CLEARBROOK CENTER Facility I.D. Number 0030023 Date of Survey: 08/30/01 Special Licensure Survey “A” VIOLATION(S): The facility’s governing body shall exercise general direction of the facility, and shall establish the broad policies and procedures for the facility related to its purpose, objectives, operation, and the welfare of the residents served. Personnel policies shall include a plan to provide personnel coverage for regular staff when they are absent. For the purpose of this Section only, “disaster” means an occurrence, as a result of a natural force or mechanical failure such as water, wind or fire, or a lack of essential resources such as electrical power, that poses a threat to the safety and welfare of residents, personnel, and others present in the facility. Fire drills shall be held at least quarterly for each shift of facility personnel. Disaster drills for other than fire shall be held twice annually for each shift of facility personnel. Drills shall be held under varied conditions to: Fire drills shall include simulation of evacuation of residents to safe areas during at least one drill each year on each shift. 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. At a minimum, there shall be at least one staff member awake dressed and on duty at all times. There shall be available sufficient, appropriately qualified training and habilitation personnel, and necessary supporting staff, to carry out the training and habilitation program. Supervision of delivery of training and habilitation services shall be the responsibility of a person who is a Qualified Mental Retardation Professional. Appropriately qualified staff shall be provided in sufficient numbers to meet the training and habilitation needs of the residents. At a minimum, staffing shall be provided as described in Section 350.810(b) of this Part. A registered nurse shall participate, as appropriate, in planning and implementing the training of facility personnel. Direct care personnel shall be trained in, but are not limited to, the following: 1) Detecting signs of illness, dysfunction or maladaptive behavior that warrant medical, nursing or psychosocial intervention. 2) Basic skills required to meet the health needs and problems of the residents. The resident’s record shall include information regarding the physician’s notification and response regarding any serious accident or injury. These regulations were not met as evidenced by the following: A) Privacy Issues not addressed. 1.) R58, (per Clearbrook Face Sheet of 7/23/01) is a 41 year old ambulatory male with diagnoses of Mental Retardation, Autism, Hyperactivity, and Seizure Disorder. The Level of Functioning (LOF) information submitted by the facility on 8/13/01 indicated R58 as profoundly retarded. On 8/14/01 at 6:50a.m. upon entry to the East Wing, R58 was observed behind the desk nude, rummaging around in the garbage can, handling charts and papers, and closing/opening cabinet doors. No staff member was noted in the area. After a few moments, E17 came by the desk, saw R58 and redirected him to his room. E17, while standing in the hall, stated she had just worked a double shift. At 6:58a.m., R58 again walked out of his room without any clothing on and E17 walked away and left the area. E20, the nurse who was standing by the medication cart at the end of Plum Hall, noticed R58 (still nude) walking towards her and stated to R58, "While you are here, let me give you your medicine." Standing next to R58 at the medication cart were (2) direct care staff, E11 and E16, a housekeeper, E21, and ( 2) residents, R6 and R62. At approximately 7:05a.m., E11, direct care staff, directed R58 back to his room, passing E22, housekeeper, on the way. During this 10 minute episode when R58 wandered the halls without any clothing on, no staff member (of the 6 staff who were present in the immediate area) offered R58 any clothing. 2.) On 08/15/01 at 8:58a.m., R13 age 50 male diagnosed with Passive Aggressive Personality, Major Depression, Seizure Disorder and Mental Retardation per facility Face Sheet) was observed getting out of his bed. R13 was nude and his room door was open. E12, direct care staff, entered R13's room along with R84, leaving the room door open. R84 sat down in the front seating area of R13's room while E12 helped R13 shower, leaving the bathroom door open. At 9:06a.m., E12 walked R13, who was still nude, out of the bathroom in front of R84 and the door was still open. 3.) On 08/14/01 at 7:40a.m., R28 age 37 male diagnosed with Cerebral Palsy and Mental Retardation per facility Face Sheet) was observed sitting on the toilet in the bathroom between his room and room 316. The bathroom door to room 318 was wide open. The bathroom door leading to room 316 was closed. A knock was heard on the closed bathroom door, and E24, shift supervisor, walked in followed by R25. E24 proceeded to assist R25 with brushing his teeth while R28 remained seated on the toilet. At 7:50a.m., R28 was asked how he feels about people coming into the bathroom while he's on the toilet--is it okay with him or would he like some privacy? R28 quietly responded, "privacy". 4.) Two additional examples of the facility not ensuring privacy to clients were observed on 08/16/01 at 4:08p.m. on the West Side. A large message board hanging on the wall behind the nursing station was easily viewable by anyone standing on the other side of the station, including visitors. The board contained personal information about R2: "Please wake at night to toilet (he sits) give him 12 oz. of water while on toilet." and R19: "save stool specimens." B) Review of the facility's Incident/Injury Reports with accompanying Investigation Reports revealed that during the six month period from 2/15/01 - 8/15/01, there were 76 injuries initially classified as being of unknown origin. Following investigation, the origin of 11 of 76 injuries had been determined. Of the remaining 65 injuries, 22 had no investigations conducted and 19 were not completed within five days of the date of occurrence. Examples include the following:
