cx (culture) for parasites before they can accept him..." Entry completed by Case Management (Z-3).

9/06/00: "...Little Willow transfer can go through after mom signs papers there...Continue care until transfer." Entry completed by physician (Z-4). 9/07/00: "...Little Willow transfer awaiting stool for O and P (ova and parasites), awaiting G-tube placement..." Entry completed by physician (Z-4).

9/07/00: "as above. Doctor (Z-5) consulted for g-tube placement. Will proceed prior to Willow's placement..." Entry completed by R-1's physician Z-2.

Documentation for 9/08, 9/09, 9/10, and 9/11/00 completed by the physicians (Z-2, Z-4) all reflected the pending transfer to the "Little Willow".

On 9/12/00 Physician orders were written by R-1's attending physician (Z-2) to "transfer R-1 to the Little Willow".

Per telephone interview with R-1's prior attending physician (Z-2) on 01/05/01 at 10:45 a.m., Z-2 stated she had talked with R-1's family, the facility's medical director (Z-7) and facility staff, and that R-1 had been scheduled for placement at the Little Willow. Z-2 confirmed that she did not consider "R-1 an emergency admission to the facility".

Telephone interview with the facility's medical director (Z-7) on 1/08/01 at 3:15 p.m. confirmed that R-1 was not an emergency admission to the facility.

During the investigation of the Incident of 9/13/00 involving R-1, no documentation was provided by the facility to verify that:

1) any staff person of the facility went to the hospital to screen R-1 for appropriateness during his nine day hospital stay;

2) any staff person of the facility reviewed R-1's hospital progress notes prior to admission to the facility on 9/12/00.

c) Review of client files and review of hospital records/progress notes revealed behavioral needs that were not identified on the pre screening assessment.

Per review of R-1's file at the facility and as confirmed per interview with the PAS (Pre Admission Screening) agent (Z-6), an ICAP (Inventory of Client and Agency Planning) was completed on 9/07/00 while R-1 was in the hospital.

Per review of the ICAP information, under the motor skills section, it was identified that "R-1 could stand alone and walk for a least six feet always or almost always without being asked". Under the behavior section of the ICAP, it was identified that R-1's behaviors of eating broken glass and head banging were "extremely serious, a critical problem".

Per telephone interview with PAS Agent (Z-6) on 1/04/01 at 8:25 a.m., Z-6 stated that she had talked with the facility administrator (E-1) prior to completing the PAS screening on R-1 and had discussed R-1's admission to the facility. Z-6 stated that she met with R-1's mother at the hospital and completed the ICAP on 9/07/00. Z-6 stated that when she was at the hospital, R-1 was in a crib with very high bars and had padding around the crib.

Per review of the hospital progress notes, documentation was also noted throughout R-1's Intergrated and Patient Progress Notes that R-1 had multiple episodes of agitated behavior requiring Ativan medication to assist in calming him down while in the hospital. Documentation was also noted of R-1 requiring constant supervision and 1:1 care while in the hospital due to agitation.

During the surveyor's investigation of R-1's Incidents for 9/12/00 and 9/13/00, the facility did not provide the surveyor with documentation to verify that the facility had reviewed R-1's hospital Progress Notes and or reviewed R-1's ICAP results prior to R-1's admission to determine if R-1's behavior needs could be met by the facility.

Per review of the facility's client file on R-1, documentation does not verify that the facility followed their own policy and procedures and reviewed all medical and behavioral information prior to admitting R-1 to the facility to determine if they (the facility) could meet R-1's needs.

Per telephone interview on 1/05/01 at 11:10 a.m. with the Forensic Pathologist (Z-8) (who completed the autopsy and autopsy report on R-1), Z-8 stated that it was his "professional opinion that R-1 was not adequately assessed by facility staff prior to his admission to the facility".

2) The facility failed to provide sufficient staff monitoring and supervision to R-1 to prevent injury as based on R-1's health status and history which resulted in R-1's death.

a) R-1's client file does not reflect R-1's needs for supervision as based on his admission nursing assessment and or his patient transfer form from the hospital.

Per review of R-1's client file, at the time of admission on 9/12/00, the licensed practical nurse (E-3) completed an Admission Nursing Assessment that identified R-1's diagnosis of Sanfilippo Syndrome.

(Per review of the Autopsy Report completed by the Forensic Pathologist (Z-8), Z-8 identified that "with this decedent's condition (Sanfilippo Syndrome) falls and eventual inability to get out of bed are normal".)

Under the functional status section of Admission Nursing Assessment, this assessment identified that R-1 required "1 person assist to transfer" and "1 person assist to ambulate".

Per review of the Patient Transfer Form that was sent to the facility on 9/12/00 with R-1, documentation under Nursing Assessment and Recommendations identified "patient needs constant supervision will crawl out of crib or bed".

Per review of the admitting physician's orders completed by the director of nursing (E-2) and signed by the facility's medical director (E-7):

R-1's need for "1 person assist to transfer and 1 person assist to ambulate" were not included in R-1's physician's orders as identified on the Admission Nursing Assessment; and

R-1's need for constant supervision was not included in R-1's physician's orders.

Per review, R-1's admission physician's order sheet does not include orders for special procedures or orders required for the safety and well being of R-1.

Per interview with the director of nursing (E-2) on 1/03/01 at 10 a.m. in the facility's conference room, E-2 stated that she did not put "needs constant supervision" on R-1's admitting orders because the "facility does not provide clients with one on one".

Per interview with the facility administrator (E-1) in the facility conference room at 11:45 a.m., E-1 stated that she had talked with R-1's mom (Z-1) and informed her that the facility could not provide constant supervision to R-1. E-1 stated that Z-1 had agreed with this. E-1 later provided the surveyor with a copy of documentation (no date) that had been completed by her (E-1) that stated:

"Upon return from the hospital, mother and I discussed situation of the facility not being able to give one on one for R-1. I explained to mother we would put him as close to nurses station as possible and do frequent checks on him to ensure his safety. There was no objection from mother."

Per telephone interview with R-1's mother (Z-1) on 1/03/01 at 10:15 a.m., Z-1 stated that she had "told the facility that R-1's balance was off and that he fell a lot. Z-1 stated that she had "warned them ahead of time" (prior to admitting R-1 to the facility). Z-1 stated that she could not watch R-1 twenty four hours a day, "so that's why I put him there". Z-1 stated that the facility had discussed the low profile bed with her, but the facility had never told her that they could not provide R-1 with constant supervision. Z-1 stated "if they had told me they could not provide constant supervision to him (R-1), I never would have left him there".

On 1/05/01, while at the facility, the surveyor was presented with a letter from R-1's prior attending physician (Z-2). Per review of the letter written by Z-2, the following was noted:

"R-1 was an inpatient at Memorial Hospital Carbondale from 9/04/00 through 9/12/00/ While hospitalized, a full time sitter was provided because we were unable to provide and appropriate, safe environment. Upon his transfer to Little Willow, there was no intention that he would require or receive full time, one-on-one care. I suspect that the notation on the transfer sheet was from the nursing staff based on their experience with R-1..."

Per telephone interview with R-1's prior attending physician (Z-2) on 1/05/01 at 10:45 a.m., Z-2 stated that R-1 had been supervised while at the hospital by family, sitters and the nurses. Z-2 stated that R-1 would "bang his head" and "crawl out of his crib". Z-2 stated that "the nurses had tried mattresses on the floor around the crib, but R-1 would not stay on the mattresses and the floor was tiled underneath". Z-2 also stated that while in the hospital, "nursing staff had padded R-1's crib, but this didn't work". Z-2 stated that while R-1 was in the hospital she had discussed with his family, the Little Willow staff and the facility's medical director (Z-7) regarding R-1's need for a helmet, need for a chair restraint during the day, and R-1's need for supervision during waking hours. Per review of R-1's client file, no documentation was noted that identified Z-2's discussion with facility staff regarding R-1's needs for a helmet, need for a chair restraint, and or R-1's need for supervision during waking hours.

Per review of R-1's Patient Transfer Form and per telephone interview with the registered nurse (Z-9) (who completed R-1's transfer form from the hospital to the facility on 9/12/00) at 3:55 p.m. on 01/03/01, Z-9 stated that R-1 had required constant supervision and had required sitters while at the hospital. Z-9 stated that R-1 would climb over and out of his crib and the hospital had attempted mattresses on the floor to prevent injury. Z-9 stated that R-1 would still climb out and off of the mattresses and would be all over. Z-9 stated that she had contacted the facility at about 8 a.m. on 9/12/00 and had given report. Z-9 stated that she had talked with a male nurse (E-4) at the facility and had informed them at that time of R-1's need for constant supervision. (Hospital documentation reflected that a call was placed to the Little Willow on 9/12/00 by Z-9 at 8:30 a.m. to give report of transfer at 1 p.m.)

Per review of the facility records and R-1's client file, no documentation was noted of Z-9's call to the facility to report R-1's transfer to the facility and R-1's need for constant supervision. Additionally, no documentation was noted in R-1's file to verify that the facility had contacted the hospital and or R-1's prior attending physician (Z-2) to clarify the recommendation for R-1's need for constant supervision.

Per review of the facility's schedule and as verified per the facility administrator through review of the time cards on 1/08/01, E-4 (the facility's only male nurse on 9/12/00) had worked a 12 hour shift and was present and on duty at the time Z-9 telephoned the facility.

Per telephone interview with licensed practical nurse (E-4) on 1/05/01 at 10:30 p.m., E-4 stated that he did not recall working the morning of the 12th. E-4 stated that he did not recall taking a call from the hospital informing the facility that R-1 was being admitted. E-4 stated that if he had of taken a call from the hospital, he would have documented the call on a piece of paper and passed the information on. E-4 stated that he thought the DON (Director of Nursing) (E-2) had told him that morning.

b) Nursing documentation for R-1 on 9/12/00 and 9/13/00 did not reflect that R-1 was provided with adequate supervision to prevent injury.

After R-1 was admitted on 9/12/00, documentation at the time of admission reflected that R-1 was placed in a crib and began thrashing around so he was placed in a wheel chair and then into a low lying bed.

Per review of the licensed practical nurse's (E-3) Employee Statement, E-3 documented: On September 12th, I admitted R-1 to Little Willow facility....Later that night I took R-1 to his room and laid him down. He got up out of bed and began heading for the doorway. He was unsteady on his feet so I took his hand and walked him up to the front nursing area so that I could keep a eye on him. I placed him in a play pen that is right next to the nurses desk so that I could keep a eye on him and he attempted to climb out of the play pen. I then gave him Ativan 1 mg IM (Intramuscular) and took child into my arms and rocked him for comfort until my shift was over at 10 p.m.

Per review of an Employee Statement completed by licensed practical nurse (E-4), the following was noted:

"On 9/12/00 at app. (Approximately) 11:15 p.m. when going down blue hall passing meds (medications) I looked into R-1's room. R-1 was up by the wall between his bed and the air conditioner. He was leaning on the wall and taking short unsteady steps towards the air conditioner. At this time I went in and assisted him back to bed."

Per telephone interview with the licensed practical nurse (E-4) on 1/05/01, E-4 stated that R-1 had a low profile bed and mats on the floor because he remembered having difficulty walking on the mats while helping R-1. When E-4 was asked by the surveyor as to what nursing measures were taken due to R-1's wandering behaviors with unsteady gait? E-4 stated that "I thought I told the tech to keep a closer eye on R-1". E-4 stated that he did not remember if he documented this or not.

Per review of R-1's nursing notes, no nursing documentation was noted for 9/12/00 after 8 p.m. until 9/13/00 at 1:15 a.m. R-1's incidents of wandering were not documented in R-1's nursing notes as appropriate.

Per review of the facility's staffing schedule and as confirmed per telephone interview with the facility's administrator on 1/09/01 at approximately 11 a.m., only two nurses (E-4 and E-5) and one direct care staff member (E-6) were present and on duty on 9/13/00 from 12 a.m. until 2:07 a.m. (due to a call in) to provide R-1 with closer supervision and to care for the needs of 35 other clients of the facility.

Per review of R-1's client files at 1:15 a.m. on 9/13/00 (after being in the facility less than 12 hours), R-1 sustained an unwitnessed laceration to his right forehead which required emergency medical attention and suturing.

