LOCUSTWOOD HEALTH CARE CENTER
Date of Survey: 06/05/01
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 residents comprehensive assessment and plan of care. Adequate and properly supervised nursing care and and personal care shall be provided to each resident to meet the total nursing and personal care needs of the resident.
The DON shall oversee the nursing services of the facility including:
Overseeing the comprehensive assessment of the residents needs, which include medically defined conditions and medical functional status, sensory and physical impairments, nutritional status and requirements, psychosocial status, discharge potential, dental condition, activities potential, rehabilitation potential, cognitive status, and drug therapy.
If physical therapy, occupational therapy, speech therapy or any other specialized rehabilitative service is offered, it shall be provided by or supervised by, a qualified professional in that specialty and upon the written order of the physician.
RESIDENT AS PERPETRATOR OF ABUSE. WHEN AN INVESTIGATION OF A REPORT OF SUSPECTED ABUSE OF A RESIDENT INDICATES, BASED UPON CREDIBLE EVIDENCE, THAT ANOTHER RESIDENT OF THE LONG-TERM CARE FACILITY IS THE PERPETRATOR OF THE ABUSE, THAT RESIDENTS 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.
These regulations are not met as evidenced by:
Based on record review and interviews, the facility failed to protect a resident from sexual abuse by:
a) Failure to report and investigate a possible sexual abuse involving one resident (R2) in a timely manner which created the potential for further sexual abuse to R2 or other residents.
b) Failure to monitor the activities of residents who have a history of aggressive behaviors .
The findings include:
Review of the May, 2002 Physician Order Sheet listed R2's diagnoses as Congestive Heart Failure, Anxiety, Osteoarthritis, Hypothyroidism, Depression, Dementia of Alzheimer's type with Delusions and Degenerative Joint Disease. The Resident Assessment dated 03/11/02 assessed R2 to have a short and long term memory problem and to be severely impaired in cognitive skills for daily decision making. R2 was assessed as requiring extensive assist to being totally dependent on staff. R2's behaviors were identified as: wandering, verbally abusive, physically abusive, socially inappropriate and resistive to care. During an interview on 05/21/02 at 8:30 AM in the conference room, E1, E3 and E2 commented that R2 was very confused and had a habit of removing her clothes and exposing herself.
Review of the facility's timeline of events, clinical records, emergency room reports, and staff, resident, and physician interviews indicated the following:
On 05/17/02 between 1:30 PM and 2:00 PM, staff undressed and put a hospital gown on R2 after putting her to bed. R2's diaper had been removed. Around 4:00 PM, E16 went to get R2 up for supper and found a discharge in R2's peri-area, on R2's upper thighs and the soaker (incontinent pad).
E16 reported R2's discharge to E15. About 4:15 PM, E15 examined R2 and observed a moderate amount of clear secretions with bright red streaks on the pad. The facility's timeline of events indicated at 4:20 PM, E15 notified Z10 who then assessed R2. Z10 listened to lung sounds. However, Z10 did not do a vaginal exam and he assumed R2 had a Urinary Tract Infection and ordered a culture and sensitivity of R2's urine.
Through interview on 05/22/02 at noon in the conference room, E15 indicated that she reported R2's discharge to E17. E17 told E15 that sometimes R2 has discharges.
Around 8:30 PM, E15, accompanied by two nurse aides, went in to catheterize R2 for a urine specimen. It was at this time that E15 noted the vaginal vault was widely opened and red. There was more discharge with bright red blood draining from the vagina.
On 05/22/02 at noon in the Director of Nursing's office, E15 stated, "It was the first time that I had observed (R2's) vaginal area. I never thought about a sexual encounter but the vaginal vault was open so wide and this is not normal for a woman of this age. I left the facility at 1 AM on 05/18/02 and I couldn't shake it off. I went to bed and returned to the facility at 6 AM. At 8 AM, I called (E17) to report how I felt but (E17) was on another line and said that she would return my call. I waited. When I didn't hear from (E17), I called (E2) at home around 10:45 AM."
At 12:10 PM, E2 returned to the facility. At 1:00 PM, E2 examined R2. No bleeding or drainage from the vagina was noted and vaginal vault was not opened. A bruise was observed to R2's left medial thigh. At 1:30 PM, E1 was notified and an investigation was started. At 4:00 PM, R2 was transferred to the hospital for an evaluation.
Review of the Emergency Room report dated 05/18/02 revealed:
"Pelvic exam: External genitalia are quite excoriated and erythematous over inner and outer labia. There appears to be some superficial abrasions noted bilaterally. Beside the vaginal canal there are multiple what appears to be superficial lacerations and tears on all walls of the vagina surrounding the cervix. There is minimal active bleeding. The cervix itself has no trauma. Rape kit done. Urinary Analysis=Klebsiella"
Interview with Z8 on 05/23/02 at 2:37 per telephone, "Assault possible - can't be sure."