Interview with E18 at approximately 3p.m. on 8/21/01 in the Conference Room revealed the facility does not have a prescribed protocol or procedure to follow that describes what constitutes a thorough investigation. The facility's policy entitled Investigation/Notification Procedures states "The Administrator or his/her designee must conduct an investigation, documented Investigation Report". No other information regarding what investigative steps must be followed is given. Interview with E18 and E19 on 8/20/01 at approximately 3:40p.m. in the QMRP office revealed that the facility does not have a comprehensive system in place that allows the facility to identify patterns or trends of injuries and which identifies individuals who are sustaining high numbers of unknown injuries. E19 stated that he and E18 and E4 look at incidents on a monthly basis but they do not document their findings or recommendations for possible corrective actions to be taken. E19 stated there "is no neutral committee or body which reviews investigations and subsequent summarizations of injuries" to determine the thoroughness of the investigations and ensures appropriate corrective and protective steps are taken. During interview with E18 on 8/15/01 at approximately 11:40a.m. in the Conference Room, E18 acknowledged that investigations were not consistently and thoroughly completed. E18 stated during the interview "Now I understand what's expected, I see...". 1) Examples per incident/injury reports include: R87-has a history of ingesting inedibles, including cleaning liquids. One of 5 ingesting incidents in the past 6 months occurred May 15, 2001, when R87 drank toilet cleaner solution which he took from the housekeeper’s cart. Dates of other PICA incidents: 04/15/01, 04/18/01, 05/17/01 and 06/12/01. R44-June 2, 2001, his 1:1 staff left him unattended and later found him with blood on his nose. R36-April 1, 2001, noted with burns of the face and chest (blisters started to form on the chest 04/03/01). Source: possibly hot water. Outside contractor “set the wrong control to the high limit.” R27-February 21, 2001, found outside in the yard. His body temperature was 95.7F. R62-June 15, 2001, a phone call was received from a neighbor. R62 was walking down Campbell St. turning to School Dr. R62 “left the building without the knowledge of any staff member....” 2) R79 is a 47 year old male whose diagnoses include Profound Mental Retardation (MR), cerebral palsy, and seizure disorder per the facility's Face Sheet. Per observation throughout the survey, R79 is wheelchair dependent and nonverbal. Per the facility's Investigation Report, on 2/22/01, 10A.m., R79 was noted to have "multiple human bites present on left outer forearm". The investigation reads "Resident: non-verbal. E26 (hab aide) stated at 9:15a.m. 'No injury noted' He appeared happy at that time. E27 (QMRP) Present on unit from 9:15 - 9:30. During that time she noted no injury. Roommate: Not present in building during this period. E24 (hab aide) “reported injury at 10:00a.m.. No other staff present in the general area at that time." The report indicates R79 was prescribed antibiotics and given first aid for the bites. No other staff or residents were interviewed. Report concluded that the bites suggested "client to client aggression although aggressor has not been identified with any degree of certainty.” R79 sustained another injury as a result of human biting on 3/9/01 at 11:30p.m.. Per the Incident report of 3/9/01, R79 was heard to "cry out" and when staff went to check on him he was found with a human bite mark on his left forearm and skin broken on 2nd and 3rd digits of his left hand. Per the Nurse's Note of 3/9/01, "Lt (left) 2 + 3 fingers with skin torn and open. Bruising noted to third finger". Per the Nurse's Notes of 3/9/01 and 3/10/01 covering this injury, R79 was sent to the local community hospital emergency room for evaluation and was diagnosed with human bites and a fracture of the third finger of the left hand. He was prescribed antibiotics for ten days and his finger was splinted. Per interview with E18 (Asst. Administrator) on 8/21/01 at approximately 3p.m. in the Conference Room, R79 has experienced "several" bite injuries, most thought to be caused by his previous roommate, which resulted in a recent room change around the middle of March. Review of Incident reports revealed at least four additional injuries to R79 during the time period from 2/01 to present, two of which were bites. 