Review of R-1's nurse's notes revealed that at 1:15 a.m. on 9/13/00, the licensed practical nurse (E-4) "was called to blue hall. Child (R-1) was standing in front of Rm (room) 106. Child has abrasion et (and) 3/4 inch (above) right eye. Cause unknown. First Aid given by (E-5) RN (registered nurse) et (and) pressure to stop et (and) slow bleeding."

Review of R-1's nurse's notes, documentation revealed that Z-2 (R-1's physician) was contacted and orders were received to send R-1 to the Emergency Room for evaluation and treatment. While at the Emergency Room R-1 received 5 stitches to his right forehead. R-1 returned from the Emergency Room back to the facility at about 5 a.m. on 9/13/00.

Review of the Jackson County Ambulance Services Emergency Medical Technician (Z-10) Voluntary Statement taken by the Carbondale Police on 9/14/00 the following was revealed:

"9/13/00 1:30 a.m. Got a call to the Little Willow for a patient that has fallen out of bed and has a laceration to the head... Patient had an approximately 3-4 cm laceration on his forehead just above right eyebrow... Patient's laceration appeared so deep that it looked as if you could see his skull..."

When R-1 was returned to the Little Willow at about 4:30 a.m. (4:51 a.m. per Transporter Report) Z-10's statement revealed that there were "no rails on R-1's bed" nor "pads to keep him from falling out of the bed again". R-1 was placed in bed by the transporters (Z-10 and Z-11) and nursing staff left the room. Per Z-10's statement, "When Z-11 and I (Z-10) were leaving, no one had gone back in R-1's room to check on him or change his diaper. I (Z-10) felt this to be another accident waiting to happen".

Per telephone interview on 1/05/01 at 10:30 p.m. with the licensed practical nurse (E-4) who was on duty at the time R-1 was returned to the facility (9/13/00 at 4:51 p.m.), E-4 stated he did not recall if the mats were down by R-1's bed or not when he (R-1) was returned back to the facility.

Per review of the nursing notes and per review of the Emergency Room Records dated 9/13/00, within 18 hours of being returned back to the facility after requiring Emergency Medical attention, R-1 was found by facility staff in his bedroom, unresponsive. Nursing staff began CPR (Cardio Pulmonary Resuscitation) and R-1 was again transported by the Jackson County Ambulance Service to the Carbondale Emergency Room in "full arrest" at 11:07 p.m. R-1 was pronounced dead by the Emergency Room Physicians at 12:02 a.m. on 9/14/00.

Per review of the Death Certificate, R-1's cause of death was identified as "Subdural bleed secondary to fall". The Death Certificate also identified Skill Nursing Facility as place of injury.

3) Facility failed to take effective and corrective action to prevent further injury from occurring after R-1 fell on 9/12/00 and sustained a laceration to his right forehead.

Per interview with the facility's administrator (E-1) on 10/10/00 at 10 a.m., E-1 stated that no actual investigation had been completed by the facility. E-1 stated that no actual final report had been completed that identified actions taken by the facility.

Per review of the facility's investigation, no documentation was provided to the surveyor that identified that the facility had investigated how R-1 sustained a laceration to his right forehead on 9/13/00. Telephone interview with the licensed practical nurse (E-4) on 1/05/01 at 10:30 a.m., E-4 stated "No" when asked by the surveyor if he had checked for a blood path or pattern to determine how R-1 sustained the laceration to his head?

Per review of the facility's staffing schedule and as confirmed per interview with the facility's administrator, E-4 (licensed nurse), E-5 (registered nurse) and E-6 (direct care staff) were on duty on 9/13/00 when R-1 fell.

Per review of the statements taken by the facility, no questions were asked of E-4, E-5, nor E-6 in regards to how R-1 could have sustained his injury.

Per interview with the facility's administrator (E-1) and per review of the information submitted by the facility to the surveyor on 1/05/00, the only modification made to R-1's environment after his fall, was the placement of a door alarm that was attached to R-1's bedroom door .

Per interview with direct care staff (E-7) on 1/03/01 at 2:15 p.m., E-7 stated that at the time they (E-7 and E-8) found R-1 on 9/12/00 at 10:30 p.m. E-7 stated that R-1's bedroom door was shut with the alarm set. E-7 verified that R-1 could not be seen by staff in the hall until staff opened R-1's bedroom door.

R-1's client file revealed that the facility's medical director (Z-7) ordered a helmet for safety on 9/13/00 (at approximately 1 p.m.). No constant supervision was provided to R-1 while he was in his bedroom for safety until a helmet had been secured. No helmet was secured by the facility prior to R-1's death.

Per review, no documentation was provided to the surveyor by the facility as to how staff were to monitor R-1 while he was in his bedroom with the door shut, to prevent further injury from occurring.

As based on review, after the facility secured employee statements completed by the licensed practical nurses (E-3 and E-4) that revealed that R-1 had been found twice by nursing staff walking unsteadily in his bedroom on 9/12/00 ( with mats in place), and after R-1 fell on 9/13/00 at 1:15 a.m. and sustained a laceration to his forehead requiring suturing, the facility neglected to place sufficient safeguards into place to ensure that R-1 was free from serious and immediate threat(s) to his physical health and safety.

Per review of the facility's statements taken during their investigation and as confirmed per interview with the facility's administrator on 10/10/00, the facility neglected to investigate to determine how R-1 sustained a laceration to his right forehead on 9/13/00 and to take effective and corrective action to prevent further injury from occurring to R-1.

After returning from the Emergency Room on 9/13/00 at approximately 5 a.m., less that eighteen hours later, R-1 suffered an unwitnessed "fatal fall" in his bedroom at the facility.

Per review of the Incident Report Employee Statement completed by the facility's administrator (E-1) dated 10/19/00, E-1 documented:

"After reviewing all employee statements as to the events of 9/12/00 - 9/13/00 concerning the injury and death of R-1. I am unsure as to the cause of death of this little boy. I can not see where staff acted inappropriately in this sad and unfortunate situation."

Per review of the Forensic Pathologist Report completed by Z-8, the following was noted:

"Cause of Death: Intracranial Hemorrhage due to blunt trauma consistent with fall due to Sanfilippo Syndrome.

(Approximate interval from onset to death was identified as minutes.)

Manner of Death : Accident

Opinion:Based on the history provided me, including the statement by Z-10 (Emergency Medical Technician), and on my findings in a forensic autopsy, my opinion is that R-1 died from bleeding inside his head caused by a severe blow to his head, consistent with a fall onto a hard floor. Comment:

As the posterior scalp did not lacerate full thickness with this fall, it is possible a thin layer of soft material was between the decedent's head and the apparently asphalt tile on concrete floor. The Emergency Medical Technician's (EMT's) description of the pads on the floor seems to fit such a material.

The relative healthiness of this patient, even with the many small bruises, is striking commendation for the excellent care render to him for more than six years at home by his mother and family until just two days prior to his demise. With this decedent's condition, falls and eventually inability to get out of bed are normal. However, the provision for protection from the falls was questioned by the EMT (Emergency Medical Technician) on delivering the decedent to Little Willow after his fall and laceration of his forehead the night before. Less than 24 hours after that fall, the decedent suffered his fatal fall. The results of two days under the responsibility of Little Willow staff are quite different from those rendered at home. The combination of Sanfilippo Syndrome and R-1's size and activity clearly justified placement under professional care. This case indicates the care was not as professional as one might have wished; protection against falls and damage from them was not adequate."

Date of Survey: 07/18/01

Incident Investigation of July 1, 2001 and Complaint Investigation

A” VIOLATION(S):

The facility’s governing body shall exercise general direction of the facility and shall establish the broad policies for the facility related to its purpose, objectives, operation, and the welfare of the residents served.

An owner, licensee, administrator, employee or agent of a facility shall not abuse or neglect a resident. (Sections 2- 107 of the act)

Resident as perpetrator of abuse. When an investigation of a report of suspected abuse of a resident of the long-term care facility is the perpetrator of the abuse, that resident’s condition shall be immediately evaluated to determine the most suitable therapy and placement for the resident, considering the safety of that resident as well as the safety of other residents and employees of the facility. (Section 3-612 of the act)

These Requirements are not met.

Based on review of the Incident Reports dated 05/08/01 and 07/01/01, record verification, observation, review of the facility's Investigation(s) including staff's written statements, review of the facility's policy and procedures, and per staff interviews, the facility has neglected to implement their own written policies and procedures that prohibit mistreatment, neglect or abuse of the client, for 6 of 6 clients involved in the Incident of 07/01/01 (R-5, R-6, R-7, R-8, R-9, and R-10) having the potential to impact all clients of the facility as evidenced by:

A) Facility neglected to implement their written policy and procedure on investigating and reporting abuse neglect and or incidents;

B) Fifteen minute bed checks not completed as appropriate to assist in monitoring clients at night as identified per the Incident Report Investigation of 05/08/01;

C) Proper physical examination not provided with appropriate medical follow as appropriate as identified per the facility policy in regards to sexual abuse;

D) Safeguards not in place immediately after the incident of 07/01/01 to prevent further potential abuse; and

E) Receiving facility for R-5 not fully informed of the reason for R-5's discharge from the facility to assist in protecting and safeguarding the clients of the receiving facility.

Findings include:

A) Facility neglected to implement their written policy and procedure on investigating and reporting abuse neglect and or incidents.

Per review of the facility's policy and procedure on Incident and Abuse and Neglect Investigation Procedure the following was revealed: It is the policy of this facility that all incidents be promptly and thoroughly investigated.

When the incident or suspected incident of abuse is reported, the Administrator, or the party designated by the Administrator will investigate the incident.

A. Interview with the person(s) reporting the incident
B. Interview with the resident if possible
C. Interview with any witnesses to the incident
D. Review the resident's medical record
E. Interview with the staff members having contact with the resident during the period of and immediately after the alleged incident
F. Interview with the resident's roommate, family members or visitors, if applicable
G. Interview with the alleged perpetrator
H. If the alleged perpetrator is a staff member, a review of his or her employment record and an interview with his/her supervisor
I. Review all of circumstances surrounding he incident

If the incident is abuse, the suspected individual will be denied access to the resident while the investigation is being conducted.

Review of the facility's policy and procedures on abuse/neglect reporting identified abuse as "any physical, mental or verbal injury or sexual assault inflicted on a resident other than by accidental means". Under this policy, sexual abuse is defined as, but not limited to, sexual harassment, sexual coercion, or sexual assault. Additionally under this policy, "Upon receiving a report of physical or sexual abuse, the resident shall be examined and provided with appropriate follow up medical attention, as needed. Findings of the examination will be recorded in the resident's medical record. Attending physician, family and law enforcement will be notified as appropriate".

Per review of the Report dated 07/02/01 that was submitted to the Illinois Department of Public Health regional office by the facility director (E-1), the following was noted:

"On the morning of 07/01/01, resident R-5 was seen by staff, per staff interview and documentation at 4:45 am. At 5 A.M. resident (R-5) was found in another peer's bedroom. Resident's were both found fully clothed, no apparent injury to either resident, In a room, two doors down, two female residents were found with toothpaste squirted on them. One of the girls had a light abrasion noted on the side of her nose. There were no other injuries noted. The physician was notified. The facility has attempted to notify the families. An internal investigation is currently being conducted. ..."

Review of the facility's Investigation (including staff's written statements) for 07/01/01, record verification and interviews with staff present on 07/01/01, revealed that R-5 was found by E-30 (Certified Nursing Assistant-CNA) on 07/01/01 at approximately 5 A.M. in Room 205 (R-7 and R-8's bedroom). R-5 was found on top of R-8, straddling his (R-8's) chest /neck. R-5 had no clothing on other than a shirt and R-5's penis was on the side of R-8's face.

Review of the statements and interviews with staff (E-8, E-14, E-25, E-26, E-27, E-28, E-30, E-31, and E-36) who were present and on duty after 4 .A.M. on 07/01/01 revealed:

Room 205; R-7's Jejunostomy-Tube (J-Tube) had been pulled out and was found at the foot of the bed.. R-7's gown and stomach were bloody.

