VILLAS OF SHANNON
Facility I.D. Number 0043851
Date of Survey: 02/11/02
Incident Report Investigation of 02/02/02
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 residents'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.
All necessary precautions shall be taken to assure that the residents' environment remains as free of accident hazards as possible. All nursing personnel shall evaluate residents to see that each resident receives adequate supervision.
These requirements are not met as evidenced by:
Based on observations, record review and interviews, the facility failed to:
a) Immediately implement interventions concerning a note written by a resident about hurting herself;
b) Monitor a resident with 1:1 (one to one) after an attempt to harm herself,
c) Remove all safety razors and a hammer on a unit to ensure the safety of a resident.
This resulted in 1 resident self inflicting wounds to her left arm and wrist. This applies to 1 of 5 residents in the sample. (R2).
The findings include:
Review of R2's hospital record dated 1/17/2002 revealed the following diagnoses of "Schizo Affect, Relapse, Recurrent, Severe." R2 was transferred to this facility on 1/19/2002.
Review of R2's nurses' note entry of 1/26/2002 10:30 p.m. revealed, "(R2) handed a letter to the CNA (E11). Apparently, the letter (R2) wrote sounds like she is going to hurt herself and she felt low and depressed. Visually monitored every 15 minutes."
Review of the letter written by R2 revealed, "I feel like to hurt myself. I would like to burn my hand and heel. My mind is mixed up. I feel sad, because I'm far away from home, I need help, I'm hearing voices telling me to run away. Help me"! This note was dated 1/27/2002.
On 2/07/02 in the facility conference room, in the afternoon E1 was requested to provide evidence of the 15 minute monitoring log on 1/26/02 for R2. Review of the facility bed check tracking log fails to show monitoring of R2 on 1/26/02, 1/27/02 or 1/28/02. This information was verified with E1. The nurses' notes for these same days fail to show checks were done or who did them.
On 02/07/2002 at 11:30 a.m. in R2's room, R2 was asked what she recalled had happened on 2/2/2002. R2 stated, "Somebody left a razor in the bathroom. I got sad and foggy minded. Someone left the razor in the bathroom; so I took the razor and hurt myself. I slashed my wrist. I hear voices, like in the next room or on TV. Suddenly, I hear them inside of me. Everybody is busy here and nobody listens. On Saturday (2/2/2002), it happened. I was blue. I went to the bathroom. It's hearing voices to slash my wrist. They say, 'You are a trouble maker', then I would make a slash. 'You are not a good mom', then I would make another slash. 'You are not a good person', then I made another slash. I feel like I'm in prison here. It was easy to get a razor. If someone is blue, you can use it to hurt others or yourself. These are not too deep. I could go deeper if someone makes me angry."
At this time R2 was requested to show the condition of her arm. An observation was made of R2's left lower arm and wrist. There were several slashes noted.
Review of the nurses' notes entry dated, 2/2/02 revealed that R2 was supposed to be on 1:1 with staff from 8 a.m. to 4 p.m. (Transportation with ambulance service was unavailable until 4 p.m.).
On 2/7/2002 at 1:20 p.m. in the rehab room, E11 was asked about the 2/2/02 incident when R2 slashed her wrist. E11 stated, "I woke (R2) about 7 a.m. (R2) got up. At about 7:45 a.m., (R2) was leaning in the doorway. She said she felt anxious and sad. (R2) raised her sleeve and I saw the scratches. R2 said I'm hearing voices and they want me to hurt myself. (R2) took me into the shower room (#7). In the hamper area where the towels are, there was a dirty (used) razor (that R2 used). I watched R2 (checked her every ½ hour) until her ride came from the hospital about 4 p.m. I sat at the desk at the end of the hall. I could see
if (R2) left her room. Yes, I did go into the TV room to light cigarettes for other residents. I did leave the desk to go to the bathroom. I asked (E7) to watch (R2) while I went. I ate lunch at about 12:30 p.m. I got my tray (from the facility kitchen). I was gone about 4-5 minutes. No, this was an exception when I had no one relieve me (to monitor R2)."
E11 and this surveyor walked into the TV room and E11 demonstrated the areas that she would have been assisting other residents with their cigarettes. E11 admitted that she did not have full visibility of R2's room at all times during the period of time on 2/2/02 from approximately 8 a.m. to 4 p.m., when she was assigned to do 1:1 with R2. E11 stated, "We probably could have used an extra person. No, we probably did not have enough staff, but I did the best I can." R2 wrote me this note about how she was feeling. No, I don't remember when she wrote me this note. On 2/7/02 at 2 p.m. in the main dining room, E7 was asked if E11 asked her to monitor R2 while E11 went to the bathroom. E7 stated, "No one ever asked me to monitor for (R2's) whereabouts while they went to the bathroom or took lunch."
E1 could not provide evidence that 1:1 was provided to R2 from 8 a.m. to 4 p.m. on 2/2/02.
On 2/7/2002 during tour of the facility with E1, 5 razor blades were found in the bathroom adjoining rooms N2 and N4. When asked what she thought about finding these razors, E1 stated, "I think we have a problem." R2's room is located 3 doors/room up from N5.
At 10:30 a.m., a hammer was found on the second shelf of a bookcase next to the bed in R17's room.
At 10:35 a.m. in the north hall, E1 stated, "I believe men who have razors are supposed to be supervised. Staff are supposed to collect the razors after the incident with (R2)." Tools are supposed to be locked up.
On 2/7/02 in R5's room at 11 a.m., R5 was asked what type of razor he used to shave. R5 stated, "I can't use electric, it burns. I hide a razor in my drawer." R5 showed the razor to this surveyor which he stored in the top unlocked drawer of his dresser in his unlocked room.
On 2/7/02 in R10's room at 11:25 a.m., R10 was asked if she ever uses a razor. R10 stated, "I shave my armpits and beard. I have a razor in my drawer. (E16) told me to turn the razor in 2 days ago, but I haven't shaved yet." A razor was observed in R10's top dresser drawer. The room and dresser were both unlocked.