3) R62 is a 31 year old female whose diagnoses include Profound MR, Major Depression and Seizure Disorder per her Behavior Program of 10/17/00. Per an Incident Report of 6/29/01, R62 was "Noted several hematomas and abrasions on knees, legs, arms. L (left) leg, below knee 1.) hematoma 2"X 2", 2.) hematoma 1"X 1". Abrasion on L knee approx 1" X 1". R(right) knee abrasion 1 ½" X 1". L(left) leg side 3. hematoma 3" X 1", L elbow abrasion ½" x ½", L wrist area 4.) hematoma 1" X 1" origin unknown". The investigative report revealed that three employees were interviewed, i.e. the nurse who completed the incident report, the QMRP who first noticed the injury and brought it to the attention of the nurse, and one hab aide. R62's mother was also spoken with, and per the report she "said that nobody at the Commons knew what happened or how it happened....(she) expressed some of her concerns which will be followed up...". No other employees or residents were interviewed regarding their having knowledge of how these injuries occurred. In addition, the report only addresses the bruises to R62's knees and not the abrasions and hematomas to her elbow, wrist or outer left leg and left shin. Review of Incident reports from 2/01 to present revealed at least four additional unknown injuries sustained by R62 during this time period. 4) R54 is a 26 year old female whose diagnoses include Profound MR, Intermittent Explosive Disorder, and Seizure Disorder per the Facility's Face Sheet. Per an Incident Report dated 4/24/01, R54 was noted "during shower, aid noted several bruises, 4 - 2 inches wide on R (right)back of arm, 2 -2 inches wide on L (left) forearm, 1 -1 inch wide L upper breast, 1 - 1 inch wide upper R shoulder (back), 1 - 2 inches wide R outer foot. No bleeding noted." The Investigation Report dated 4/27/01 revealed that only the nurse who completed the Incident Report and the hab. aide who initially reported the injuries were interviewed. Per the investigation, neither staff had any information as to how the bruise occurred. No other staff or residents were interviewed. The report concluded with "Based on the information above, it has been concluded that the origin of this injury is unknown." Review of Incident reports from 2/01 to present revealed at least five additional unknown injuries sustained by R54 during this time period. 5) R70 is a 37 year old male whose diagnoses include Severe MR and Chronic Undifferentiated Schizophrenia, per the facility's Face Sheet. Per an Incident Report dated 6/22/01, R70 was reported to have sustained "two 2" lacerations to the right side of his mid-back - Origin unknown." The Investigation report of 6/25/01 revealed only the nurse who completed the Incident Report was interviewed. The hab aide who worked with R70 on the day the injury was discovered was "not available for interview due to vacation (one week)". No other staff or residents were interviewed. The report concludes "the origin of the injury cannot be determined..." 6) R87 is a 36 year old male whose diagnoses include Profound MR and Autism, per the facility's Face Sheet. Per a nursing note dated 4/18/01, R87 was noted to have a black left eye. No Incident Report or investigation concerning this injury was completed. Review of the Incident Reports from 2/01 to present revealed that R87 has sustained at least eight additional injuries of unknown origin during this time period. In addition, he has been involved in five incidents of PICA in which he ingested his own urine on 4/15/01, drank toilet bowl cleaner on 5/15/01, drank antimicrobial liquid soap on 5/17/01, drank shampoo on 6/12/01 and ingested a liquid ink-like substance on 4/18/01. Of these fourteen injuries/incidents, ten were not investigated and one was not thoroughly investigated. Comments noted at the bottom of several Incident Reports stated "No investigation needed". 7) Other examples of injuries of unknown origin which were not investigated or which were not thoroughly investigated in order to rule out abuse or neglect as a possible cause include R#s 4, 7, 8, 9, 10, 12, 13, 25, 27, 28, 30, 34, 35, 36, 40, 44, 45, 47, 48, 51, 55, 56, 57, 60, 66, 72, 78, 84, 86, 89. C) General observations and interviews on the East Side on 8/15/01 from 6:30 a.m. to 8:51 a.m. revealed the following: Interview with E9, nurse, at the nursing station, east side at approximately 6:40 a.m. revealed for the 46 clients who live on the area, there are 2 direct care staff (E10 and E11), who are in the clients' rooms providing personal care and 1 direct care staff (E12) who had not arrived to work (per surveyor's observation, E12 arrived at 6:50 a.m.). E9 also stated that on the night shift there were 2 direct care staff (E15 and E16) working on the east side for 46 clients who have high personal care needs. E9 was observed proceeding down the hallway with the medication cart to do medications. Surveyor observed E10 in room 204 with the door closed assisting clients with a.m. care, E11 observed in room 234 with the door closed assisting with a.m. care and when E12 arrived at 6:50 he went into room 219 with the door closed assisting clients with a.m. care. No staff was observed out on the unit supervising clients from 6:30 a.m. to approximately 7:55 a.m. which is evident by the following examples: 1) Per Clearbrook Commons Face Sheet and Behavior Program on 8/20/01, R1 