Room 207; Staff found R-6 laying on her stomach in her bed with her buttocks exposed (substance smeared on buttocks). R-9 who shared a bedroom with R-6, was also found exposed from the neck down and had been smeared with a substance. Scratches were noted on her nose and cheek with a small amount of bleeding. A hair brush was found in R-9's bed. A bloody towel was found in R-6's and R-9's bathroom.

Room 209; Staff found R-10's diaper had been ripped up in little pieces in his bed. R-10's gown was off and draped over his waist.

Room 201; Staff found that the bathroom door connecting R-5's room to Room 203 (shared by R-11 and R-12) was open. The alarm on the bathroom door was in the off position. R-5's front door was still shut with the alarm engaged.

Per interview with the facility director (E-1) on 07/03/01 at 1:30 - 1:40 P.M. in the director's office, E-1 stated that the facility had secured initial statements from E-14 (Licensed Practical Nurse/LPN), E-27 (Habilitation Technician/HT), E-26 (Habilitation Technician/HT), E-8 (Programmer), and E-25 (Licensed Practical Nurse/LPN) in regards to the incident of 07/01/01 involving R-5. Review of the schedule for 07/01/01 revealed that the facility's initial statements were from the third shift staff who worked the shift of 06/30/01 to 07/01/01. Review of the schedule revealed that E- 1 did not identify that statements had been secured from any of the morning staff that had been present on 07/01/01.

Per review of the employee statements and staff interviews the following was revealed:

Employee Statement written by E-30 (Certified Nursing Assistant/CNA): "5:08 A.M. "E-25 the LPN told me to go to R-7's room and read the volume and clear the J-tube reading on his tube. As I was walking towards the room I smelled a very minty smell. When I approached R-7 and R-8's room the door was closed. I open the door and the first thing I saw was R-8's catheter bag on the floor. Next I saw R-5 on top of R-8 (straddling R-8's neck) with his penis on the side of R-8's face. R-5 only had a shirt on. I told R-5 to get up and get out of the room. I noticed on R- 5's hand(?) a white substance. I then went to R-9's and R-6's room. R-9 was covered head to toe-everywhere with a dried white substance. She also had blood on the bridge of her nose-that had dried- and on her cheeks. A hairbrush was between her legs and a toothbrush was also present. She was completely nude. A toothpaste tube and diaper rash ointment tube was on the floor. R-6 was lying face down on her bed with white substance rubbed on her buttocks. R- 6's diaper was undone laying underneath her. I went thru the bathroom and saw a bloody towel on the floor. I checked R-5's alarm and it was off. (The bathroom door one). Without disturbing anything I immediately went to the nurses station to report what I had found. I asked E-25 who was supposed to be doing 15 minute checks. E-25 stated she did not know. I told her to come down the hall. E-31 (CNA in training) followed shortly behind us. When E-25 looked in R-9's and R-6's room, she looked at E-31 and said "You have to see this". E-25 then covered her mouth and laughed. I turned away and went back up front. I saw E-28 clocking in and had her go down the hall. By then E-25 had the 3 midnight techs in the hallway with her. E-25 went back to the nurses station to call E-2 and E-1. I had gone to the linen close and heard E-28 tell E-25 that R-7's J-tube was pulled out and he had blood on his gown. E-28 had said something about other residents being checked and E-25 said "Yeah I guess we better check them." Completely frustrated at the reaction of E-25 and the 3 midnight techs, I went to work on the other hall. E-28 and I'm not sure who else, cleaned up the girls."

Per interview with E-30 (CNA) on 07/05/01 at 1:30 to 2:00 P.M. in the facility conference room, E-30 confirmed her written statement of 07/01/01 was an accurate account of what she found on 07/01/01. During the interview, E-30 stated that when she found R-5, R-5 was wearing a red baseball shirt. E-30 stated that R-5 had no bottoms on and that R-5 was straddling R-8 trying to put his penis in his (R-8's) mouth. E-30 stated that when she was in R-9's room, R- 9 was covered from head to toe in toothpaste and or diaper rash ointment. E-30 stated that "R-9 had blood smeared on her nose and cheek and even in her pubic hair". E-3- stated that "a hairbrush was between R-9's legs just inches away from R-9's vaginal entry". E-30 stated that R-9 "usually smiles but did not that morning". E-30 stated that "a tear rolled down from R-9's eye and that she appeared to be scared".

When E-30 was asked by the surveyor if she had been interviewed by the facility staff on 07/01/01 as per the facility policy on incidents and abuse/neglect investigation? E-30 stated that she was not interviewed by any facility staff on 07/01/01 after the incident. E-30 stated that she had been told to fill out a statement, but that she did not leave the statement. E-30 stated that no one from the facility contacted her about her statement until 07/03/01 which was two days later after the incident of 07/01/01.

Per interview with E-36 (Certified Nursing Assistant in training) on 07/06/01 per telephone interview from 8:58 to 9:03 A.M., E-36 stated that she had worked on 07/01/01 from 5 A.M. to 1 P.M.. E-36 stated that she was currently in training. E-36 stated that she had dress R-5. E-36 stated that when she first saw R-5, R-5 was dressed in a baseball type shirt. E-36 stated that R-5 had nothing under the shirt. E-36 stated that R-5 had no underwear on, only a shirt. When E-36 was asked if she had written a statement about the Incident of 07/01/01 or been interviewed by facility staff? E-36 stated that she did not write a statement. E-36 stated that she was never interviewed by the facility staff until 07/05/01 when she was interviewed by the facility's attorney".

Employee Statement of E-31 (Certified Nursing Assistant in training): "At 5:15 A.M. I was walking to get a drink of water when I saw one of the nurses with her hands over her face in pure shock. I said what was wrong? She said "Oh my God!! Take a look at R-9. When I seen her, I was in pure shock!! She was without clothing and was covered from head to toe in toothpaste. There was small scratch marks on the inside of her eyes and there were signs of blood. R-6 was on her stomach shivering with her diaper off as well. I went into the room next door and I saw R-7 with blood all over his gown, at first I had no clue to whey their was any blood until I looked under his gown and seen that the feed tube was pulled out. Everybody at this time was just finding out what had happened so I just covered everybody up R-9, R-6, and R-7 and went up front to sit on the couch. When I seen R-5 he was fully clothed t-shirt and gray pants and he had a little toothpaste on his forehead."

Per interview with E-31 on 07/03/01, from 3:55 P.M. to 4:25 P.M., E-31 stated that he had been present in the facility on 07/01/01 about 5 A.M., but was not scheduled. E-31 stated that he had observed the clients the morning of 07/01/01. E-31 stated that on 07/01/01 when her saw the bloody towel and the toothpaste in the bathroom sink of R-6 and R-9's bathroom, there was "enough blood on the towel to be worried". E-31 stated that he was unsure of where the blood had came from. When E-31 was asked by the surveyor if he had been interviewed on 07/01/01 (per the facility's policy)? E-31 stated that no one asked him for a statement until 07/03/01.

Employee Statement of E-28: "I (E-28 Habilitation Technician) went down green hall about 5:30 A.M.. R-5 was still running around and I went into R-8 and R-7's room. R-7's J tube was pulled completely out. I then went and told the nurse that was on duty about R-7. We all went down to see what else was done. R-8's diaper was torn off. R-9 was covered with toothpaste. R-6's diaper was pulled off and toothpaste was on her butt. R-5's bathroom door was not locked."

Per interview with E-28 on 07/03/01 at 2:40 to 3 P.M. in the facility conference room, E-28 stated that she had been on duty on 07/01/01 and had observed R-7's J-tube out and R-6 and R-9 smeared with a substance. E-28 stated that neither R-6 nor R-9 had a diaper or gown on covering their bodies. E-28 stated that "midnight shifts are to do 15 minute checks" and that they "made a big mistake". When E-28 was questioned as to how midnight shift made a big mistake? E-28 stated "the bathroom alarm was turned off and R-5's door was open".

Per review of the facility's investigation report written (submitted to the surveyor on 07/03/01) by E-2 (Director of Nursing) dated 07/02/01, E-2 documented:

"Res (resident) R-5 had gotten out of bed et (and) left his room and went down hall et (and) was found lying on a mattress with a male peer. At this time, staff went et and checked all res (residents) on the wing, In this they found 2 female peers (1) with gown off et (and) diaper off with toothpaste smeared on face, Sm. (small) abrasion on left side of nose with Sm (small) amount of blood, hair brush also found in bed. (2) female lying on abd. (abdomen) with toothpaste across lower back diaper folded back, nurse checked both females et (and) no signs of semen or vaginal discharge noted, no bruises noted on either. Res (resident) was cleaned up staff no distress noted. After further investigation, it was noted a male peer had his diaper removed. and another male peer was found fully clothed with diaper intact but feeding tube was lying in bed at foot. Wandering res (resident) was fully clothed in shorts and tee shirt and requires assist with dressing."

B) Fifteen minute bed checks not completed as appropriate to assist in monitoring clients at night as identified per the Incident Report Investigation of 05/08/01.

During the Incident Report Investigation of 05/08/01 (regarding R-1 who expired on 05/08/01), E-2 (Director of Nursing) had informed the surveyor on 06/14/01 at 3:00 P.M. to 3:45 P.M. in the QMRP office, during the Daily Status Meeting that the facility was now doing 15 minute bed checks when clients are in the bed and that extra staff had been placed on third shift to assist in monitoring clients at night.

Per review of the 15 minute bed checks for morning of 07/01/01, staff documented that all bed checks had been completed. Further review revealed that E-26 (Habilitation Technician-HT) had initialed all bed checks from 4 A.M. to 8 A.M. for 07/01/01 for R-5, R-6, R-7, R-8, R-9, R-10, R-11, and R-12.

Employee Statement of E-26 (Habilitation Technician): "I E-26 did the 15 minute checks until about 12 A.M. or 12:30 A.M. After that, I did rounds only until about 4:20 A.M. or 4:25 A.M., every two hours. Between rounds I did paper work, took breaks and relieved the sitter for R-13 at about 3:00 A.M. to 3:30 A.M. for lunch. Our last round started between 3:45 A.M. to 4:00 A.M. it was done about 4:25 or 4:30 A.M.. We took a break at that time with the nurse. At about 4:45 A.M., E-8 went down green hall to check the kids and empty R-8's catheter. She came back and only said the output for R-8. There was also at least two other 5 A.M. Techs in the building. At this time we went down purple hall to get the adult residents up. Probably 15 to 20 minutes later at 5:15 A.M. we were told that there was an incident on green hall with R-5. We went to R-9's room and she had toothpaste on her face and R-6's diaper was off. The alarm in R-5's room malfunctioned and there was a mess on green hall."

Telephone interview with E-26 on 07/12/01 at 10:20 P.M. to 10:57 P.M. revealed that she did not complete any bed checks after 4:30 A.M. on 07/01/01. E-26 stated that they started their last round at about 3:30 A.M. and completed about 4:30 A.M.. E-26 stated that the last time she saw R-5 in the bed was about 4:30 A.M.. E-26 stated that after 4:30 A.M. they (E-26, E-27, E-8, and E-25) all went outside the facility for break leaving only one nurse (E-14) and a staff who was on 1:1 for R-11. E-26 stated that they all returned back into the facility about 4:45 A.M.. E-26 stated that she sent E-8 to empty R-8's catheter bag. E-26 stated she sent E-8 then did bed checks for that hall. (Prior interview with E-8 on 07/11/01 from 3:30 P.M. to 3:50 P.M., outside the facility, E-8 stated that she had emptied R- 8's catheter bag at about 4:45 A.M. E-8 stated that she did not do any further bed checks after staff returned from break after 4:45 A.M. for R-5, R-6, R-7, R-9, and R-10, nor for any other clients on green hall and had gone to assist on purple hall.) E-26 stated that she had filled the blanks in for the time of 4 A.M. to 8 A.M. because she thought the 15 minute bed checks had been done.

E-26 stated that when she was in R-9's room, she had cleaned R-9 up (face, breast, pubic hair) of the toothpaste and blood on the morning of 07/01/01. E-26 stated "R-9 looked like she was sleepy, but she was not smiling". E-26 stated that she threw the brush away that she found in R-9's bed and had thrown the bloody towel in the dirty hamper. When E-26 was asked why she had not put this information in her written statement? E-26 stated "I wasn't sure what they wanted me to put" and it was 8:30 A.M. and time to go home. E-26 stated that she was not interviewed by facility staff (E-32 Administrator) until 07/02/01.

