Cottonwood Health Care Center
Facility I.D. Number # 0043513
Date of Survey: 03/15/02
Incident Report Investigation of 03/05/02
The facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of the resident, in accordance with each resident's comprehensive assessment and plan of care. Adequate and properly supervised nursing care and personal care shall be provided to each resident to meet the total nursing and personal care needs of the resident.
Objective observations of changes in a resident's condition, including mental and emotional changes, as a means for analyzing and determining care required and the need for further medical evaluation and treatment shall be made by nursing staff and recorded in the resident's medical record.
The DON shall oversee the nursing services of the facility including: Planning an up-to-date resident care plan for each resident based on the resident's comprehensive assessment, individual needs and goals to be accomplished, physician's orders, and personal care and nursing needs. The plan shall be in writing and shall be reviewed and modified in keeping with the care needed as indicated by the resident's condition.
These requirements are not met as evidenced by:
Based on observation, record review and interview, the facility failed to adequately supervise R1's escalating behavioral outbursts, failed to revise R1's care plan to address individualized approaches to these outbursts, and failed to implement prevention programs. R1 threw hot water at R2, causing second degree burns to R2's face, shoulders, and breast area.
Per admission record, R1 was admitted to the facility on 11/26/99 with Schizoaffective Disorder and Post Gangrene. R1's MDS (minimum data set) of 10/30/01 indicates no behaviors with easily altered sad and anxious mood. The MDS of 1/25/02 indicates the behavior of verbal abuse happens 1 to 3 days out of seven and the behavior is easily altered. The only mood state that is identified is anxiousness, which is also easily altered according to the MDS.
Interviews with E9 (Psycho/Social Instructor), E10 (Activity Assistant), E11 (Certified Nurses Aide - CNA) on duty on 3/5/02 indicated that they were present when R1 rolled his wheelchair up to where R2 was seated in her wheelchair and threw hot water on R2 at 1:20 PM in the dining room. R2 was taken to the hospital. Assessment records indicate R2 had first and second degree burns of the right face, neck, and chest area. The police were called and R1 was taken to jail were R1 remained as of 3/13/02.
E9 was interviewed in the classroom at 9:30 AM on 3/13/02. E9 stated she saw R1 go to the microwave that was kept in the activity room. According to E9, R1 heated "something" in a cup for 3 to 5 minutes. R1 immediately left the room and "rolled towards dining room, then I heard a loud scream."
E10 was interviewed in the classroom on 3/13/02 at 10:30 AM. E10 stated that around 2:00 PM on 3/5/02 she was in the activity room. According to E10, R1 was in his wheelchair and had a "large thermal cup" which was "approximately 22 ounces." E10 stated that she "could see the steam coming up from cup." E10 questioned R1 about the hot water, but R1did not respond. The next thing E10 heard was R2 "screaming help help...other residents were saying that (R1) threw water on (R2)." "(R2) was red - face wet - soaked."
E11 was interviewed by telephone on 3/13/02 at 10:45 AM. E11 stated she was sitting in the dining room directly behind R2 when the incident happened. E11 stated R1 wheeled in from the activity room stopped at R2's wheelchair and "threw the hot water on (R2). (R2) yelled ... and R1 wheeled quickly to the other door."
R2 was interviewed on 3/8/02 at 11:00 AM and 3/12/02 at 9:40 AM in R2's room. R2 stated "(R1) hates me...threw ice water at me one time on patio and one time at supper table before trays were served." R2 stated staff were for sure aware of the incident at the supper table because they asked (R1) if he meant to do it and (R1) stated "Yes." R2 stated staff told R2 she had to stay away from R1.
On 3/5/02 at the time of the incident R2 stated she had sat at the same table with R1during bingo. After bingo she was waiting to go out to smoke. R2 stated she was sitting at the patio door and R1 came up to her and threw hot water on her, and she screamed for help. R2 was observed on 3/12/02 with scabbing on the right side of her face with patchy bright pink areas. R2's right neck and upper chest had the same appearance.
R1's nurses notes on 3/5/02 state "1:20 PM Resident threw scalding water at female peer...incident was totally unprovoked...."