age 61, male has a diagnosis of Impulse Control Disorder, Bi-Polar, Depression with Obsessive-Compulsive Features, Mild Mental Retardation. R1 has a behavior intervention program for Elopement, Wandering, Physical Aggression, Verbal Aggression and Agitation. R1 smokes cigarettes. At 6:30 a.m. R1 observed at the front hallway by the nursing desk with his right hand down the front of his pants, pacing back and forth appeared agitated and stated he wanted his cigarette. Then he proceeded to the front door foyer area, sitting by the front entrance then back to the east side nursing station desk. Per R1's behavior program Wandering is defined as "leaving the program areas at the Commons or day program without direct staff supervision but staying on Clearbrook property.” No staff observed monitoring of R1's wandering or elopement except every 30 minutes when staff completed a 30-minute check sheet. 2) Per review of Clearbrook Commons Face Sheet on 8/21/01, R64 age 29 female has a diagnosis of Mental Retardation, Seizure Disorder and Spastic Quadriplegia. R64 observed 8/15/01 in the Peach living room at approximately 7:00 a.m. on a bean bag laying face down in a fetal position, self stimulating by bouncing pelvic area up and down. R64's hair was uncombed and wearing no shoes or socks. R64 remained in this position until approximately 7:30 a.m. when she got up and laid on the couch until she went to the dining room at 7:40 a.m. E14, QMRP, was observed in the Peach Dining Room assisting R64 to chair, when the surveyor asked E14 where R64's shoes and socks were. E14 looked down at R64's feet then left the dining room to obtain her shoes and socks. At 8:30 a.m., R64 completed her breakfast. R64 returned to the bean bag in the living room to her previous position to engage in self stimulation. Then sat up and put her whole right hand in her mouth, took hand out of mouth and started slapping right side of face. E14 entered the living room for approximately 30 seconds at approximately 8:50 a.m., then left the living room. R64's rumination and self abusive behavior continued until 8:55 a.m. (approximately 25 minutes). There was no staff in the living room to redirect to a more appropriate activity. 3) Per review of Clearbrook Commons Face Sheet on 8/21/01, R6 age 41 female, has a diagnosis Mental Retardation, Downs Syndrome, Autism and Left Corneal Cataract. R6 observed at 7:24 a.m. sitting on the floor in the Peach living room biting on her tee shirt, twisting back and forth holding up her shirt exposing her breast. No staff in the living room area. At the completion of her breakfast, at approximately 8:32 a.m., she returned to the living room and sat on the couch and continued chewing her tee shirt and twisting back and forth until approximately 9:00 a.m.. Per R6 IPP dated 2/27/01 and Monthly Summary June 2001, reviewed by surveyor on 8/22/01 revealed R6 needs staff redirection to engage in other activities other than self-stimulation. No staff in the area to redirect R6 to a more appropriate activity. 4) Per review of Clearbrook Commons Face Sheet on 8/21/01, R54 age 26 female has a diagnosis of Mental Retardation, Intermittent Explosive Disorder, Seizure Disorder. R54 was observed at 7:20 a.m. in the Peach living room in a wheelchair by the TV biting her wrist (approximately) every 2-3 minutes until approximately 7:50 a.m. when she went to the Peach dining room. No staff present in the living room from 7:20 a.m. to 7:50 a.m. R54 also observed in the living room on 8/15/01 at approximately 8:35a.m. in the Peach Living Room sitting on the couch, rocking hard back and forth, hitting both of her thighs hard with both fist. This self-abusive behavior continued until approximately 8:50 a.m. No staff in the Peach Living Room from 8:35 a.m. to 8:50 a.m. Review of R54's Behavior Program on 8/21/01 revealed R54's target behaviors are self injury, physical aggression, and property damage. No staff was in the living room to redirect R54 to a more appropriate activity. Review of Incident/Injury Report from 4/3/01 to 7/24/01 revealed 6 documented injuries of unknown origin. 5) Per review of Clearbrook Commons Face Sheet on 8/21/01, R57 age 34 female has a diagnosis of Mental Retardation, Megacolon, Excessive Drooling. R57 observed in the Peach Living Room on 8/15/01 from 8:30 a.m. to approximately 8:51 a.m. sitting on the couch with R52. R52 got up from couch at approximately 8:38 a.m. and stood by the television doorway. R57 began biting her left wrist continuously and appeared agitated. This behavior continued for approximately 12 minutes, no staff in the living room to assist R57 in reducing her agitation and self-abusive behavior. R57's biting of her left wrist has resulted in injury per review of Nurses Notes dated 6/10/01 and 6/11/01 and R57 is to wear a wrist protector to prevent injury to the area. No wrist protector observed in place on her left wrist through out surveyor observations. 