On 05/30/02 at 12:50 PM per telephone, Z9 stated, "(Z8) shared with me. Based on (Z8's) report it sure sounded like vaginal penetration to me." When asked by surveyor, "Do you feel that sexual assault occurred?" Z9 replied, "It sure seemed like a sexual assault to me. It was something rigid and it could have been an object. There were superficial tears inside the vagina."
On 05/18/02 at 8:15 AM in the dining room, R2 stated to an employee, "I got a poke in the hole."
Per interview at random times and places, several staff admitted to being afraid of R3 and suspected R3 of committing the sexual assault on R2. R3 has a history of sexual aggression and was recently admitted to the facility on 04/23/02 after being in a mental health facility since 03/25/02.
During interviews at random times and places, E15 and E11 commented that they had been shown R3's mental health records and had advised E1 not to admit R3 to the facility. R3 was admitted a couple of days later. There was no instructions given to the staff on how to meet R3's needs.
R3's record review indicated that R3 had been writing love letters to another female resident. On 05/29/02 at 2:45 PM, E11 stated, "I heard that (R3) would go down the women's hallway because he liked one of the residents (R10). It made (R10) nervous and she did not like having (R3) around." During an interview with R10 on 05/29/02 at 3:15 PM, R10 stated, "(R3) would come down the women's hall and ask for cigarettes or a light. He suggested to me that there was an empty room down the hall and that we could move in there together. He said that we could have 6 kids. He never touched me; but I'm happy that he is no longer here."
In order to reach R10's room R3 would have to pass R2's room on the right. R2 would be visible from the hallway. R2 would often expose herself by removing her clothes.
Review of R3's care plan dated 05/09/02 does not address the following:
a) R3's need to go down the women's hall to obtain cigarettes from R10 and/or the activity department located at the end of the women's hall.
b) R3's love letters to R10 or the unwanted relationship with R10 that R3 was trying to establish.
On 05/22/02 at noon in the Director of Nursing's Office, E15 stated, "I felt it might have been (R3) that assaulted (R2). (R3) stayed in his room all evening (on 05/17/02) which was different for (R3). I observed a scratch on (R3's) nose and forehead and he wouldn't cooperate with a body check."
A body check was done on R3 at 2:30 AM on 05/19/02 and revealed multiple scratches and marks.
During an interview on 05/21/02 at 9:45 AM in the conference room, E3 stated, "We don't have a policy for admitting residents with a mental illness diagnoses because we shouldn't be admitting mentally ill residents. This facility does not have adequate staff to take care of these people. (E1) admitted them without programming. The staff are not trained to care for this type of resident."
R3's Mental Health Assessment (a pre-admission screening) dated 04/11/02 indicated that he had an extensive psychiatric history. R3 had 27 admissions to a mental health center and 5 admissions to an institution for the criminally insane. The last admission was from 01/07/01 to 03/11/02. R3 had maladaptive behaviors identified as: Criminal Justice System Involvement, Antisocial behavior, Physical violence toward others, Property damage, Threatening others with physical assault or injury, Sexual aggression, and Victim of physical or sexual abuse.
R3's Diagnostic impressions were listed on this assessment as:
AXIS I: Schizoaffective Disorder, Bipolar Type, Most Recent Episodic Manic
AXIS III: Obesity, High Blood Pressure and Varicose Veins.
R3's Problem List was:
R3's Service Needs were identified as:
R3's May 2002 Physician Order Sheet had orders for the following psychotropic medications:
Klonopin 0.5mg Give 1 tablet by mouth twice daily (1PM & 8PM)
Depakote 500mg tablet EC - Give 2 tablets three times per day
Chlorpromazine 200mg - Give 1 tablet four times per day
Desyrel 100mg - Give 1 tablet at bedtime.
The Pre-Admission Screening for Mental Health (PAS/MH 1) dated 04/11/02 indicated that R3 required a nursing facility level of care and psychiatric rehabilitation services.
On 05/22/02 at noon in the Director of Nursing's office, E15 stated, "(E1) showed me (R3's) history and I told (E1) that we shouldn't admit a resident with the behaviors that (R3) had. Shortly after that, (R3) was admitted to the facility. I told the girls that they shouldn't go down the hall alone but they should go in pairs."
On 05/29/02 at 2:45 PM in the dining room, E11 stated, "Yes, I was afraid of (R3). I talked to (E1) prior to (R3's) admission and showed (E1) (R3's) and (R8's) history's. I told (E1) that the facility shouldn't admit them. Three to four days later (R3) was here. There was no preparation for the staff for dealing with residents with behaviors like (R3's). I went and bought a set of walkie-talkies. I didn't want the girls to be down there without being able to call for help."
Review of the nursing notes revealed the following behaviors since admission on 04/23/02:
04/24/02 (2000) - "Inappropriate conversations at times."
05/01/30 (10-6) - "Woke up at 2:30 AM walking in men's hall. Then using phone...Became upset more as time passes that he couldn't do the things he wanted."
05/01/02 (1400) - "Resident came to the nursing station and stated, 'I've pee'ed in the bed three times and need my bed clothes changed. Resident is not incontinent."
