PEDIATRIC REHAB INSTITUTE
Facility I.D. Number0042788
7464 N. Sheridan Road
Chicago, IL 60626
Date of Survey 07/12/01
Annual Licensure; Special Survey; 2ND Follow-up to Survey of 09-19-00; 2ND Follow-up to Complaint 0084437; Follow-up to Complaint 0182053; Complaints 0182199, 0182233, 0182303, 0182414, 0182590; IRI OF 06-11-00
"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.
All personnel shall have either training or experience, or both, in the job assigned to them.
AN OWNER, LICENSEE, ADMINISTRATOR, EMPLOYEE OR AGENT OF A FACILITY SHALL NOT ABUSE OR NEGLECT A RESIDENT. (Sections 2-107 of the Act)
A FACILITY EMPLOYEE OR AGENT WHO BECOMES AWARE OF ABUSE OR NEGLECT OF A RESIDENT SHALL IMMEDIATELY REPORT THE MATTER TO THE FACILITY ADMINISTRATOR. (SECTION 3-610 OF THE ACT)
A FACILITY ADMINISTRATOR WHO BECOMES AWARE OF ABUSE OF A RESIDENT SHALL IMMEDIATELY REPORT THE MATTER BY TELEPHONE AND IN WRITING TO THE RESIDENTS' REPRESENTATIVE. (Section 3-610 of the Act)
A FACILITY ADMINISTRATOR, EMPLOYEE, OR AGENT WHO BECOMES AWARE OF ABUSE OR NEGLECT OF A RESIDENT SHALL ALSO REPORT THE MATTER TO THE DEPARTMENT. (Section 3-610 of the Act)
EMPLOYEE AS PERPETRATOR OF ABUSE - WHEN AN INVESTIGATION OF A REPORT OF SUSPECTED ABUSE OF A RESIDENT INDICATES, BASED UPON CREDIBLE EVIDENCE, THAT AN EMPLOYEE OF A LONG-TERM CARE FACILITY IS THE PERPETRATOR OF THE ABUSE, THAT EMPLOYEE SHALL IMMEDIATELY BE BARRED FROM ANY FURTHER CONTACT WITH RESIDENTS OF THE FACILITY, PENDING THE OUTCOME OF ANY FURTHER INVESTIGATION, PROSECUTION OR DISCIPLINARY ACTION AGAINST THE EMPLOYEE. (SECTION 3-611 OF THE ACT)
These Regulations are not met.
Based on observation, interview and record review, the facility failed to ensure R28 was protected from abuse/neglect displayed by E9 and E17 which was observed on a television video broadcast aired on 5/15/01. E9 and E17 were observed lifting R28 in a manner that disregarded his special needs and not giving proper physical support.
Findings include:
1) Review of R28's chart general information sheet indicates the following diagnoses for R28: a 10 year old male, Cerebral Palsy, Spastic Quadriparesis, Seizure Disorder, Developmental Delay, and Profound Mental Retardation.
6/21/01 Record review of R28's Medical Care Plan indicates R28 is a 2-man lift.
6/21/01 Record review of facility policy indicates individuals more than 45 lbs. are to be a 2-man lift.
6/26/01 Review of physician order sheet for 6/01 indicates R28's weight is 50.5 lbs.
R28 was observed in 1st floor North Day room on television video being lifted by E9 in a manner that disregarded R28's special needs. E9 did a one man lift and was holding R28 by his one arm and one leg and was not giving him proper support.
Interviews of E9 on 6/21/01 at 2:15PM in the Admission Office-->E9 indicates it was he in the video, and he cannot really explain why he did what he did. He indicates it was probably from playing with R28, and that he has swung a couple of other individuals. He picks them up a lot and it was spontaneous movement. He did not know how much R28 weighed. He did not know from viewing the video where he was moving R28 from or to. He states it was an inappropriate transfer and that there was potential for harm even though his intentions were good, and if something had happened then he would have been responsible.
Per facility's interviews of Z3, E33, and E34, E9 has on other occasions displayed lifting individuals inappropriately like an airplane and carrying them on his shoulders.
Per facility's interviews of Z17, Z18, Z3, Z29, E32, and E34, R28 was lifted by E9 by his one arm and one leg on the television video.