Per interview with E-27 (Habilitation Technician) on 07/03/01 from 2:10 to 2:35 P.M. in the facility conference room and interview with E-8 (Certified Nursing Assistant/CNA) on 07/11/01 from 3:30 to 3:50 P.M. outside of the facility confirmed that the 15 minute bed checks had been completed until about 4:30 to 4:45 A.M. on 07/01/01. E-27 and E- 8 also confirmed that staff had taken their breaks together outside of the facility leaving only the nurse (E-14) and the 1:1 sitter for R-11 alone in the facility.

Per interview with E-8, E-8 stated that "I did not do any more 15 minute checks on the green hall after returning from break". "I feel like it's my fault and I should have checked all of them." E-8 stated "they should have been taken to the hospital, but they didn't take them".

C) Proper physical examination not provided with appropriate medical follow as appropriate as identified per the facility policy in regards to sexual abuse.

Review of the facility's policy and procedures on abuse/neglect reporting identified abused as "any physical, mental or verbal injury or sexual assault inflicted on a resident other than by accidental means". Under this policy, sexual abuse is defined as, but not limited to, sexual harassment, sexual coercion, or sexual assault. Additionally under this policy, "Upon receiving a report of physical or sexual abuse, the resident shall be examined and provided with appropriate follow up medical attention, as needed. Findings of the examination will be recorded in the resident's medical record. Attending physician, family and law enforcement will be notified as appropriate".

Per record verification of R-5, R-6, R-8, R-9 and R-10, none of the client records revealed that facility staff had documented the occurrence of the incident of 07/01/01 with the exception of R-7 who required hospitalization as a result of his J-tube being pulled out. No documentation was noted for 07/01/01 that identified that the clients had been examined and that the physician and family had been notified as identified per the facility policy.

Incident Report and record verification of the Nurse's Notes revealed: For R-6: Incident Report dated 07/01/01: "Resident found in bed laying on stomach with toothpaste squirted on lower back." (No signature other than E-1's facility director.)

Nurse's Notes: 07/03/01 "Late entry- At about 0515 Res (resident) was found in her bed laying on her stomach with her total backside exposed. She had toothpaste on her lower back that was just squirted on there and had not been rubbed around. She did not seem to be in any type of distress. After a complete examination, there was no bruises, scratches or any signs of any kind of sexual activity apparent. no vaginal discharge, no semen. After getting cleaned up, I went back to check on her and there were no S/S (signs or symptoms) of any pain or discomfort." No signature was noted on the Nurse's Notes.

Interview with E-25 on 07/03/01 from 4:50 P.M. to 6 P.M. in the facility's conference room, E-25 confirmed that she had written the late entry into R-6's Nurse's Notes.

For R-9: Incident Report dated 07/01/01: "Face was scratched by another child."

Nurse's Notes: 07/02/01 "Late Entry- At about 0515 Res (resident) was found in her bed with clothes off and toothpaste rubbed all over her body. She did not seem to be in any type of distress and upon examination there was no bruises any where on her body and no signs of any sexual activity such as vag. (Vaginal) discharge or any semen, She did have a couple of scratches on her nose and left upper cheek with a small amount of blood. No additional injuries were found." Signed by E-25.

Per interview with E-25 on 07/03/01, E-2 stated that she had checked and looked at R-6 and R-9 and did not see any evidence of any injury. When E-25 was questioned by the surveyor as to how she checked the clients? E-25 stated that she did not check R-6 and or R-9 vaginally nor had she pulled their legs apart after finding the clients on 07/01/01. When E-25 was asked by the surveyor why she had documented that she had checked R-6 and R-9 and found no signs of sexual activity? E-25 began to cry and stated that she was "told by E-1 (facility director) to write that" . E-25 also stated that when she had called the facility director (E-1) on 07/01/01, E-1 told her not to contact R- 9's parents and that she (E-1) would deal with the incident on Monday morning. E-25 stated that she also was told "under no circumstances" document that another resident pulled out R-7's J-tube."

(Interview of staff present (E-14 (LPN), and direct care staff E-26, E-22, E-28, E-30, and E-31)at the time R-6 and R- 9 were found and cleaned up on 07/01/01, confirmed that they had not observed the nurse (E-25) do a body check of the two female clients.)

Interview with E-25 on 07/03/01 also revealed that she did not call the physician to inform him of the incident regarding R-5, R-6, R-8, R-9 , nor R-10 on 07/01/01.

Per telephone interview with Z-10 (physician) on 07/03/01 from 4:20 to 4:30 P.M., Z-10 stated that E-13 (Registered Nurse/RN) had called him on 07/01/01 and told him about R-7's J-tube being out and that R-5 had scratched people and was found on top of R-8. Z-10 stated on the next day, he was informed that the ladies (R-6 and R-9) were undressed, but that R-5 was dressed at the time of the incident. Z-10 stated that he suggested to the facility that they may want to have the females examined at the emergency room. Z-10 stated that he was informed by the facility that they wanted to hold out until they concluded their investigation. Z-10 stated that he informed the facility that the parents needed to be notified and if they desired, the facility should send the clients to the hospital for examination.

Per record verification and as confirmed per interview with R-6's guardian (Z-13) on 07/03/01 at the facility and per telephone interview with R-9's guardian (Z-14) on 07/07/01 from 5:10 to 5:50 P.M., neither of the guardians were informed of the incident on 07/01/01, nor did the facility notify these guardians of the physician's recommendation to have their daughters seen at the hospital for examination.

Per telephone interview with Z-14 on 07/07/01 from 5:10 to 5:50 P.M., Z-14 stated that they had been on vacation during the week of 07/01 thru 07/07/01. Z-14 stated that she had not left home until about 4:50 P.M. on 07/01/01. Z- 14 stated that when she arrived home there was a message from the facility from 07/02/01, a message from the emergency room on 07/03/01, and a message from the Illinois Department of Public Health. Z-14 stated that the facility should have notified her of the incident of 07/01/01 on 07/01/01.

D) Safeguards not in place immediately after the incident of 07/01/01 to prevent further potential abuse.

Per record verification, R-5 is a 19 year old ambulatory male that functions at a severe to profound level . Review of individual program plan and as confirmed per interview with E-37 (QMRP) on 07/11/01 from 3 to 3:10 P.M., R-5 had behavior programs developed to address Inappropriate Masturbation, Physical Aggression, Inappropriate Touching, and had been receiving Sex Education 1:1 with E-37 prior to his discharge. Interview with E-37 also confirmed that R-5 had a program in place for elopement constituting the alarms on his bedroom door.

a) 1:1 nor intensive monitoring not provided to R-5 after the incident of 07/01/01 as appropriate.

Review of the Employee Statement written by E-25 (Licensed Practical Nurse), E-25 documented that "Techs were told to be sure and cont. (continue) to keep a very close eye on R-5 to ensure that he stayed in his room. Also to help resolve the situation, he was gotten up out of bed early and brought into the dining room and had 1:1 supervision at all times". (No date identified.)

Per interview with E-25 on 07/11/01 at 10:30 to 10:45 A.M. in the facility's conference room, E-25 stated that she had written this statement after she had talked with the surveyor on 07/03/01. E-25 stated that the statement was for Monday 07/02/01, but was written on Wednesday or Thursday. E-25 stated that she did not know when E-14 had countersigned this statement, nor had she seen him sign. Per review of staff assignments for the day of 07/01/01 and per interview with the morning, afternoon and evening staff of 07/01/01, the following was revealed:

E-35 (Technician Supervisor) worked 10 A.M. to 10 P.M. on 07/01/01. Per interview with E-35 on 07/12/01 at 10:05 A.M. to 10:35 A.M., E-35 stated that her position involves scheduling staff for the various group rooms. E-35 stated that on 07/01/01, R-5 was not on 1:1 but was in the group room "Adventurers" with other clients and the programmer. E-35 stated that prior to her leaving the facility on 07/01/01, R-5 was in his bedroom with the alarms on. No sitter was placed at his door on 07/01/01.

E-7 (Activity Staff) worked 9 A.M. to 9 P.M. on 07/01/01. Per interview with E-7 on 07/12/01 from 12:58 P.M. to 1:10 P.M. in the facility's conference room, E-7 stated that she was told about the incident involving R-5 and the others. E-7 stated that R-5 was not on 1:1 that day (07/07/01). E-7 stated that she had observed R-5 down in the Adult group room . E-7 stated that R-8 was also in the Adult group room and she found that odd due to the incident that morning". E-7 stated that was in various areas of the facility during her 12 hour shift and would have known if R-5 was on 1:1. E-7 stated that when she left, R-5 was in bed with the alarms on the door. No sitter was present.

E-34 (Certified Nursing Assistant) worked 6 A.M. to 2 P.M. on 07/01/01. Per interview with E-34 on 07/12/01 at 2:10 to 2:15 P.M. in the facility's conference room, E-34 stated that he did not observe R-5 on 1:1 that day (07/01/01). E-34 stated that he had worked with R-11 one on one that day. E-34 stated that he was not aware of R-5 having 1:1 on 07/01/01 after the incident.

E-31 (Certified Nursing Assistant in training) worked 2 P.M. to 10 P.M. on 07/01/01. Per interview with E-31 in the facility's conference room at 2 P.M. to 2:05 P.M., E-31 stated that he worked either 1 to 9 P.M. or 2 to 10 P.M. on 07/01/01. E-31 stated that he did not observed R-5 on 1:1. E-31 stated that R-5 had been in his group room and was in the class with R-8 and the other clients. E-31 stated that R-5 could not leave the group room, but this would be the same monitoring that R-5 would receive any other day. E-31 stated that no sitter had been at the door on Sunday night (07/01/01) and that he was not asked to sit by the door until the night of 07/02/01.

b) Alarm on R-5's door not functioning properly, nor hall monitors working to assist in alerting staff if R-5 left his room during the night prior to and after the incident of 07/01/01.

After the incident of 07/01/01, the facility did not immediately begin their investigation and staff interviews confirmed that R-5's door alarm was "not working properly".

Per review of E-25's statement documented on a Nurse's note (no date), E-25 documented, "I walked around at the beginning of my shift and looked at all the alarms on all the outside of the doors. I did not look at the one on the bathroom door. However, after were cleaning the res (resident) up and R-5 was back in his room, a tech went to open the bathroom door and the alarm went off. I went to get the keys to turn it off and reset it and she said she was sorry she thought it was off because it didn't sound earlier when it was open. I have never turned that alarm off, so to the best of my knowledge the alarm was on and maybe for some reason did not sound when it was opened before."

Per review of the Employee Statement completed by E-1 (facility director) on 07/02/01, the following was revealed:

"Upon investigation of R-5's bathroom alarm, E-32 (administrator) and the maintenance man (E-38) opened the bathroom door with alarm in on position and the alarm did not sound. We shut the door and lightly tapped on the alarm then open it again. The alarm did not sound except to chirp lightly. We then closed the door and knocked hard on the alarm, this time when door was opened alarm sounded. In conclusion, it is obvious that we have a malfunctioning alarm. New alarm is being purchased and applied today."

Per interview with E-1 (facility director) on 07/11/01 from 4:05 to 4:35 P.M. in the facility conference room, E-1 confirmed that the door alarm was not checked until 07/02/01 to determine whether the alarm was working properly. E-1 stated that the door alarm that was on R-5's bathroom door was not working properly on 07/02/01 when checked.

On 07/03/01, the surveyor observed a video camera positioned down the green hall of the facility for the clients on the 200 wing. On 07/11/01, a memo was posted on the Nurse's station that stated that any one messing with the camera/monitor wold be terminated.

E) Receiving facility for R-5 not fully informed of the reason for R-5's discharge from the facility to assist in protecting and safeguarding the clients of the receiving facility.