R1's behavior tracking sheets indicate that from 12/1/01 to 1/31/02 R1 had no aggressive behavior that was being tracked. On 2/1/02 the behaviors of "verbal aggression,...outbursts, documents when resident calms down with VC (verbal cues)" were added to the Flow Sheet Record. These added areas remained on the flow sheet through 3/5/02. There are only 4 episodes of "verbal aggression" documented in that time frame. These are documented on 2/10/02, 2/24/02, 2/25/02, and 2/28/02. There is no explanation of what these outbursts were, what interventions were needed, or their effectiveness in calming R1 down. These incidents do not match the incidents as documented in the nurses notes and social service notes.
R1's nurses notes and social service notes indicate the following behaviors leading up to the 3/5/02 incident: Social Service/Case Manager notes indicate on 1/16/02 "Res. (resident) complaining about conflict he is having with a peer (R2). They apparently had a argument last P.M. Res. was counseled about avoiding or ignoring peer and not (to) let her get him upset...." There was no further note concerning the conflict between R1 and R2.
E2 (R1's Case Manager) was interviewed on 3/8/02 at 1:45 PM and stated there were no further notes concerning R1 and R2's conflict because he was not made aware that the conflict continued to exist. He stated that R1 and R2 were told to stay away from each other. E2 thought that approach was working because he had not heard anything indicating there was a problem between the two of them for approximately 7 weeks. E2 stated that R1 was having increased manic episodes, but he had taken R1 to the psychologist regarding this on 2/26/02. R1's Seroquel was increased to 150 mg at night. E2 stated "If I don't know altercations are happening I can't prevent them."
E2 and E3 (R2's case managers) stated during interview on 3/8/02 that they had not been told of the cold water incidents.
E8 (Administrator) was interviewed on 3/13/02 at 11:55 AM and stated everyone knew to keep R1 and R2 away from each other.
R4 was interviewed on 3/13/02 at 9:50 AM. Per MDS dated 10/30/01, R4 is moderately cognitively impaired but can understand and make self understood always. R4 stated "(R1) was making serious threats against (R2) to other residents hoping (R2) would stop pestering (R1)."
E6 (CNA), E5 (Licensed Practical Nurse - LPN), E7 (Activity Aide/Door Monitor), E9, E10, and E11 were interviewed the morning of 3/13/02 and all stated they were not aware of problems between R1 and R2 and had not been told to keep them away from each other.
Nursing notes from 1/30/02 contain several references to increased behaviors. Nurses notes of "1/30/02 ...rubbed his face extremely hard causing nose to become extremely red (looks like a sunburn)." Nurses notes of 2/2/02 "1:45 PM ...grabbed CNA on breast - was counseled - it was then reported by another CNA he grabbed her buttock - again counseled - resident has been very loud, demanding - counseling continues."
Social service notes state 2/2/02 "Res. grabbed staff's breast - res. acting very manic at present."
Nurses notes indicate on 2/8/02 "7:30 AM Resident while in D/R (dining room) became agitated with female peer began yelling ....Resident picked up chair et (and) attempted to hit female peer - housekeeping staff intervened before contact was made..counseled with effect...." This incident is not addressed by E2 (case manager) in the social service notes. E2 was interviewed on 3/8/02 at 1:45 PM and stated he had never been made aware of this incident. E2 stated he documents what he is made aware of.
Record review of nurses notes, behavior tracking sheets, social service notes, and medication administration sheets indicate a continued increase in behaviors with R1 receiving Valium 5 mg for "anxiety" 20 times from 2/3/02 to 3/3/02. This was an increase from no Valium needed from 1/16/02 to 2/1/02. There is no indication as to what the "anxiety" is, causal factors surrounding the complaints of anxiety, or treatments other than the drugs being used.
Per interview with E4 at 8:35 AM on 3/13/02. R1 was on no behavior modification programs.
R1's care plan as of 3/8/02 had not been updated to include individualized approaches to address R1's increased manic episodes, aggression, or personal conflicts with R2.
The facility has no policy or procedures in place to address escalating aggressive behavior or changes in mental status. E8 (Administrator) stated as inservice on Behaviors/Assessments was given around 2/20/02. The inservice format indicates assessments - identifies residents that exhibit behavioral symptoms that require additional or new treatment programs....Significant changes would also require a review/revision of care plan...Evaluate seriousness of...symptoms...safety issues...review intensity, duration, frequency, effects on resident or others...identifying factors of behavioral symptoms is critical.