Telephone interview on 6/25/01 of Z26 at 2:49PM, indicates when Z26 saw R28 being picked up by his arm and leg on the broadcast that it was definitely an improper way to handle R28, and that was the first time he had seen R28 handled that way.
Based on observation, interview, and record verification, the facility failed to thoroughly investigate three allegations of inappropriate lifts/transfers of R28 and R6.
Findings include:
1) On 5/14, 5/15 and 5/16/01, a local TV news station aired an undercover segment regarding the facility. On 5/15/01, the TV news station aired a segment showing two employees conducting inappropriate lifts/transfers of R28 on two separate occasions.
R28, per the Diagnosis Listing provided by the facility, is a 10-year-old male diagnosed with Profound MR, Cerebral Palsy, Seizure Disorder and Spastic Quadriparesis.
Per observations 6/12/01 at 2:52PM, R28 is non-ambulatory, non-mobile and non-verbal.
On 6/7/01 at 1, E2 (former Assistant Administrator) was interviewed in the 1st floor conference room. E2 verified R28 was the client shown on the local TV news segment 5/15/01 that was inappropriately lifted/transferred on two different occasions by two employees. E1 (Administrator) and E2 were interviewed 6/7/01 at 1:05PM in the 1st floor conference room. E1 and E2 were asked if the facility investigated the local TV news segment that documented two employees inappropriately lifting/transferring R28. E1 verified the facility did not investigate the TV news segment involving R28.
On 6/21/01, E1 provided surveyors copies of statements of 10 CNAs and two nurses interviewed regarding the local TV news segment that aired 5/15/01. These statements were obtained approximately five weeks after the airing of the inappropriate lift/transfer of R28.
2) R6, per the Diagnosis Listing provided by the facility is a 29-year-old male diagnosed with Profound MR, Cerebral Palsy, Seizure Disorder and Lung Abscess. R6 was observed 6/13/01; he is non-ambulatory, non-mobile and non-verbal.
Per review of the facility’s Investigation of Incident, E7 (QMRP/RSD) and E27 (Receptionist) provided statements (no dates) that on 5/27/01 at 1:40PM, R6 was lifted/transferred “upside down.” E7 and E27's statements document they saw 3 CNAs (Z12, Z13 and Z14) lifting and transferring R6.
Per the statements, R6 was observed “upside down”, “ ... his upper back and head were on the chair, resting on the seat and lower back rest.” “These staff members had this client’s legs raised in the air w/pants down.” “... the client was lifted so high that his knees were higher than his head and his feet were sticking high in the air...” Per the Incident Report, Z12, Z13 and Z14 were interviewed and indicated R6 was being transferred from his wheel chair to his bed. E3 (DON) investigated this incident and noted no evidence of abuse or neglect.
E3 was interviewed 6/19/01 at 2:50PM in the Administrator’s Office regarding the above-noted incident with R6. E3 was asked if E7 and E27 were interviewed about the incident involving R6. (E7 and E27 witnessed the 5/27/01 incident). E3 indicates E7 and E27's (witnesses) statements were taken. E3 was asked if the observed lift/transfer of R6 (5/27/01 at 1:40PM) by E7 and E27 was an appropriate transfer. E3 was asked if it was appropriate to lift/transfer R6 “upside down.”
Based on observation, interview and record verification the facility failed to prevent further potential abuse while the investigation was still in progress for 2 allegations of inappropriate lifts/transfers involving R28 and R6.
Findings include:
1) On 5/14, 5/15 and 5/16/01 a local TV news station aired an undercover segment regarding the facility.
On 5/15/01 the TV news station aired a segment showing an employee conducting an inappropriate lift / transfer of R28.
R28, per the Diagnosis Listing provided by the facility, is a 10 year old male diagnosed with Profound MR, Cerebral Palsy, Seizure Disorder and Spastic Quadriparesis. Per observation 6/12/01 at 2:52PM R28 is non-ambulatory, non-mobile and non-verbal.
