The facilitys 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.
The facility shall provide training and habilitation services to facilitate the intellectual, sensorimotor, and effective development of each resident in the facility.
AN OWNER, LICENSEE, ADMINISTRATOR, EMPLOYEE OR AGENT OF A FACILITY SHALL NOT ABUSE OR NEGLECT A RESIDENT.
These regulations are not met as evidenced by the following:
Per record review, R1 was admitted to the facility on 04/18/02 with a history of suicidal/self injurious behavior attempts.
1) Per review of the Incident Report dated 04/21/02 and confirmed per interview with R1 on 04/24/02 at 3:30 P.M., R1 was physically restrained by facility staff due to her refusal to take her medications. While restrained by staff, R1's mouth and nose were covered by staff to prevent her from spitting out the medication.
Review of the Incident Report dated 04/21/02 identified that "At approx (approximately) 7:30 P.M. resident (R1) awaken by this writer (E2-Licensed Practical Nurse) to take meds (medications). Resident refused stated "I'm not going to take them!" Got assistance from staff to give meds. Resident became very destructive to property. Began hitting head on the wall. Pacing constantly cursing @ (at) staff. She then tried to cut her wrist with plastic, from her radio. This writer advised staff to remove anything dangerous from the room. This writer contacted Administrator, put resident 1:1 with staff. Resident still upset when this writer left. Activity director remained here."
Interview with R1 on 04/24/02 at 3:30 P.M. confirmed that she had been "forced" to take her medication on 04/21/02 by E2. During this interview, R1 stated, "I refused to take my meds because I can take it an hour before or an hour after med time. E2 threatened me and said that she would get staff and call the doctor if I didn't take my meds then. They (E3, E4 and E5 Direct Service Persons) held me down on the bed like in a restraint. E2 put the medicine in my mouth and they held my arms and my legs. I tried to fight them. I would spit them out (the medication) and they kept putting the meds back in my mouth. E2 pulled my hair and head back and put the medicine in my mouth. Then E3 held my nose and covered my mouth with her hands. I couldn't breath. I have asthma and I could have choked. They didn't give me any water. After they let me go, I got "really mad" and tied a pillow case around my throat to kill myself. I also tried to cut my wrist." During this interview, R1 stated that she had told the Activity Director (E6) that night (04/21) what staff had done to her. R1 stated "I'm afraid, because E2 will force me to take my meds again and no one will stop her." "I talked to a counselor two days ago."
Interview with E4 on 04/24/02 at 3:50 P.M. confirmed that R1 had been restrained by staff on 04/21/02. E4 stated that he had "held R1's arms" and that E3 and E5 had held R1's feet. E4 stated that the nurse (E2) gave R1 her meds and that R1 spit out the meds. E4 stated E3 held R1's nose after being told by the nurse. E4 stated that he had only worked at the facility for two months and wasn't comfortable with the situation that had occurred on 04/21/02 with R1.
Interview with E3 on 04/26/02 at 10:07 A.M. confirmed that she had worked 8 A.M. to midnight on 04/21/02. E3 stated that R1's behavior had started before 8 P.M.. E3 stated that R1 was upset and was only talking about hurting herself before she was restrained. E3 stated "E2 told us to hold her down. I was at her feet ankles holding her. R1 was fighting as E2 tried giving her meds. R1 spit the medication out. E2 had us sit R1 up and E4 held her arms behind her back. E2 put the meds in her mouth and R1 would spit them out. E2 told me to cover her mouth and hold her nose. After she (R1) took her meds, she sat up and began cursing. R1 slammed her bedroom door many times. R1 also threw her personal radio and broke the plastic covering. R1 then tried to cut her arm with the plastic. R1 began tearing up everything. We probably caused R1's later behaviors because she was really pissed off that she was made to take her meds."
Interview with E2 on 04/24/02 at 4:30 P.M. confirmed that R1 had been restrained by staff on 04/21/02. During this interview E2 stated: "R1 had been upset with her roommate earlier during the day and I felt R1 needed her Ativan to calm down. I tried giving her four meds. R1 kept trying to spit them out. R1's nose "might have been held by E3" during the restraint hold to get R1 to take her medication. E2 confirmed that R1's aggressive and suicidal behaviors did not occur until after R1 was restrained by staff. E2 stated "It's possible" when asked by the surveyor if staff restraining R1 may have caused R1's behavior(s). E2 stated, "I have never dealt with clients that are mentally retarded and dual diagnosed. They are different from the other clients we have. I don't like working with these type of people and I wish I didn't have to."