05/02/02 (2-10) - "Resident was making sexual advancements towards female resident and staff."
05/04/02 (10:30 AM) - "Staff member came and reported to nurse that this resident grabbed her by her clothes and threatened her with bodily harm. He took her pop and threw it on the floor. This staff member reports that this resident has made sexual gestures toward her in the past."
05/04/02 (2-10) - "(R3) was outside making sexual movements while female residents outside also. (R3) looking at the residents winking his eye at them and whistling."
Review of social service notes dated 05/14/02 revealed, "(R3) has a history of aggressive physical and sexual behavior and this behavior has begun to be displayed within this facility. (R3) has been targeting a particular female resident and is writing inappropriate messages to her; following her around and obsessed with conversations regarding her...(R3) is not appropriate for residing in this facility. He imposes a risk of danger to others."
During an interview on 05/21/02 in the conference room, E3 stated, "We don't have adequately trained staff to take care of these people here. We were keeping an eye on (R3) by doing 15 minute watches starting on 05/14/02."
Review of the resident monitoring sheets from 05/14/02 through 05/20/02 revealed that there was no documentation from 8 AM to 1PM on 05/15/02 and from 6 AM to 9 PM on 05/16/02. The documentation consisted of initials of staff and not R3's location. On 05/17/02 between 10 - 11 AM the monitoring sheet was initialed that R3 had been seen in the facility. R3 had been out of the facility on 05/17/02 at that time for an appointment at another facility, verified by E2 on 05/22/02 at 10:30 AM in the conference room.
The Mental Health Assessment (a pre-admission screening) dated 03/22/02 indicated that R8 had 7 admissions to a mental health center and had spent the last 20 years in an institution for the criminally insane. R8 had maladaptive behaviors identified as: Criminal Justice System Involvement, multiple felonies and incarceration; Antisocial Behaviors; Physical violence toward others; Property Damage; Threatening others with physical assault or injury; Suicidal gestures or threats; Suicide attempts; and Self-mutilation.
Treatment Recommendations on this assessment were:
R8's Diagnostic Impressions were listed as:
AXIS I: Schizoaffective Disorder, Bipolar Type.
AXIS III: Hypertension, Post Cerebral Vascular Accident with Hemiparesis, Hepatitis C, Post Patella Fracture and Surgery, Chronic Uvulitis and Post Cystectomy
R8's Service Needs were identified as:
The PAS/MH 1 dated 03/22/02 indicated that R8 required a nursing facility level of care and psychiatric rehabilitation services.
The R8's May 2002 Physician Order Sheet (POS) had orders for two psychotropic medications twice a day: Tegretol XR and Zyprexia.
Record review indicated that R8 was admitted to the facility on 04/02/02 and a care plan was not developed until 24 days later on 04/26/02.
The care plan dated 04/26/02 has the following interventions:
On 05/22/02 at 3:45 PM in the small front lobby, Z6, E2, E14 verified that the facility was not doing any behavior monitoring on R8. Review of R8's clinical record lacked documentation of 1:1's. On 05/22/02 at 9:15 AM in the dining room, E14 stated, "1-1's are not yet being done and there is no documentation in the charts."
The Mental Health Assessment (a pre-admission screening) dated 03/15/02 indicated that R4 had been hospitalized at the mental health center 67 times since 1972. R4 has also been at facilities for the criminally insane. R4 had maladaptive behaviors identified as: Antisocial behavior; Physical violence toward others; Self-injurious behaviors; Property damage; Threatening others with physical assault or injury; Suicidal gestures or threats; Suicide attempts; and Self-mutilation.
R4's Diagnostic impressions were listed:
AXIS I: Schizoaffective Disorder, Depressed
Intermittent Explosive Disorder
AXIS II: Dependent Personality Disorder
AXIS III: Gastroesophageal reflux disorder, edentulous
R4's Service Needs were identified as:
The May 2002 Physician Order Sheet listed the following psychotropic medications for R4:
Risperdal 1.5mg - give 1 tablet at bedtime
Depakote 500mg EC - give 1 tablet three times per day
The care plan dated 04/11/02 has the following approaches:
Review of R4's clinical record lacked documentation of counseling and behavior tracking. On 05/22/02 at 3:45 PM in the small front lobby, Z6, E2, E14 verified that the facility was not doing any behavior monitoring for R4. During an interview on 05/21/02 at 9:45 AM in the conference room, E3 verified that counseling was not being done and that staff were not trained to do the counseling for this type of resident.
R7 was admitted to the facility on 04/04/02 from a Mental Health Center with a diagnosis of AXIS I: Bipolar Disorder NOS and AXIS II: Borderline Personality Disorder with paranoid and dependent personality traits.
R9 was admitted to the facility on 03/07/02 from a Mental Health Center with a diagnosis of AXIS I: Schizoaffective Disorder, Alcohol Abuse and AXIS II: Paranoid Personality Disorder.
The Mental Health Assessments indicated that R7 required psychiatric rehabilitation services that the facility was unable to provide.