On 6/7/01 at 1PM E2 (former Assistant Administrator) was interviewed in the 1st floor conference room. E2 verified R28 was the client, shown on the local TV news segment 5/15/01 that was inappropriately lifted/transferred by 2 employees on 2 different occasions. E1 (Administrator) was interviewed 6/7/01 at 2:30PM in the 1st floor conference room. E1 stated E17 was 1 of the 2 employees who was shown on the TV news video-tape. E1 stated E17 was employed by the facility 3/8/01 until 5/1/01. E17 was not employed by the facility when the TV news segment was aired 5/15/01. E1 stated, (6/7/01 at 2:30PM) the facility could not identify the 2nd employee who was in the videotape inappropriately lifting / transferring R28. E1 also stated the facility did not investigate the TV news videotape of the inappropriate lift/transfer.
On 6/19/01 the facility corresponded with a representative of Illinois Department of Public Health and identified E9 (nurse) as the 2nd employee in the TV news segment inappropriately lifting/transferring R28.
On 6/21/01 at approximately 2:15PM E9 was interviewed in the Admissions Office. E9 verified he was the employee on the local TV news videotape that lifted/transferred R28. On 6/21/01 at approximately 6PM E9 was observed working (nursing duties).
2) R6, per the Diagnosis Listing provided by the facility, is a 29 year old male diagnosed with Profound MR, Cerebral Palsy, Seizure Disorder and Lung Abscess. R6 was observed 6/13/01, he is non-ambulatory, non-mobile and non-verbal.
Per review of the facility's Investigation of Incidents, E7 (QMRP / RSD) and E27(receptionist) provided statements (undated) that on 5/27/01 at 1:40PM, R6 was lifted/transferred "upside down."
E7 and E27's statements document they saw 3 CNA's (Z12, Z13 and Z14) lifting and transferring R6.
E7 and E27's statements document, R6 was observed "upside down", "... his upper back and head were on the chair, resting on the seat and lower back rest." "These staff members had this client's legs raised up in the air w/pants down." "... the client was lifted so high that his head and his feet were sticking high in the air..."
E3 was asked if it was appropriate to lift/transfer R6 "upside down."
E1 (Administrator) stated, 6/19/01 at approximately 2:55PM, the 3 CNA's (Z12, Z13 and Z14) were in-serviced regarding appropriate lifts and transfers. E1 stated the in-services were held May and June 2001.
However, per review of In-Service records provided to surveyors there was no evidence of Z12, Z13 and Z14 being in-serviced. E1 was interviewed 6/21/01 at 5:30PM in the Admissions Office. E1 stated 1 or 2 of the CNA's (Z12, Z13 or Z14) have not been back to the facility. E3 was interviewed 6/21/01 at 1:50PM in the small conference room. E3 was asked for Z12's, Z13's and Z14's schedule of days worked since the above noted (5/27/01) incident. E3 did not provide this information to surveyors as of 6/25/01. E1 also stated she was not sure if the 3 CNA's were at the facility when the in-services (on lifting and transferring) occurred.
Based on observations and interviews the facility failed to take appropriate corrective action on E9, who was shown on a news clip aired on May 15, 2001, as improperly lifting R28.
Findings include:
1) R28, per the Diagnosis Listing Sheet provided by the facility, is a 10 year old male whose diagnoses includes Cerebral Palsy and Spastic Quadriparesis.
E9 was shown by an undercover investigation that aired on TV May 15, 2001. E9 was shown to improperly lift R28.
Review of R28's medical care plan revealed that R28 needs two staff to lift him.
The facility was able to identify E9, on June 19 2001 as the staff shown on TV on May 15, 2001. As of June 25,2001 the facility had not taken corrective action towards E9.
Based on observation, interview and record verification the facility failed to have available qualified professional staff to carry out and monitor various professional interventions including appropriate lifting of R28.
Findings include:
1) On 5/14/01, 5/15/01 and 5/16/01 an undercover segment was aired on a TV news station regarding the facility. Two employees were shown conducting an inappropriate lift of R28. Per the Diagnosis Listing provided by the facility, R28 is a 10 year old male diagnosed with Profound Mental Retardation, Cerebral Palsy, Seizure Disorder and Spastic Quadriparesis.
Interview with E9, Registered Nurse (R.N.) on 6/21/01 at 2:02 p.m. in the admissions office revealed he was responsible for an inappropriate lift of R28. He could not really explain why he did what he did. He stated he had done the lifting in "play" swinging R28 by one arm and one leg. Review of R28's medical care plan reveals R28 is a 2 man lift.