6) Per review of Clearbrook Commons Face Sheet, R87 age 35 male has a diagnosis of Mental Retardation and Autism. R87 was observed on 8/15/01 at approximately 7:57 a.m. in the Plum Dining Room. When surveyor entered dining room, R87 was observed eating out of the garbage can. Direct care staff, E16, arrived to the dining room at approximately 7:58 a.m. and told R87 to stop eating out of the garbage. Review of R87's Behavior Program; his targeted behaviors are PICA which is defined as ingesting inedible substances or ingesting edibles stolen from others. Review of Incident/Injury Report revealed R87 had 5 incidents of ingesting inedibles on 4/15/01, 4/18/01, 5/15/01, 5/17/01 and 6/12/01 (Drinking his urine, Toilet Cleaner, Shampoo, Antimicrobial Liquid Soap and Ink). No staff was in the Plum Dining Room area to monitor R87 to prevent him from eating pica. 7) Additional examples include R4, R61, R55, R56, R51, R76, R22 and R18. 8) Direct care staff are not available. At 7:45 a.m. on 8/14/01, E31, Nurse on the West Side stated during interview in the Teal Kitchen "we are so short of staff (direct care). There is only E24 and one female, maybe 2, down Teal Hall and they have to get people up at this time. They (the residents) sit here (in the kitchen) and get upset." At approximately 8:00 a.m. the following was observed in the Teal Kitchen: E30 in dining room with a 1:9 client ratio. E30 trying to dish out breakfast. R36 observed displaying stereotypical behaviors - shaking head, hands and body; R32 very upset and verbal; R29 - talking loudly; R9 upset with R2's grunting and is hollering at R2. At approximately 8:00 a.m. R2 vomits into his bowl of cereal. E30 runs out of the kitchen to get the nurse, E31, responds by coming into the dining room. E31 leaves the dining and E30 resumes dishing out breakfast. R2 is observed to continue to eat the cereal into which he has vomited and into which his nose is now running. When E30 is asked if R2 has a new bowl of cereal, she states "I went to get the nurse and he started eating the cereal". E30 then removed R2's cereal bowl. 9) E16, direct care staff, observed in the Plum Dining room serving the breakfast meal on 8/15/01 from approximately 7:58 a.m. to approximately 8:10 a.m. at which time E13, QMRP, arrived to assist E16. E16, at 8:03 a.m. gave R1, R87 and R82 a bowl of hot cereal. E16 continued serving the other 10 clients who are able to feed themselves which took approximately 10 minutes. R1, R87 and R82 left the area upon completing their cereal at approximately 8:07 a.m. E16 was unaware that R1, R87 and R82 did not receive the balance of their meal which included eggs, toast, butter and jelly. E13 (QMRP) was assisting E16, was unaware the 3 individuals had not been served their entire breakfast until she was interviewed on 8/15/01 at 11:00 a.m. in the RSD office. E16 was the only staff in the dining room serving 16 individuals and there were no additional staff in the dining room to monitor the clients until E13 arrived at 8:10a.m.. 10) Per review of Clearbrook Commons Face Sheet on 8/21/01 R4 age 41 male has a diagnosis of Mental Retardation, Autism, and Obsessive Compulsive Disorder. R4 observed on 8/13/01 in the Peach Hall Dining room at approximately 5:00 p.m. to 5:15 p.m. eating his food with his hands. E14 was in the dining room by R4's table, E14 did not re-direct R4 to use his plastic spoon. 11) Staff also failed to monitor the following individuals while in the dining room on 8/15/01 for the breakfast meal: R80, R81, R83, R84, R85, R86, R88, R89, R90, R24 and R74. 12) Interview with E13, QMRP, on 8/15/01 at approximately 11:00 a.m. in the Residential Service Director (RSD) Office revealed "no one staff are assigned to watch clients in the hallway, day room, etc. E11 the shift supervisor is to monitor on the East Side but she was doing direct care this a.m. (8/15/01). Of the 13 staff the East Side, 4 staff were actually working on 8/15/01. East Side staffing from 6:00 a.m. to 10:00 a.m. should be 1 nurse and 12 direct care staff.” Surveyor observed on 8/15/01 from 6:30 a.m. to 9:00 a.m. 3 staff providing direct care for 46 clients; E10,direct care, E11, shift supervisor and E16, direct care. Interview with E14, QMRP, on 8/16/01 at 11:10 a.m. in the Residential Service Director (RSD) Office revealed during "High- Impact Time (6:00 a.m. to 10:00 a.m.) we have a problem with staffing at this time and we are aware of the staffing problems. Ideally it should be 12 direct staff for the East Hall and 12 direct staff for the West Hall. Minimum staffing should be 6 direct care per hall during High-Impact Time." Additional interview with E14 revealed "each direct care staff is responsible for their group of clients during the shift. No assigned staff to monitor because staff are responsible for their own group only." Interview with E18, Assistant Administrator, on 8/15/01 in the West Side Conference Room at approximately 2:00 p.m. revealed the facility is "budgeted for: 24 direct care staff from 6:30 a.m. to 10:00 a.m.; 24 direct care staff from 2:30 p.m. to 11:00 p.m.; and 6 direct care staff on the midnight shift for 90 clients." Interview with E8, Residential Service Director, on 8/15/01 at approximately 3:50 p.m. in the conference room stated he is "comfortable with 6 direct care staff on each side on the p.m. shift, 5 on each side for the a.m. shift (6:30 a.m. to 10:00 a.m.) and 2 per side for the night shift". E8 also states the facility is budgeted for 24 direct care staff for the days, 24 direct care for the p.m.'s, and 6 on the night shift". For the same time period revealed 22 of the 65 injuries of unknown origin had not been investigated. D) Nursing