Per review of the facility's resident roster, four clients have been admitted to the facility within the past months with diagnosis of mild mental retardation and with dual diagnosis. E2 confirmed that restraining R1 to take her medication was not normal nursing practice.
E2 stated that she had notified the physician and that "he was all right with the whole situation".
Per telephone interview with Z1(Facility's Medical Director) on 04/26/02 at 11:45 A.M., Z1 stated that he was not aware that R1 had been restrained to take her medications. Z1 stated, "I was told she was restrained because she was aggressive and attempting to hurt herself." Z1 stated "No" when asked by the surveyor if the facility had informed him that R1's nose and mouth and been covered while she was restrained. Z1 stated "They should never have covered her nose and mouth to get her to take her medication."
Review of R1's Physician Orders and Medication Administration Record (MAR) for the month of April 2002, R1 was to receive Ativan 2 mg (milligrams) and a Birth Control pill at 8 P.M. and Seroquel 300 mg and Tegretol 600 mg at 9:00 P.M. Review of R1's MAR with E8 (Licensed Practical Nurse) on 04/30/02 at 10:05 A.M., E8 confirmed that R1's Seroquel and Tegretol should not have been given by E2 at 7:30 P.M. on 04/21/02.
Interview with E6 (Activity Director) on 04/24/02 at 5 P.M. confirmed that R1 had informed her that staff had held her nose and mouth to get her to take her medication on 04/21/02. E6 stated that "R1 was upset about the medication deal." E6 stated "I felt it was abuse." E6 stated that she did not write the details down, but had reported the incident to her immediate supervisors (E1 Assistant Administrator and E7 Administrator) the evening of 04/21/02.
Per interview with E1 (Assistant Administrator) on 04/24/02 at 5:15 P.M., E1 stated that she was informed by E-6 on 04/21/02 that staff had forced R1 to take her medication. E1 stated that she did not recall being informed if R1's nose was held. E1 stated that when she arrived the next day, she had E2 fill out an Incident Report, Physician's Telephone Orders and a Restriction of Rights Notice. E1 stated that R1 had the right to refuse her medication, and that staff should not have restrained her to get her to take her medication. E1 confirmed during this interview that no investigation had been completed by the facility.
Interview with E7 (Administrator) on 04/26/02 at 2:07 P.M. confirmed that he had been informed by E6 on 04/21/02 that staff had restrained and held R1's nose to get her to take her medication. E7 confirmed during this interview that no action had been taken by the facility to investigate possible staff abuse against R1 that had occurred on 04/21/02.
2) Record review identified that R2 was restrained twice at 9A.M. and 5P.M. on 03/16/02 by facility staff to allow nursing staff to administer her medication.
Review of R2's Nurse's Notes dated 03/16/02 identified that E9 (Licensed Practical Nurse) documented: "1010 received telephone call resident was non compliant with taking am medications. Resident rept'd (reported) to have thrown chair and items off dresser. Tore down curtains. When approached in am by staff. Parents (mother) notified resident was noncompliant and may need to seek additional prn (as needed) mediation. Resident was sitting calmly in dining room chair, informed resident she must take medication as prescribed by physician. Crushed medications in 0.5 cc (cubic centimeters) H20 (water) and with staff assistance, resident swallowed 70% crushed medications. Administrator and DON (Director of Nursing) notified. Administrator present during entire episode. Resident resting quietly in room at this time."
Interview with E7 (Administrator on 04/26/02 at 2:07 P.M., E7 confirmed that he was present on 03/16/02 when E9 gave R2 her medication. During this interview, E7 stated: "I was notified about R2's behavior and that she had not taken her meds. Her parents said she had to be forced to take her meds." When E7 was asked by the surveyor to define "forced", E7 stated to "put in a glass, crush up the medication and put the medication into water." E7 stated that E9, E10 and E11werepresent with him on 03/16/02. E7 stated that R2 was held briefly so that E9 could administer her medication.