Per interview with Z-16 (QMRP) on 07/06/01 from 1 P.M. to 1:30 P.M. at R-5's receiving facility, Z-16 stated that he had received information at the time of the preadmission screening at the facility. Z-16 stated that he had been informed that R-5 was an "emergency placement because R-5 was 19 years of age and no longer needed special care". Z-17 (Director of Nursing for the receiving facility) was also present at the facility during this interview, and confirmed that she was under the impression that R-5 had aged out of the facility. Z-16 and Z-17 provided the surveyor with the informational packet that had been received at the time of the pre-admission screening and at the time of R-5's discharge. Per review of the information received by the R-5's receiving facility, no behavioral information was provided to inform the facility of R-5's in appropriate sexual behaviors.

Per interview with E-37 on 07/11/01 from 3 to 3:10 P.M. in the facility conference room, E-37 stated that R-5 had behavior programs developed to address Inappropriate Masturbation, Physical Aggression, Inappropriate Touching, and had been receiving Sex Education 1:1 with E-37 prior to his discharge. Interview with E-37 also confirmed that R-5 had a program in place for elopement. E-37 stated that he had not informed Z-16 and or Z-17 of R-5's inappropriate sexual behaviors, because "I thought it would be better for R-5 if they didn't know".

Based on review of the Incident Report dated 07/01/01, record verification, , review of the facility's Investigation(s) including staff's written statements, review of the facility's policy and procedures, and per staff interviews, the facility has failed to have evidence that all alleged violations are thoroughly investigated for 6 of 6 clients involved in the Incident of 07/01/01 (R-5, R-6, R-7, R-8, R-9, and R-10) having the potential to impact all clients of the facility as evidenced by:

Findings include:

When the incident or suspected incident of abuse is reported, the Administrator, or the party designated by the Administrator will investigate the incident.

If the incident is abuse, the suspected individual will be denied access to the resident while the investigation is being conducted.

Per review of the Report dated 07/02/01 that was submitted to the Illinois Department of Public Health regional office by the facility director (E-1), the following was noted:

Review of the facility's Investigation (including staff's written statements) for 07/01/01 , record verification and interviews with staff present on 07/01/01, revealed that R-5 was found by E-30 (Certified Nursing Assistant-CNA) on 07/01/01 at approximately 5 A.M. in Room 205 (R-7 and R-8's bedroom). R-5 was found on top of R-8, straddling his (R-8's) chest /neck. R-5 had no clothing on other than a shirt and R-5's penis was on the side of R-8's face.

Review of the statements and interviews with staff (E-8, E-14, E-25, E-26, E-27, E-28, E-30, E-31, and E-36) who were present and on duty after 4 .A.M. on 07/01/01 revealed:

Room 205; R-7's Jejunostomy-Tube had been pulled out and was found at the foot of the bed.. R-7's gown and stomach were bloody.

Room 209; Staff found R-10's diaper had been ripped up in little pieces in his bed. R-10's gown was off and draped over his waist.

Per review of the employee statements and staff interviews the following was revealed:

a) Record verification of the Nurse's Notes revealed:

For R-6; 07/03/01 "Late entry- At about 0515 Res (resident) was found in her bed laying on her stomach with her total backside exposed. She had toothpaste on her lower back that was just squirted on there and had not been rubbed around. She did not seem to be in any type of distress. After a complete examination, there was no bruises, scratches or any signs of any kind of sexual activity apparent. no vaginal discharge, no semen. After getting cleaned up, I went back to check on her and there were no S/S (signs or symptoms) of any pain or discomfort." No signature was noted on the Nurse's Notes. Interview with E-25 on 07/03/01 from 4:50 P.M. to 6 P.M. in the facility's conference room, E- 25 confirmed that she had written the late entry into R-6's Nurse's Notes.

For R-9; 07/02/01 "Late Entry- At about 0515 Res (resident) was found in her bed with clothes off and toothpaste rubbed all over her body. She did not seem to be in any type of distress and upon examination there was no bruises any where on her body and no signs of any sexual activity such as vag. (Vaginal) discharge or any semen, She did have a couple of scratches on her nose and left upper cheek with a small amount of blood. No additional injuries were found." Signed by E-25.

Per review of the facility's investigation report written (submitted to the surveyor on 07/03/01) by E-2 (Director of Nursing) dated 07/02/01, E-2 documented:

Per review of the summary of the Investigation of the facility regarding the incident of 07/01/01, dated 07/06/01 that was submitted to the Illinois Department of Public Health regional office, it was concluded by the facility that:

"1. R-5 was found in R-8's bed. R-5 was disrobed from the waist down. Both boys were immediately assesses by the nurse and there was no injury found to either of the residents."

The facility's investigation does not reflect that E-30 found R-5 in R-8's bed and per interview with E-30 on 07/03/01 and per review of E-30's written statement, R-5's penis was near R-8's head and R-5 was attempting to put his penis in his (R-8's) mouth.).

"2. R-5 and R-9 were found exposed with toothpaste/cream squirted on their bodies. The girls were examined by the nurse and it was found that there was no evidence of any sexual activity such as blood, semen, or bruising in the genitalia area. The resident's were examined at the emergency room and it was determined that there was no indication of sexual activity. One of the girls had a slight abrasion on her nose."

(The facility's investigation does not reflect that E-25 (licensed Practical Nurse on duty at the time of the incident) stated in an interview of 07/03/01, that she "did not check R-6 and or R-9 vaginally" nor had she pulled their legs apart after finding the clients on 07/01/01. During the interview of 07/03/01 when E-25 was asked by the surveyor why she had documented that she had checked R-6 and R-9 and found no signs of sexual activity? E-25 began to cry and stated that she was "told by E-1 (facility director) to write that". Additionally, the facility's investigation does not identify that the physician was fully informed of the incident and that the facility had not followed his recommendations until 07/03/01. Per telephone interview with Z-10 (physician) on 07/03/01 from 4:20 to 4:30 P.M., Z-10 stated that E-13 (Registered Nurse/RN) had called him on 07/01/01 and told him about R-7's J-tube being out and that R-5 had scratched people and was found on top of R-8. Z-10 stated on the next day, he was informed that the ladies (R-6 and R-9) were undressed, but that R-5 was dressed at the time of the incident. Z-10 stated that he suggested to the facility that they may want to have the females examined at the emergency room. Z-10 stated that he was informed by the facility that they wanted to hold out until they concluded their investigation. Z-10 stated that he informed the facility that the parents needed to be notified and if they desired, the facility should send the clients to the hospital for examination. Review of the hospital reports contained in the records revealed that R-6 and R-9 did not go to the emergency room for evaluation until 07/03/01.)

Additionally the facility's conclusion identified that:

"..5. R-5 received 1:1 supervision until the time of his discharge" (on 07/05/01) ....

(The facility's investigation does not reflect that 1:1 was not provided to R-5 until 07/02/01 as confirmed per interviews on 07/11 and 07/12/01 with E-25, E-35, E-34, E-31, and E-7. Per review of the Employee Statement written by E-25 (Licensed Practical Nurse), E-25 documented that "Techs were told to be sure and cont. (continue) to keep a very close eye on R-5 to ensure that he stayed in his room. Also to help resolve the situation, he was gotten up out of bed early and brought into the dining room and had 1:1 supervision at all times". (No date identified.)

"6. R-5's full chart was made available to (name of the receiving facility) staff at the time of discharge."
"7. The (Name of facility) met with the staff from (name of the receiving facility) to discuss R-5's continuity of care."

(The facility's investigation does not reflect that R-5's behavior programs for inappropriate sexual behaviors were in a file cabinet in the QMRP's (E-37) office and not in R-5's chart. Per interview with E-37 on 07/11/01 from 3 to 3:10 P.M. in the facility conference room, E-37 stated that R-5 had behavior programs developed to address Inappropriate Masturbation, Physical Aggression, Inappropriate Touching, and had been receiving Sex Education 1:1 with E-37 prior to his discharge and that programs were in his file cabinet.. Interview with E-37 also confirmed that R-5 had a program in place for elopement. E-37 stated that he had not informed Z-16 and or Z-17 of R-5's inappropriate sexual behaviors, because "I thought it would be better for R-5 if they didn't know".

"...10. Facility verified by staff interview and documentation that the 15 minute checks were done through out the night of 06/30/01 through 07/01/01."
"11. It was verified by staff interviews hat at 4:45 A.M., a staff member was in R-8's room changing his catheter bag."

The facility investigation does not reflect that staff of the facility had filled in the blanks for the 15 minute bed checks and that staff after 4:30 A.M. did not do further bed checks on the green hall with the exception of emptying R-8's catheter bag. Per telephone interview with E-26 on 07/12/01 at 10:20 P.M. to 10:57 P.M. revealed that she did not complete any bed checks after 4:30 A.M. on 07/01/01. E-26 stated that they started their last round at about 3:30 A.M. and completed about 4:30 A.M.. E-26 stated that the last time she saw R-5 in the bed was about 4:30 A.M.. E- 26 stated that after 4:30 A.M. they (E-26, E-27, E-8, and E-25) all went outside the facility for break leaving only one nurse (E-14) and a staff who was on 1:1 for R-11. E-26 stated that they all returned back into the facility about 4:45 A.M.. E-26 stated that she sent E-8 to empty R-8's catheter bag. E-26 stated she thought E-8 then did bed checks for that hall. (Prior interview with E-8 on 07/11/01 from 3:30 P.M. to 3:50 P.M., outside the facility, E-8 stated that she had emptied R-8's catheter bag at about 4:45 A.M. E-8 stated that she did not do any no further bed checks after staff returned from break after 4:45 A.M. for R-5, R-6, R-7, R-9, and R-10, nor for any other clients on green hall and had gone to assist on purple hall.) E-26 stated that she had filled the blanks in for the time of 4 A.M. to 8 A.M. because she thought the 15 minute bed checks had been done. Additionally, the facility's investigation does not reflect that staff all went to break together at approximately 4:30 A.M. leaving only E-14 (LPN) and the one on one staff in R- 11's bedroom alone in the facility. The investigation did not reflect also that the facility's hall monitoring cameras were not functioning properly and were not displaying the bedroom halls of the facility, only the basement hall of the facility.)

"12. The families and physicians have been notified."

(The facility's investigation does not reflect that staff of the facility did not fully inform the physician of the incident, nor the clients' guardians of the Incident of 07/01/01. Per telephone interview with Z-10 (physician) on 07/03/01 from 4:20 to 4:30 P.M., Z-10 stated that E-13 (Registered Nurse/RN) had called him on 07/01/01 and told him about R-7's J-tube being out and that R-5 had scratched people and was found on top of R-8. Z-10 stated on the next day, he was informed that the ladies were undressed, but that R-5 was dressed at the time of the incident. Z-10 stated that he suggested to the facility that they may want to have the females examined at the emergency room. Z-10 stated that he was informed by the facility that they wanted to hold out until they concluded their investigation. Z-10 stated that he informed the facility that the parents needed to be notified and if they desired, the facility should send the clients to the hospital for examination.

Per record verification and as confirmed per interview with Z-13 while at the facility on 07/03/01, R-6 was taken to the hospital on 07/03/01 by her parents after being notified by the facility of the incident on 07/01/01. Z-13 stated that she had not been informed that R-6's diaper was off and that she was naked from the waist down with toothpaste smeared on her backside. Z-13 stated that she made the decision to take R-6 to the hospital for examination. Z-13 stated that she was very upset and that she had been at the facility on 07/01/01. Z-13 stated that they had taken her daughter (R-6) out of the facility on that Sunday for ice cream, and no one at the facility had informed her of anything that had occurred. Z-13 stated that she had not been contacted by the facility until 07/02/01 when a message was left on her answering machine.

Per telephone interview with Z-14 on 07/07/01 from 5:10 to 5:50 P.M., Z-14 stated that they had been on vacation during the week of 07/01 thru 07/07/01. Z-14 stated that she had not left home until about 4:50 P.M. on 07/01/01. Z- 14 stated that when she arrived back home from her vacation there was a message from the facility from 07/02/01, a message from the emergency room on 07/03/01, and a message from the Illinois Department of Public Health. Z-14 stated that the facility should have notified her of the incident involving her daughter immediately on 07/01/01. Z-14 stated that she thought they should have taken her daughter (R-9) to the hospital that Sunday and should not have waited until Tuesday the 3rd.