examples follow: R71 is a 56 year old male with diagnoses of Mental Retardation, Cerebral Palsy, Hydrocephalus, Seizure Disorder, and Kyphoscoliosis (per Clearbrook Face Sheet of 8/15/01). The Level of Functioning (LOF) information submitted by the facility on 8/13/01 indicated R71 to be profoundly retarded. R71 is non-ambulatory, requires a 2 person or Hoyer lift for transfer, and has a gastrostomy tube. On 8/20/01 at 11:15a.m. E4, Director of Nursing (DON), stated that R71 had developed a decubitus ulcer Stage 2 on 7/29/01 which later progressed to Stage 3. Observations with E4 on 8/20/01 at 11:25a.m. in R71's room noted R71's right lower buttock with a large approximately 6", blue-red skin toned area, in the center of which was an approximate 2" x 2" x 1-2 cm in depth, open area with red serosanguinous drainage and white tissue. On the right upper buttock/hip area were (4) ½ -1 cms “healing blister/ abraised areas. E4 stated," they are probably tape burns." Review of the "Pressure Ulcer Risk Assessment" of 7/07/01 indicates a total score of "8", "high risk". When surveyor asked if there are procedures in place for high risk individuals, E5, nurse, on 8/20/01 at 4:50p.m., in the DON's office stated, "There are no written policies: we nurses just know what to do, like give more fluids and reposition." E4, in the DON's office at 4:50p.m. on 8/20/01, stated that the facility has no current decubitus ulcer prevention protocols and procedures. E4 stated that R71 is repositioned every 2 hours, has an air mattress and special pillows. Observations on 8/21/01 at 4:15p.m. in R71's room noted R71's bed without an air mattress. E7 , R71's QMRP, on 8/22/01 at 4:20p.m. stated to E4, DON, that R71 did not have a special mattress. E4, on 8/21/01 at 2:30p.m. in the DON's office, stated that R71 is repositioned every 2 hours and nursing is aware of this from data collected from" direct care shift charting on a log". Record verification of the Resident Repositioning Chart data from 6/01/01 to 8/19/01 indicated morning and afternoon repositioning was done, but there was no documentation indicating that R71 was repositioned on the night shift. E7, QMRP, on 8/20/01 at 4:55 p.m. in the DON's office stated that from 11:00p.m. to 7:00a.m. only room checks are done, not repositioning. Surveyor asked if R71 needed repositioning during the night and E7 stated, "No, he's in a recliner in the a.m.." E8, the facility Residential Service Director, stated on 8/22/01 at 5:45p.m. in the office, that regarding the 24 hour Repositioning Chart, "Some Q's use it (for every 2 hour repositioning) others don't; and, if it's used properly, all columns should be checked." E4, DON, stated on 8/22/01 at 5:50p.m. that there are inconsistencies as to when clients are being repositioned. 2.) According to her April, 2001 Physicians' Order Sheet (POS), R29 is age 36 female diagnosed as having Undifferentiated Schizo(phrenia) , Seizures, Self-abusive and Disruptive Behavior, Agitation, Moderate Mental Retardation, Iron Deficiency Anemia, Tardive Dyskinesia, and a history of Chronic Urinary Tract Infections. Her Physical Therapy Consultation of 10/31/2000 states that she "is able to ambulate independently and safely, however, she at times will lurch forward and walk too fast which compromises her balance." R29 is verbal. During review of Incident/ Injury Reports, per an Incident Report dated 04/13/01 at 8:10a.m., E23 heard R29 "yell"; R29 reported she fell. The report states that R29 was transferred to a local hospital emergency room. A summary of R29's care by Z1, an orthopedic surgeon, was faxed to the facility on 08/21/01. The summary states that the x-rays taken on 04/13/01 "revealed spiral, slight comminuted, unstable, displaced fracture of the distal half of the tibia with multiple fractures of the shaft of the fibula. The patient was treated with reduction and locked intra medullary rod fixation of the fracture of the right tibia on 4/13/01." An Investigation Report dated 04/24/01 and signed by E3, QMRP, states that E23 was interviewed by E3 regarding R29's fall. According to the report, E23 "stated that she was walking by the kitchen, and heard a yell. She went to go see what the problem was, and she saw R29 lying on the floor. She did not see R29 fall, but only heard the yell. She immediately helped R29 up, and brought her to the nurse, where R29 was assessed for injuries. E23 stated that something had previously been spilled on the floor and housekeeping had just finished cleaning up the mess. E23 mentioned that there were no other staff or clients in the vicinity that could have injured R29, and that she most likely slipped on the wet floor." A Nurse's Note by E29, nurse, states that R29 returned to the facility from the hospital on 04/15/01 at 2:30p.m. E29's note includes that "Report given to Z2 (physician). Per Z2 resume all previous medication." The note also includes "...home PT ordered." No readmission physician's orders to include medications, treatments, activity level, diet, or physical therapy were noted on R29's April 2001 Physician's Order Sheet (POS), nor were either E4 nor E5 able to locate them during an interview in the conference room on 08/20/01 at 5:44p.m. The Physician Transfer Orders of 04/15/01 from the hospital indicate that R29 is to "ambulate (with) walker", may have Vicodin as needed, is to have an x-ray taken at the office in 8 days, and states what her weight bearing status is to be. Regarding rehabilitation, "Physical Therapy Eval & Treatment" is marked with an "x"; these transfer orders are signed by Z1. During the 08/20/01 interview with E4 and E5, E4 stated that she believes new orders are needed upon a resident's return to the facility "after 3 days in the hospital." R29 was in the hospital 04/13/01-04/15/01. No policy was provided by the facility to support this statement. After indicating that a nurse from the hospital telephoned regarding R29's transfer back to the facility, an entry on the Nurse's Notes by E32, nurse, of 04/14/01 at 11a.m. concludes with the following: "...will need PT (physical therapy) QD (each day) , w/c (wheelchair with) leg lift--walker & elevated toilet seat., DON (Director of Nursing) informed of these plans." A hospital Physical Therapy Initial Evaluation dated 04/14/01 reads in part that R29 "needs active cuing for use of walker..." The evaluation recommends "Home PT" and the "need for gait training and transfers." It also states that R29 is at "High risk of fall." No documentation regarding physical therapy was noted during review of R29's file. Per interview with E3, QMRP, on 08/22/01 at 1:50p.m. in the conference room, R29 has received no physical therapy since her fracture on 04/13/01. A 04/17/01 8p.m. Nurse's Note by E33, nurse, states that R29 "fell this p.m. Incision noted to have moderate amount of bleeding. 4x4 placed on incision. Instructed to remain in wheelchair. Only to get up (with) assist. Pain med given at 8P. DON notified." No incident report was noted for this fall. According to E18, assistant administrator, during an interview in the conference room on 08/22/01 at 1:14p.m., there is no incident report for R29's fall of 04/17/01. No physician notification of this fall was found to be recorded in the Nurse's Notes. On 08/22/01 at 4:19p.m. in the conference room, E33 confirmed during an interview that she did not notify any physician of R29's fall and bleeding incision on 04/17/01 (4 days after R29's fractures and surgery). During this same interview, E33 stated that ,"in retrospect, I probably should have notified the doctor." The summary of R29's care faxed to the facility by Z1's office notes that on her visit to Z1 on 04/23/01, "The incision over the proximal tibia/knee shows slight widening but is not split open. There is some redness about the incision. "This same notation states that R29 "has been walking on her splint...picking at her leg...has removed the suture from her proximal incision..." 3) Per her 04/01 POS, R34 is age 51 female diagnosed as having Severe Mental Retardation, Cerebral Palsy, Glaucoma, Insulin Dependant Diabetes Mellitus, Dysthymic Disorder, History of Major Depression and Intermittent Explosive Disorder. R34 was observed throughout the survey to be in a wheelchair. During review of incident/injury reports, a report about R34 being transported to a hospital for treatment on 04/25/01 was noted. Per a 04/25/01 11:30a.m. Nurse's Note by E5, nurse, the facility was "notified by wkshop nurse that client sent to (hospital) ER for eval(uation). At 1p.m., E5 entered the following nursing note: "Wkshop nurse stated BS (blood sugar down) & client unresp(onsive). Paramedics to central, BS @ that time 23..." The hospital ER record of 04/25/01 lists a diagnosis of "Acute Hypoglycemic Episode." Per file review, at 6:30a.m. on 04/25/01, R34's Accucheck revealed her glucose to be "66" as documented by E31. An order on R34's April, 2001 POS reads: "call MD if below 80 or above 300" (regarding the Accucheck). There is no documentation in the Nurse's Notes of the physician being notified of R34's Accucheck of "66" on 04/25/01. According to R34's Medication Administration Record, 42 units of Novolin 70/30 was given by E31 to R34 the morning of 04/25/01. R34 went on to workshop. File review also reveals that on 04/20/01 an Interim Staffing was held "to discuss (R34's) eating habits b/c (because) she was recently sent to the hospital b/c (because) of her diabetes. And she has been very depressed lately.” Per interview with E4, director of nursing, on 08/22/01 at 4p.m., R34 "has been (a) feeding problem since admission, about 1 ½ years ago". E4 went on to say that R34 "plays around with food, pushing it around on her plate." Despite R34's eating history and the 04/20/01 staffing, she was not started on "food tracking" until 04/27/01 after her emergency room visit. An Incident Report from day training on 4/25/01 states that at 11:45 a.m., R34 was found to be unresponsive and "...pale and her eyes were rolling in her head." The incident report continues by stating that the blood sugar "was unreadable via accu (check)..." The Investigation Report reads that her blood sugar was "zero". A call to 911 was made and R34 was transported via ambulance to a local hospital emergency room. 4) During review of incident/accident reports, an incident of "Neglect of Duty/Client" of June 2, 2001 midnight shift was noted. According to the report, ...it was concluded that there was only one particular staff that neglected his duty which required disciplinary action resulting to work suspension. This particular staff will also be