Interview with E10 on 04/26/02 at 3:53 P.M. and on 04/30/02 at 2 P.M. confirmed that she was present on 03/16/02 when R2 was restrained to take her medication. During this interview, E10 stated: "I came in about 9 A.M. There was a lot of commotion. E7 was here and everyone was trying to get R2 to take her medications. R2 refused and kept pushing the medication away. I figured they needed to get medication in her because of her disruptive behavior. R2 was laying on the bed when she was restrained. E3, E4, E7, E9 and I think E11 were in R2's bedroom at the time. I'm not sure who instructed me to hold her legs. They kept saying "hold her legs". R2 was kicking and everyone was holding her. E9 gave the medication in a spoon and she kept spooning it into her mouth."
Interview with E11 on 04/26/02 at 10:33 A.M. confirmed that she was present on 03/16/02 when R2 was restrained to take her medication. E11 stated that "I had her head cradled, E7 was at her side by her arms and E10 was at her feet. E9 administered R2's medication and one of the staff present held her nose off and on." E11 could not recall who had held R2's nose, but stated "I was uncomfortable with the whole situation."
Per telephone interview with E9 on 05/02/02 at 3:50 P.M., E9 confirmed that she had been called on 03/16/02 due to R2's refusal to take her medication. E9 confirmed that staff had restrained R2 so that she could administer her medications. During this interview, E9 stated: "R2 had refused her medication almost every day for the week. I felt it was a judgement call. R2 needed her medication. R2 had behaviors during the week and had become aggressive. R2 became aggressive when we attempted to give her medication. E4, E7, E10, E11, and I think E12 assisted in holding R2. I think E10 held her nose, but I'm not really sure." During this interview, E9 confirmed that no Physician Order had been received by the facility to restrain R2 to take her medication.
Review of R2's Nurse's Notes dated 03/16/02 identified that E2 documented: "1700 ... Resident (visitor) refused to take (medication) by spoon x 2. This writer tried using syringe to administer meds with help of staff. While trying to administer meds, resident kicked this writer. Resident (visitor) redirected per staff. Continued to administer resident spitting out..."
Interview with E12 on 04/26/02 at 3:40 P.M. confirmed that R2 had been restrained by staff on 03/16/02 to take her medication. During this interview E12 stated: "I recall the incident when R2 was restrained. The nurse (E2) called me, E4, and E3 to help her give R2 her meds. We held her arms and head. R2 still wouldn't take her meds so we sat her up at a sixty degree angle. We got on each side of her and held her upper and lower arms. R2 spit her medication in our face and smiled afterward. I think E2 was using a syringe that day to get R2 to take her medication."
Telephone interview with E3 on 04/30/02 at 2:20 P.M. confirmed that she had been present on 03/16/02 and had assisted in restraining R2 while E2 gave her medication.
Per interview with E1 on 04/26/02 at 10:56 A.M., E1 confirmed that staff should not be restraining clients to assist in administering their medications. E1 also confirmed that staff should not be holding the client's nose and or covering their mouths during the restraint. E1 confirmed during this interview that restraining a client for refusing to take their medication without a physician order was a form of abuse. E1 also confirmed that no investigation had been completed by the facility. E1 did not start an investigation until questioned by the surveyor on 04/24/02.
During interviews with direct care staff E4 on 04/24/02 and E5, E10 and E12 on 04/26/02, staff confirmed that they had not been provided with needed training in working with clients with dual diagnosis.
Per interview with E1 on 04/26/02 at 10:56 A.M., E1 stated "We just admitted another client yesterday from a psychiatric unit. Staff have not been trained to work with clients with dual diagnosis." During this interview, E1 confirmed that no preadmission reviews have been done by the Interdisciplinary Team to determine if the newly admitted client's needs can be met by staff prior to the client's admission.
Review of the facility's policies and procedures on Client Protections identified that each resident or guardian shall be informed of the right to refuse treatment, including but not limited to medication. Additionally, the policy identified that physical restraints would not be used for staff convenience, nor without the written order of a physician.
Review of the facility's policies and procedures on medication administration identified that all medications would be given as physician ordered. No procedures were identified as to what staff are to do if a client refuses their medication(s).