Per telephone interview with Z-15 (R-7's guardian) on 07/06/01 at 3:40 to 3:53 P.M., Z-15 stated that she had been notified on 07/01/01 that her son was being taken to the hospital because his tube had come out.

Z-15 stated that the hospital social worker had informed her while at the hospital that a client of the facility had pulled R-7's J- tube out. Z-15 state that she had no further contact from the facility until she called the facility on 07/06/01 to ask why the Illinois Department of Public Health had left a message on her machine. Z-15 stated that she was then informed by E-1 (facility director on 07/06/01) that a child had pulled out her son's J-tube, and that the child that did this was no longer at the facility.)

Date of Survey: 07/18/01

Complaint Investigation and Incident Investigation of May 8, 2001

"A" VIOLATION(S):

The facility shall notify the Department of any incident or accident which has, or is likely to have, a significant effect on the health, safety, or welfare of a resident or residents. Incidents and accidents requiring the services of a physician, hospital, police or fire department, coroner, or other service provider on an emergency basis shall be reported to the Department.

Notification shall be made by a phone call to the Regional Office within 24 hours of each serious incident or accident. If the facility is unable to contact the Regional Office, notification shall be made by a phone call to the Department’s toll free complaint registry number.

A narrative summary of each serious accident or incident occurrence shall be sent to the Department within seven (7) days of the occurrence.

The responsibilities of the director of nursing shall include, at a minimum, the following:

Planning of inservice education, embracing orientation, skill training, and ongoing education for all nursing personnel covering all aspects of resident care and programming. The educational program shall include training and practice in activities and restorative and habilitative nursing techniques through out-of-facility or in-facility training programs. The director of nursing may conduct these programs personally or see to it that they are carried out.

Nursing care shall include at a minimum the following:

All medications including oral, rectal, hypodermic, and intra-muscular shall be properly administered.

All 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, nursing or psychosocial evaluation and treatment shall be provided.

No resident shall be deprived of any rights, benefits, or privileges guaranteed by law-based on their status as a resident of a facility. (Section 2-101 of the act)

The facility shall also immediately notify the resident’s family, guardian, representative, conservator and any private or public agency financially responsible for the resident’s care whenever unusual circumstances such as accidents, sudden illness, disease, unexplained absences, extraordinary resident charges, billings, or related administrative matters arise.

All medical treatment and procedures shall be administered as ordered by a physician. All new physician orders shall be reviewed by the facility’s director of nursing or charge nurse designee within 24 hours after such orders have been issued to assure facility compliance with such orders. (Sections 2-104(b) of the act)

An owner, licensee, administrator, employee or agent of a facility shall not abuse or neglect a resident. (Sections 2- 107 of the act)

These Regulations are not met.

Based on interviews and record verification the facility failed to ensure the rights of all clients by not informing the parents, who are also the guardians, of physician orders that changed the medical care of 1 of 1 in the sample, who expired on 05/08/01.(R 1)

Findings include:

1. R 1 was a year old on 02/17/01. R 1 was admitted to the facility on 01-31-01 from a hospital. R 1 had multiple diagnoses including Developmental Delay, Microcephaly, Neurologic Disorder, and Severe Spasticity. R 1 also had an Tracheostomy and Gastrostomy Feeding Tube.

Per record verification of R 1's admission orders dated 01/31/01 R 1 was to receive continuous Oxygen saturation monitoring at all times (SaO2). Also humidified Oxygen (O2) per tracheostomy collar to keep his SaO2s above 93%, and cool mist humidity to tracheostomy at all times.

Record verification of orders written by Z 10 (physician) and dated 02/28/01 read: 1. Check SaO2 x 1 shift daily and 2. If RDS place on continuous oximetry SaO2. Verified by interview with Z 10 on 06/27/01 at 9:20 a.m. that this meant for the facility to check R 1's Oxygen saturation 1x every shift and if Respiratory Distress Syndrome place R 1 back on continuous Oxygen Saturation. Review of the nurses noted dated 02/28/01 do not say if parents were notified of this change in orders for R 1's medical care. Also confirmed per this interview with Z 10 that this would mean that R 1 would no longer be monitored continuously per Oxygen Saturation or Pulse Oximetry and he said "O2 Sat and Pulse Ox go hand in hand."

Further review of R 1's physician orders dated 02/11/01 state "1. DC humidified O2 per trach collar to keep O2 sats above 93%. 2. May initiate humidified O2 per trach collar prn for resp. distress..." Nurses notes dated 10:30 a.m. on 02/11/01 says " mother phoned to check on condition, report given"

Physician orders dated 04/23/01 state "D/C O2 Sat every shift to O2 Sat prn due to child's O2 Sat stable x several wks." Nurses notes dated 04/23/01 were reviewed and entries were noted to have been made at 8:00 a.m. that stated "called Z 10 (physician) to request changing O2 Sat to prn since R 1's O2 sat have stayed between 95 to 99% for several weeks. Z 10 ordered change O2 Sat to prn." Nurses notes dated 04/23/01 had additional entries at 10:30 a.m. and at 4 p.m. None of these entries document that the parents/guardians of R 1 was made aware of this change in R 1's medical care. This was confirmed per interview with E2 (director of nursing) on 06/19/01 at 2:40 p.m.

Per interview with Z1 (father/guardian) on 06/18/01 at 12:30 p.m. stated "my biggest concern is why did they take the monitor off of him? If the monitor had still been on my son would be alive. We are the guardians and we were not told they were taking the monitor off. Here at home it was on all the time. No way in h-ll I'd let them do it. This was my son's voice. If you can't hear the baby's voice it's like taking life support off of him. We found out the day he died that it was no longer on him."

Surveyor then asked E 2 (DON) about this and she said she would talk to the nurse (E 20) that had taken the order on 04/23/01 to change the O2 Sat monitor to prn. She said that the nurse was off and she would get a hold of her. Then on 06/19/01 at 2:40 p.m. E 2 told surveyor that she had talked with E 20, and that she had said that she had told Z 2 (mother / guardian) that the pulse ox/O2 SATs were discontinued and were only prn on 4/23/01.

Surveyor called Z 1 and Z 2 on 06/20/01 at 1:35 p.m. to verify that the facility had or had not notified him or his wife when the O2 Sat monitor was discontinued and only prn. Z 1 answered the phone and asked his wife if the facility ever told her that the O2 Sat was being stopped, and she said, "No! Only when the oxygen was being stopped per humidifier tube, not that the pulse oximetry was being stopped." They confirmed at this time that they both understood that O2 Sat and pulse oximetry were the same monitor. Z 1 (father) then said again that no one had told them the doctor had stopped the monitor and again said,"if they had not stopped it our son would be alive."

On 06/21/01 at 10:05 a.m. surveyor called R 1's parents to get their consent to talk with Z 9 (physician) and Z 2 (mother) answered the phone. During this call Z 2 said, "I knew when they took the O2 humidifier away, they told me about that and that was good that he could do with humidified room air only, but no one told me that O2 Sats or pulse ox was off. When we would visit we saw that the machine was not in his room and I'd get him to sleep, and put him in the crib in his room. We'd get ready to go out to lunch and we would tell the nurse to hook him up because he was asleep and by himself. It's just a cord with a piece of tape that you put on his finger or his toe. We didn't understand that they weren't using it, especially at night. We could understand during the day because staff were with him, but at night and if in crib by self in day time it should have been on. I got in trouble by Z 8 (physician), the nurses that came to our house, and the hospital because I didn't have it on him a couple of nights here at home, and that's why we had to go to court and send him to the facility, or we'd lose guardianship of him. Z 8 said he needed the pulse ox monitor all the time and would forever, and I can't understand why I got in trouble for leaving it off a couple of times and the facility was not using it all."

Based on interview and record verification the facility failed to ensure that all allegations of neglect are reported immediately to the administrator or to other officials in accordance with State law by failing to report an allegation of neglect occurring on 05/08/01 which involved one individual (R 1) and with the potential to affect all individuals at the facility.

Findings include:

1. R 1 was born on 02/17/01 and he expired on 05/08/01. R 1 had multiple diagnoses including Developmental Delay, Microcephaly, Neurologic Disorder, and Severe Spasticity. R 1 also had a Tracheostomy and a Gastrostomy Feeding Tube.

Per record verification of R 1's nurses notes dated 05/08/01 10:10 p.m. entry made by E 16 ( LPN ) stated the following: "Went into child's room to feed. When I turned on the light in childs room childs legs were sticking out of rails on crib. Child was not moving and feet were purplish /blue in color. I ran to childs crib and got legs out of rails. He was laying on his abdomen and I turned him over on his back. Child did not respond to verbal stimuli or tactile stimuli. Child was attached to humidifier. I undid childs trach mask. I called for help and asked E 3 (hab tech) to get assistance. I attempted to hear his heart or see if child was breathing. Trach was out of childs stoma, while I attempted to put trach back in stoma I breathed into childs mouth. ... E 23 (LPN) came into room at approx 10:12 p.m. We started 2 man CPR. I did breaths into trach while E 23 assisted with chest compressions. E 14 (LPN) called 911.... 10:20 p.m. entry states: "Ambulance arrived. I turned care of the child over to them. 11:00 p.m. entry states: "I called hospital to check on childs status and was told they were still working on child but there was no heartbeat. 11:15 entry still dated 5/8/1 stated: "I received a call from hospital. Child was pronounced dead at 11:10."

Interview with E 2 (director of nurses /DON) on 05/15/01 at 12:00 noon in the facility conference room revealed that R 1's tracheostomy tube had been dislodged before when he arrived at facility per ambulance for admission on 01/31/01. Further record review of R 1's nurses notes revealed three more times that R 1's tracheostomy tube had become dislodged since his admission to facility: 02/07/01, 03/18/01, and 04/24/01. Also interview with Z 3 and Z 4 (facility consultants) per phone on 06/14/01 at 9:40 a.m. stated they saw R 1's tracheostomy come out two times during the 4 hour period that they were at the facility on 02/21/01. They said the individuals were getting ready for school, and it was after breakfast. Said R 1 was by the nurses station in a play crib and the nurse was at the nurses station, as they were. Z 3 said, " I heard a raspy noise and knew his trach was out and the nurse put back in. Z 3 said: "I remember them saying that this happens with him."

Per review of the one page report that was faxed to the Illinois Department of Public Health (IDPH) dated 05/09 01 states the following: "Res R 1 popped trach out and was transferred to local hospital." Only after the facility was contacted by IDPH was more information submitted to IDPH on 05/11/01 regarding R 1.

Based on interview and record verification, results of investigations were not reported to the administrator or designated representative or to other officials in accordance with State law within five days of the incident of 05/08/01 that involved 1 of 1 individual in the sample (R 1) and having the potential to affect all individuals residing at the facility.

Findings include:

1. R 1 was found to be unresponsive in his room at the facility in his crib at 10:10 p.m. on 05/08/01 by
E 16 (LPN). Review of E 16's written statement of the incident on 05/08/01 involving R 1, review of R 1's nurses notes entered by E 16 at 10:10 p.m. on 05/08/01, and interview with E 16 on 06/21/01 at 3:30 p.m. by phone revealed that R 1's tracheostomy tube was out when E 16 found him. CPR (Cardiac Pulmonary Resuscitation) was initiated by E 16 and E 23, also an LPN, and R 1 was transported to the local hospital per ambulance at 10:20 p.m. on 05/08/01. R 1 was pronounced dead at the hospital on 05/08/01 at 11:10 p.m.

Per review of the facility's investigation of the incident of 05/08/01, and per interview with E 1 (facility director) the investigation was not completed until 05/22/01 when it was submitted to IDPH.

Based on observation, interviews, and record verification the facility failed to provide individuals with nursing services in accordance with their needs. The facility failed to ensure that all nurses address serious medical issues in a proactive manner by neglecting to adequately monitor and intervene for serious medical conditions, and by neglecting to ensure that all staff were trained to know how to monitor and intervene for serious medical conditions for 1 of 1 in the sample (R 1) who expired on 05/08/01.

Findings include:

A. Nursing neglected to adequately monitor R 1 whose tracheostomy tube had been dislodged several times prior to 05/08/01.