enrolled to take the Right, Abuse and Neglect class. In addition, he will be assigned to (for) PM shift only where closer supervision will be provided." Both reports are signed by E18, assistant administrator. A list of residents who were involved in the incident of June 2, 2001 was provided by E18; they are: R24, R38, R71, R79, R84 and R89. Written staff statements gathered by E18 during the investigation include comments such as, "staff constantly reporting that the guys are soak and wet and some have diapers full of B.M." During an interview with E18 on 08/14/01 at 4:30p.m. in the conference room, he identified the staff who was found to be neglectful to be E1, direct care staff. It should be noted that R71 currently has a stage 3 pressure sore (lower right buttocks) per interview with E4, director of nursing, on 08/16/01 at 4:16p.m. According to a Level of Functioning list provided by the facility, 5 of the 6 residents (R24, R38, R71, R79, and R84) have an overall level of functioning of profound. On 08/14/01 at 4:30p.m. in the conference room, E18 was interviewed about this incident. He stated that Administration was first notified of this allegation of neglect on 06/04/01. He also said that on the night shift, the nurse is the house supervisor and that on the night of the incident of 06/02/01 (actually starting 06/01 into the morning of 06/02/01), that nurse was E2. E2 was interviewed on 08/15/01 at 1:21p.m. on the West Side of the facility. When asked about this incident, she spoke of "not knowing where staff was" that night, but indicated that she really didn't know about the incident until she was "called at home and asked specifically about one employee (E1)." A written statement dated 6/4/01 bearing E2's signature, however, states that "For the past few weeks (E1) has been working the midnight shift...He is very lax in the care of the clients. He doesn't seem to check on or change them ..." E18's investigation of this incident concludes with, in part, that E2 will be spoken with regarding "her supervisory responsibility for midnight shift". She did not report this neglect of duty/client to Administration. Per interview with E35, shift supervisor, on 08/15/01 at 3p.m. in the conference room, she was the Supervisor on days the week-end of June 2 & 3, 2001. She stated she was notified of the incident of neglect first thing in the morning on June 2nd (about 6:30a.m.). She said she, in turn, spoke with the QMRP who was in charge on days on 06/02/01; "the Q would have been the one to notify Administration of the incident." In the conference room on 08/15/01at 3:56p.m., E3, QMRP, was interviewed. She confirmed she was on duty on Saturday, June 2, 2001 and that E35 notified her of the neglect incident when she came to work at "8 or 9a.m." that day. Not only did E3 not notify Administration of the allegation, but she stated that no one since the incident has told her she should have notified Administration immediately. E) Examples of no Fire or Disaster Drills follow: 1) Review of Fire and Disaster Drill Book on 8/13/01 at approximately 1:00 p.m. in the Conference Room from 7/00 to 8/01 revealed the facility did not conduct fire drills/disaster evacuation drills at least quarterly during the following time frames for staff and R1 to R90: Night Shift - No fire/disaster drills completed from 7/00 to 9/00, 1/01 to 3/01 and 4/01 to 6/01; PM Shift - No fire/disaster drills completed for 7/00, 8/00, 9/00. Interview with E19, Administrator, on 8/13/01 at 2:50 p.m. in the Conference Room revealed fire/disaster drill “do not appear to been completed on the evening and night shift since he is unable to locate if they were ever done”. 2) Review of Fire and Disaster Drill Book on 8/13/01 at approximately 1:00 p.m. in the Conference Room from 7/00 to 8/01 revealed the facility has not conducted fire drills and disaster drills during the following time frames under varying conditions for staff and R1 to R90: Night Shift - No fire/disaster drills completed from 7/00 to 9/00, 1/01 to 3/01 and 4/01 to 6/01; PM Shift - No fire/disaster drills completed for 7/00, 8/00, 9/00. Interview with E19, Administrator, on 8/13/01 at 2:50 p.m. in the Conference Room revealed fire/disaster drill “do not appear to been completed on the evening and night shift since he is unable to locate if they were ever done”. 3) Review of Fire and Disaster Drill Book on 8/13/01 at approximately 1:00 p.m. in the Conference Room from 7/00 to 8/01 revealed the facility did not complete evacuation drills, to the outside of the facility at least once per shift per year on the day shift, evening shift and night shift from 8/00 to 8/01. Interview with E 19, Administrator, on 8/13/01 at 2:50 p.m. in the Conference revealed he "does not have documentation that the facility had any evacuation to the outside at least once per year per shift and he is unable to determine from the fire/disaster drill sheets if the evacuation occurred to the outside of the facility" for R1 to R90 and staff. Interview with Z4 on 8/21/01 via telephone at approximately 10:30 a.m. revealed she visits weekly and "staffing is the one thing I am concerned about especially on the weekends and day training site, the facility has a nursing home atmosphere and the care is not as good as it could be with additional staff". |