1. R 1 was admitted to the facility on 01-31-01 from a hospital. R 1 was a year old on 02/17/01. R 1 had multiple diagnoses including Developmental Delay, Microcephaly, Neurologic Disorder, and Severe Spasticity. R 1 also had an Tracheostomy Tube to provide him a patent airway, and a Gastrostomy Feeding Tube to provide R 1 all of his nutrition.

Per review of R 1's nurses notes dated 03/31/01 R 1 was admitted to the facility at 6:00 p.m. on 03/31/01 by ambulance from an out of town hospital. These notes stated that R 1 was: "admitted to room #106, placed in crib by ambulance tech x 2 lying on stomach, child crying and arching back, arrived on O2 at 2.5L/min per trach collar, child turned over onto back in order to assess trach site, found trach displaced from stoma, attempts to reinsert trach unsuccessfully, Z 10 (physician), and local ambulance notified, continues attempts to reinsert trach resulted in successful reinsertion of trach by E 24 (R.N. / registered nurse) ... O2 sat. 94-96% with O2 at 5L / min. per trach collar. This was confirmed per interviews with E2 / R.N.(D.O.N. / Director of Nurses)on 05/15/01 at 12:15 p.m. in facility conference room, and also per interview with E 15 (R.N.) by phone on 06/21/01 at 11:30 a.m. She confirmed that she was the nurse on duty when he was admitted to the facility the evening of 03/31/01, and that his trach was found to be out after he was brought into the facility."

Record verification of R 1's nurses note dated 02/07/01 2 p.m. stated: " Was upset and trach popped out. Replaced without difficulty." Interview in the facility conference room with E 6 (LPN) on duty at that time stated, "He was in the baby pod and someone hollered that trach was out and I grabbed him from the staff. He was having difficulty with the trach out. It had just been a few minutes. I held him and put the trach back in and no more dyspnea noted. The trach would come out with arching and the arching was frequent."

Further record verification of R 1's nurses notes dated 3/17/01 at 10 a.m. stated: "Child was noted to have trach out after fussing." Interview with the author of this entry on 06/14/01 at 2:00 p.m. in the facility conference room stated, "Another nurse was in the hall and heard him and called for us. Having difficulty getting the trach back in and I went and put the trach back in. I wasn't actually his nurse that day."

Then per review of nurses notes dated 04/24/01 at 2:00 a.m. stated: "Res. trach out. Trach reinserted." Interview per phone on 06/18/01 at 3:05 p.m. with E 14 (LPN) the author of this entry stated, " On 4/24 when trach came out I had the monitor on R 1 and it went off, and I found the trach out. He had a way of getting so upset he'd stretched his neck out and his trach would come out, and that night he was arching his neck and the trach came out."

Interviews with Z 3 (facility consultant) and Z 4 (facility consultant) per phone on 06/14/01 at 9:40 a.m. revealed that R 1's tracheostomy had been observed to have come out two additional times that had not been documented in the nurses notes. Z 3 stated, "Z 4 and I were filling in for another consultant and were at the facility this one time on 02/21/01. We were there for 4 hours and it was in the morning. It was after breakfast and we were at the nurses station, and R 1's trach came out two times. He was in a play crib by the nurses station and the nurse was right there and put the trach back in. I remember them saying that this happens with him. “Z 4 confirmed what Z 3 had said during this interview.

Interview on 06/21/01 at 9:30 a.m. per phone with Z 6 (RN and pediatric home health supervisor) stated: "R 1 would arch his back and his trach would come out." She said she was familiar with R 1 as their department had visited R 1 when he was at home before coming to the facility.

The last documentation of R 1's tracheostomy tube being found displaced was noted in R 1's nurses notes dated 05/08/01 at 10:10 p.m. and were written by E 16 (LPN) the nurse on duty at that time. These notes stated the following : "Went into child's room to feed. When I turned on the light in childs room childs legs were sticking out of rails on crib. Child was not moving and feet were purplish / blue in color. I ran to childs crib and got legs out of rails. He was laying on his abdomen and I turned him over on his back. Child did not respond to verbal stimuli or tactile stimuli. Child was attached to humidifier. I undid childs trach mask. I called for help and asked E 3 (hab tech) to get assistance. I attempted to hear his heart or see if child was breathing. trach was out of childs stoma, while I attempted to put trach back in stoma I breathed into childs mouth. ... . Child was pronounced dead at 11:10."

Interview with E 16 (nurse) per phone on 06/21/01 at 3:30 p.m. stated: "When I turned him over and took the humidifier mask off I found the trach was out. I didn't know until I took the mask off. He slept on his stomach and unless he had his head turned toward the door you couldn't see if the trach was out with the humidifier mask on over it."

B. Nursing neglected to adequately monitor R 1 who was unable to consistently make his needs known audibly.

1. R 1 was born on 02/17/00 and on 08/23/00 R 1 required a tracheostomy tube to maintain a patent airway. Interviews were done with several staff at the facility in regards to R 1 to ascertain if R 1 could vocalize his needs to the staff at the facility.

On 05/22/01 surveyor accompanied by E 18 (QMRP) at 3:45 p.m. observed R 1's room at the facility. R 1's room was 5 rooms from the nurses station. On 06/17/01 at 2:55 p.m. surveyor observed E 1 (facility director) and maintenance staff at the facility measure the distance from the nurses station and R 1's room, and it was observed to be 60 feet to his room. ( #106)

Interview with E 3 (habilitation technician / HT) on 05/22/01 at 11:10 a.m. in the facility conference room stated: "When his trach was full and he needed suctioning you could hear the rattle. Sometimes he sounded like a squeaking mouse, and sometimes you'd hear a gasp as he caught his breath. You could hear him in another room if the door was open. He would frequently hold his breath and look at you while doing it."

Interview with E 4 (HT) on 06/13/01 per phone at 3:55 p.m. stated, "He cries and rears himself back and the trach pops out. When he first came I was on day shift and he would rear back and cry and not take a breath and I would have to blow in his face. I would have to do this at least daily. At times I could be down the hall and could hear a little squeak from him."

Interview with E 7 (HT) in facility conference room at 12:40 p.m. on 06/13/01 stated: "Every once in while you heard a sound, but not a constant sound. You had to be right there to hear him. Like a little squeaking mouse. He would be arched way back and his face would be red, and then he might make a little squeak. When he seemed to hold his breath I would just move him and he'd breath again. I'd tell the nurse. You had to keep your eye on him all the time as you couldn't hear him cry like the others."

E 8 (programmer) on 06/13/01 at 1:05 p.m. in the facility conference room states: "I could hear him when he cried if I was in the pod (room) with him, or the adjoining pod (room) with the door open."

E 9 (HT) on 06/13/01 at 1:33 p.m. at the facility in the conference room stated, "Heard him cry only one time and he sounded like a mouse squeaking. He'd get mad, arch his neck and head back, and get red in the face, but you wouldn't hear him cry. Could look at his face and tell he was crying."

E 10 (programmer) at 2:15 p.m. on 06/13/01 at facility stated: "He made a little wheezing sound. Mostly arched his back and go thru the motions. You could see him cry. I always sat in the pod where I could see him."

E 12 (programmer) on 06/14/01 at 1:35 p.m. at the facility stated: "Sometimes you could hear him cry and sometimes you couldn't. Sometimes his head would be back and mouth open and no sound."

E 22 (floor supervisor for programmers) per interview on 05/22/01 in the facility conference room stated: "He would arch his back ,even though he could not make a cry. He made a gurgling sound and you could hear this from inside a pod (room), could hear him from inside a pod, could hear in hall outside the room, but could not hear from the nurses station."

Per E 18 (QMRP/Qualified Mental Retardation Professional) said at the facility on 05/22/01 at 3:45 p.m.: "He rarely made a sound. Heard him once and only a 'ah'. A brief not a continuous cry."

E 21 (HT) stated on 05/22/01 at 5:40 p.m.: "I could hear him cry. He always made little sounds. Usually I could hear him cry from the nurses station. Some people couldn't hear him."

E 19 (programmer) on 05/22/01 at 4:00 p.m. on 05/22/01 stated: "R 1's cry was inaudible. He had a trach. He would gasp for air and then make a sound. Seemed like he held his breath and then he would gasp. If in room you could look at him and see he was crying."

Interview with E 17 (R.N. /registered nurse) on 05/22/01 at the facility stated: "I don't ever recall him making audible sounds. You could tell by looking at him if he was crying or upset." E 17 verified that she was the other nurse on duty 05/08/01.

E 20 (LPN) on 05/22/01 at the facility stated that: "You could hear him off and on when he cried. He sounded like an infant two to three months old when he cried. You could see when he was crying. Sometimes you couldn't hear depending on the way his neck was positioned. On his stomach you could hear sometimes and sometimes not."

E 6 (LPN) stated on 06/13/01 at the facility at 12:08 p.m.: "When he first got here you couldn't hear him cry, but as he got stronger you could hear him cry like a cat, like a squeaking sound. He would be in the baby pod when I was here, and I heard him if I was in the next room if both doors were open."

E 15 (RN) on 06/21/01 at 11:30 a.m. per phone stated: "I would have been more comfortable if he had been in a closer room. We could have heard him better. A lot of times he would arch, but not make a sound. I could hear him at the nurses station, but I was really listening for him. It was like he'd take a deep breath and you'd hear a noise through his trach. When he first came in he was kept at the nurses station. I don't know why he was moved. The hardest time to monitor him was at night. That's why I felt better when the monitor was on him."

E 13 (RN) on 06/18/01 at 2:40 p.m. at the facility stated: "His trach would come out with arching and he would hold his breath. He could make a noise around his trach. I'm sorry I didn't suggest an apnea monitor. I thought about it and I should have went ahead and suggested it. I don't know if they would have went ahead and did it, but I should have suggested it. The Wilkie talkies disappeared. I don't know what happened to them.”

E 1 (facility director) on 06/18/01 at the facility at 11:10 a.m. said that R 1 sounded like a new born cry- a squeaking little cry. The trach only came out when he was extremely upset. She said that he was put into a room at his mothers request. She thought it was too noisy and he'd be more comfortable. E2 (DON) on 06/14/01 at 3:00 p.m. at the facility said that he was not closer to the nurses station because R 2 required 1 on 1, and R 4 was having seizures, and after the seizures were better she wasn't moved because she doesn't accept change well.

Z 5 ( facility speech consultant ) per phone on 06/19/01 at 2:00 p.m. stated: "R 1 had an uncuffed trach tube and he had no way of creating enough air from his lungs to go over his vocal cords to cause them to vibrate. Most of his air would go out his trach . When I was at the facility I would check on him and I hadn't heard any audible sounds. I don't know what sounds E 1 heard unless the trach was occluded with a mucous plug or he somehow got his neck over the hole. If he arched his head backwards he'd cut off flow of air. He'd have to pass air above the hole to get vocal cords to vibrate. He had severe arching and there was no way of anticipating what stimulus would cause this arching. Any occlusion caused a severe neurological reaction-the arching/holding his breath. He was very fragile."

Confirmed per interview per phone on 06/21/01 at 2:20 p.m. with Z 7 (Tracheostomy Nurse from hospital R 1 was at before coming to the facility), and Z 11 (speech pathologist from the same hospital) that they had done an evaluation for a speaking valve on R 1 on 02/12/01. Z 7 stated: "because of his heightened response to any stimulus we decided to hold on trying the valve due to his extreme neurological response, the arching. The speak valve would have gone over his trach, then air would have gone thru his mouth and out of his nose. When R 1 was relaxed you might hear some voice around the trach, but not when he was arching. He had severe arching and would frequently hold his breath."

Record verification of orders written by Z 10 (physician) and dated 02/28/01, and confirmed by interview with Z 10 on 06/27/01 at 9:20 a.m. that facility was to check R 1's Oxygen saturation only 1x every shift. Also confirmed per this interview with Z 10 that this would mean that R 1 would no longer be monitored continuously per Oxygen Saturation or Pulse Oximetry and he said "O2 Sat and Pulse Ox go hand in hand."

Physician orders dated 04/23/01 state "D/C O2 Sat every shift to O2 Sat prn due to child's O2 Sat stable x several wks." Confirmed per interview with E 2 (DON) on 06/14/01 that this meant R 1 no longer had any O2 Sat / pulse oximetry monitoring after 04/23/01. Confirmed with E 2 that R 1 still continued to hold his breath and continued to exhibit severe arching that preceded his tracheostomy tube coming out. That even R 1's tracheostomy had come out 04/24/01 the next night after the pulse oximetry was discontinued. E 2 said ,"R 1 rooted all the time and arched all the time," when surveyor asked her how she thought R 1's tracheostomy had become dislodged the night of 05/08/01.

Also confirmed with E 2 at this time that staff had stated that R 1 was positioned on his abdomen when he was in the crib in his room. Confirmed per interviews that R 1's tracheostomy tube was covered with a humidifier mask at all times and staff could not see if the tracheostomy tube was in place until he was turned over and the mask removed.

Interview with Z 5 (facility speech consultant) on 06/19/01 at 2:00 p.m. per phone stated: " He had such a severe reaction when I evaluated him for plugging the trach when he was asleep that it took only one brief (1-2 seconds) occlusion (finger) to say he was not ready for any plugging. "

E 6 (LPN) stated on 06/13/01 during interview at the facility at 12:08 p.m.: "This was one of my biggest fears that the trach would come out and I wouldn't hear the staff yell for me. I went to E 1 (facility director) and got walkie talkies for the programmer and the nurse to have when caring for R 1. I tried to get him to lay on his back because if he was on his stomach you couldn't see if the trach was out. I would put him in the small play pen and position him with wedges."

Also confirmed with E 2 that per interviews with Z 7 (Tracheostomy nurse at hospital) and Z 11 (speech pathologist at hospital) that when they had evaluated R 1 at the hospital on 02/12/01 that due to, " heightened response to any stimulus decided to put the valve on hold due to his extreme neurological response/arching." E 2 confirmed that she was not aware of the results of this evaluation that been done on 02/12/01, but she would try to get a copy of the report now.

E 2 also confirmed that R 1 did not have monitoring by the O2 Sat/ pulse oximetry when he was not with staff, nor did he have constant observation by the staff at night when in his room in his crib that was located 60 feet from the nurses station after 02/28/02. This was when physician ordered the O2 Sats to be only done once per shift. And confirmed that on 04/23/01 the O2 Sats were ordered to be discontinued and only to be done as needed.

Per interview with E 23 and E 14 (LPNs) on 06/25/01 per phone at 9:15 a.m. and 06/18/01 at 3:05 p.m. per phone respectively, confirmed that they both worked the 3rd shift at the facility. E 14 stated: "Yes, he sure held his breath during his hissy fits. I'd put the monitor on him when he was fussy so I could hear him better. Just an extra precaution to have it on him." Also confirmed that he was the nurse on duty at 2:00 a.m. on 04/24/01 when R 1's tracheostomy tube came out. He said that he had the pulse oximetry on R 1 then and heard the alarm and when he checked R 1's tracheostomy was out and he replaced it. I thought it was a nursing judgement even after the doctor discontinued it."

E 23 per interview with her on 06/25/01 at 9:15 a.m. stated: “R 1 had habit of stretching his neck out and trach had popped out before. But I used the pulse ox on 3rd shift even after though it had been discontinued. I still put on his toe. I could hear him if I was at the nurses station, but if I was in another room feeding a child, or in supply room I couldn't hear him, or if a radio on in another room that I was in doing something for another child." She had confirmed that she had come on duty the night that R 1 died 05/08/01, and when she entered R 1's room E 16 was doing CPR to R 1. She stated: "his trach had been out, but had been reinserted. No monitor was on R 1 when E 23 found him at 10:10 p.m."

Interview with Z 8 (R 1's pediatrician before he came to the facility) on 06/25/01 at 1:00 p.m. per phone stated: "Yes, I'm quite aware of the severe arching R 1 would do and of him holding his breath. With his history he would drop like a rock. His O2 Sats go from stable to rock bottom. ... We initiated DCFS (Department of Children Services) because parents weren't using the pulse ox consistently at home ... and felt that he needed to be in a facility because of that. He had severe neurological problems. He had frequent hospitalizations. ... I wouldn't have trusted him to be OK. I would have had the pulse ox on him. If he could have made a noise he wouldn't have meant to. He had severe neurological problems."

C. Facility neglected to ensure that all staff were trained to adequately monitor and intervene with R 1's severe medical conditions.

1. Per interview with E 11 (LPN) on 06/14/01 at 2:00 p.m. stated : "We had to keep his trach ties tight. I had worked 10 days straight and I was off the night he died. I was off and I keep thinking if I hadn't been off he might still be alive. You had to keep the trach ties tight and the nurse (E 16) had changed the trach ties that evening, and she was a new nurse and only a fill in on her school days off. I don't think the trach ties were tight enough. You couldn't hear him at night when he was in his room and you would be in another room caring for another child. He didn't have to die. We should have had an apnea monitor. We had a fetal monitor for awhile, and then it disappeared. We never had an apnea monitor for him and we should have. The walkie talkies lasted about 4 days. They just get lax here."

Additional interviews with the Director of Nursing on 05/15/01 that Z 2 (mother of R 1) had told the facility to keep the trach ties tight when R 1 first came to the facility. Also confirmed per interview with E 5 at the facility on 06/13/01 that she had given R 1 a bath the evening of 05/08/01. She stated: "His trach bands smelled funny and I thought it was his hair so I gave him a bath. He had spit up a lot that day. Coughing up mucous. It seemed a little more that day. After his bath I asked his nurse (E 16) to change his trach band and she did."

Also interview with E 14 (LPN) on 06/14/01 at 3:05 p.m. stated: " He had a way of getting upset and the arching would pull on the ties. Several times I'd tightened it back up. Those are not charted because something I did to prevent it from coming out."

Interview with Z 1 (father) on 06/18/01 at 12:30 p.m. stated: "We told them at the facility that the trach ties were too loose. My wife tightened them up almost every time we visited. One time we went in and you could put two to three fingers between the ties and him. We kept telling them that the trach ties had to be kept tight. We had to show them how to suction him. The first weekend after he was admitted I had to show them how deep to suction. They didn't seem to know how to care for him." Then on 06/20/01 at 1:35 p.m. per phone he said: "We usually visited on Sundays. Sometimes a Saturday since I work nights." Record verification of the nurses notes revealed that they visited their son at the facility often. He stated: "About 80% of the time my son's trach ties were too loose and my wife had to tighten them."

Interview with E 17 (RN) on 05/22/01 at 5:15 p.m. at the facility confirmed that she was working with E 16 (LPN) at the facility on 05/08/01. She said she was working the other halls, not R 1's. Per this interview she stated: "Maybe one or two times I took care of him. I picked him up one time when he was still at the nurses station, and he arched his neck, turning red and I could see he was crying, but I did not hear a cry. I was scared and handed him to someone else."

Interview with E 2 ( DON) on 06/29/01 at 11:15 a.m., with E 1 on the conference call also, confirmed that E 17 works part time at the facility. E 2 said that sometimes she works one day a week and then the next week may work two to three shifts. Confirmed per the nurses schedule that E 17 works only part time at the facility , with one shift scheduled every other week ,and then 2-3 shifts every other.

Interview with E 16 ( LPN ) that was on duty with R 1 on 05/08/01 per phone on 06/21/01 at 3:30 p.m.,

E 16 said that she had become an LPN in 10/00. She said she was just finishing RN school when R 1 died. She stated: "I usually worked weekends while in school for RN. This was my first nursing job. ... I worked the first weekend he came to the facility. The pulse ox alarm went off every two seconds. O2 Sat dropped when he arched. He got so mad and he seemed to quit breathing. I would get to end of hall and it would go off. I'd run back to the nurses station to him. We kept him at the nurses station at first. I don't know why he was moved to his room. It was so hectic. I know they had an order to discontinue the O2 Sat on 4/23 and make it prn. I know it was frustrating to have it go off. .... I was not aware that the trach had come out before 05/08/01. Only knew of it coming out on admission. I found out after it came out on 05/08/01. I usually only worked weekends. I think the monitor should have been on him. She said they had walkie talkies one weekend and the next one they were gone. The first weekend I worked after he came in I worked a 16 hour shift and it was so scary. The monitor would go off and he was arching, O2 sat would drop. I couldn't hear him at the nurses station if he was in his room. The facility is noisy."

Confirmed per interview with E 1 on 06/18/01 at 11:10 a.m. at the facility that: "E 16 has been here as an LPN for approximately 8-9 months. She works part time when not in school for RN classes. Also worked for a health department while part time here." Confirmed per review of the nursing schedule dated 02/03/ 01 to 05/12/01 that E 16 usually worked the weekends and an occasional weekday shift.

Surveyor asked E 16 about the documentation in her nurses notes dated 05/08/01 at 10:10 p.m. that said that she went into childs room to feed him, and that the notes at 9:10 p.m. said he'd received feeding at 9:10 p.m. She said, "Several of the children were vomiting and I was calling the doctor and I had it in my head that R 1's feeding was to be at 8 p.m. I fed him at 9:10 p.m. and I was going in to feed him again at 10:00 p.m., and that's when I found him. Normally I wouldn't have went in at 10 p.m., usually I leave the facility at 10:00 p.m. The next day or the next day after that they called me in and made me rewrite my first page of my nurses notes. They brought me into E 1's office and E 2 was there, at least part of the time. Said I would get into a lot of trouble if I charted the feeding was late, and that I was going to feed him an hour later. But what I wrote first and rewrote was not a lie, it's true."

Record verification of R 1's medication administration orders and physicians orders for R 1's feeding was "Pediasure with fiber 120 cc every three hours bolus per G tube with 30 cc water flush. The times ordered for the feeding were 4 p.m., 7 p.m. and 10 p.m. for the 2 p.m. to 10 p.m. shift on 05/08/01.

Also confirmed per interview with E17 that she had changed R 1's tracheostomy ties that evening of 05/08/01. She stated: "Changed his trach ties after the hab tech gave him a bath." About how to tie them she said: "you have to leave room for your finger between them and his neck." She then said: "When I talked to R 1 's dad that night the first question he asked, "was the monitor on? " and I said, "no."

E 11 (LPN) on 06/14/01 at 2:00 p.m. at the facility in the conference room stated: "I used to take him to out of town hospital to see Z 9 (physician / Neurologist), and another time a speech pathologist. When I was in that hospital both said that R 1 held his breath and with hyper extending his neck could affect breathing. Z 9 said he would need the trach and he would only get bigger, not better. But he never said he'd die. This was not expected." This was confirmed per record verification of report by Z 9 dated 04/25/01.

Per interview with E 1 and E 2 per conference call at 11:15 a.m. on 06/29/01, surveyor asked them how all staff were trained to ensure that they could meet the medical needs of R 1. E 2 then said, "Basically verbally. (E1 and I) stayed until midnight, and we talked to the staff about R 1's care. All of our nurses are trained in Tracheostomy care."

Per review of the nursing schedule for 05/08/01 E 16 and E 17 were not working the night R 1 was admitted. E 15 was the nurse who was working at the facility when R 1 was admitted. This was confirmed per review of the nurses schedule, and also per verification of R 1's nurses notes of 01/31/01. E 15 ( RN) on 06/21/01 at 11:30 a.m. per phone stated: "I admitted R 1 to the facility on 01/31/01...I have another concern and that is when we get a new admission, especially one like R 1, I wish we'd get more training. Like an in-service on him to help us to know exactly how to care for him. Some aren't as hard as he was. But it would have helped with him. E 1 and E 2 screened him that day and he came shortly after that on the same day."

An inquest was held on 06/28/01 regarding R 1's death on 05/08/01. Per phone interview with Z 12 (coroner's assistant) on 07/02/01 she said that the cause of R 1's death had been determined to be from "natural causes with underlying conditions with a conclusion that R 1's Tracheostomy tube became dislodged, resulting in R 1 being unable to breath, and R 1 suffered death by suffocation or asphyxiation."

This was confirmed by record verification of the Autopsy Report dated 07/12/01 which stated that the most probable cause of death was as follows: Cerebral Anoxia, Tracheobronchitis and Pneumonitis, and Complications of Cerebral Palsy. This report further stated the following: Other significant conditions contributing to R 1's death included " Displacement of tracheal tube."