Dewitt County Nursing Home Facility I.D. Number: 0002238 Date of Survey: 07/11/2003 Annual Licensure and Complaint Survey "A" VIOLATION(S): The licensee and administrator shall be responsible for seeing that the applicable regulations are met in the facility and that employees are familiar with those regulations according to the level of their responsibilities. A descriptive summary of each incident or accident shall be recorded in the progress notes or the nurses notes for each resident involved. The facility shall maintain a file of all written reports of serious incidents or accidents involving residents. The facility shall notify the resident’s physician of any accident, injury or significant change in a resident’s condition that threatens the health, safety or welfare of a resident. The facility shall obtain and record the physician’s plan of care for the care or treatment of such accident, injury or change in condition at the time of notification. At the time of an accident or injury, immediate treatment shall be provided by personnel trained in the first aid procedures. 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. General nursing care shall be practiced on a 24-hour, seven-day-a-week basis. This includes, but is not limited to: Facility staff will make objective observation of changes in a resident’s condition and utilize them as a means for analyzing and determining care required and / or the need for further medical evaluation and treatment. These observations and descriptions of actions taken will be 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 and assistance to prevent accidents. The DON shall supervise and oversee the nursing services of the facility including, but not limited to: Developing and maintaining nursing service objectives, standards of nursing practice, written policies and procedures, and written job descriptions for each level of nursing personnel. No resident shall be deprived of any rights, benefits, or privileges guaranteed by law-based on their status as a resident of a facility. An owner, licensee, administrator, employee or agent of a facility shall not abuse or neglect a resident. A facility employee or agent who becomes aware of abuse or neglect of a resident shall immediately report the matter to the facility administrator. A facility administrator who becomes aware of abuse or neglect of a resident shall immediately report the matter by telephone and in writing to the resident=s representative. A facility administrator, employee, or agent who becomes aware of abuse or neglect of a resident shall also report the matter to the department. 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. The facility shall establish written policies and procedures to implement the responsibilities and rights provided in Article II of the Act. The policies shall include the procedure for the investigation and resolution of resident complaints under the act. The facility shall ensure that its staff is familiar with and observes the rights and responsibilities enumerated in the act and this part. These regulations are not met as evidenced by: Interviews and record reviews revealed that the facility administration failed to ensure an environment conducive to facility staff and residents reporting allegations of abuse without fear of retribution. Facility direct care staff failed to immediately report and facility administrative staff failed to thoroughly investigate 7 of 7 allegations of neglect (R18), verbal/mental/physical abuse (R15, R20, R21 and R# not disclosed), and involuntary seclusion (R1, R19). The failure of facility direct care staff to immediately report the allegations, and the failure of administration to act on information about an alleged perpetrator, resulted in the alleged perpetrator in these incidents to continue to provide direct care to the residents. Facility administration impeded the Departments’ investigation of these abuse and neglect allegations by repeatedly providing false statements during the survey. Evidence includes: 1) Allegations of verbal abuse toward R20, R21 and an unidentified resident by E18 and an allegation of physical abuse by an unknown assailant toward R15: Direct care staff failed to immediately report witnessed allegations of verbal/mental abuse by E18 involving R20 and R21. E18 was reported to threaten withholding of medications to R20 and R21 if they did not alter their behaviors. Because the staff failed to immediately report the allegations of verbal/mental abuse, E18 was allowed to continue to work providing direct resident care. Once the facility was aware of the allegations, an investigation was done. Facility administration failed to immediately act on the information from their investigation and allowed E18 to return to work. Specifics to these allegations are: a) E4 stated in an interview on 06/18/03 at 11:15 a.m. that she witnessed E18 yell from the hallway at R20. E18 told R20 that if she (R20) got up again, she (E18) would not give her medicine to her. E4 did not know on what specific date the incident occurred, but thought it was prior to 05/21/03. E4 confirmed that she did not report the incident to anyone until E2 called her (E4) on 05/23/03 about another incident. E4 stated that at that time she wrote a statement indicating that E18 had threatened R20 and gave it to E2. The statement written by E4, dated 05/23/03, confirms the following: "[E18] threatened [R20] that if she got up out of her chair she wouldn't give her her medicine.” E2 confirmed in an interview on 06/20/03 at 9:30 a.m. that she received this statement on 05/24/03. E19 stated in an interview on 06/20/03 at 10:05 a.m. that he overheard E18 tell R20 that if she didn't quit getting on the call light, she (E18) wasn't going to give her (R20) her medicine. E19 stated that sometimes R20 got agitated when E18 told her that, but other times she would continue to try to get up or turn her call light on. E19 that E18 appeared to get agitated because she had to interrupt the first floor medicine pass to come to the second floor and give medications to R20. E19 stated that E18 used a very stern voice but did not yell. E19 stated that he did not report the incident to anyone until he was called on 05/23/03 by E2 about another incident. b)E13, confirmed in an interview on 6/18/03 at 11:50 a.m. and 6/20/03 at 8:30 a.m. that she witnessed E18, "hollering" at R21, that she (E18) was not giving her anything for her (R21) cough, that she was tired of her (R21) asking for cough medicine and that she (R21) didn't have anything ordered, that she (E18) was tired of her (R21) yelling and she would have to wait until morning. E13 confirmed that E18 was in the room with R21 and was talking loud enough to be overheard in the hallway by herself and other aides in the hall. E13 stated that R21 seemed to be upset and that E18 came down later and apologized to R21. E13 stated that she did not report the incident (05/22/03) to anyone. A written statement dated 05/23/03 and signed by E13 confirms the following: R21 was coughing on 05/22/03 and constantly on the call light. R18 when told, first stated she wasn't coming down. Later E18 came down and told R21 that "she has had enough.” When R21 yelled out again, E18 stated, "[R21] Knock it off.” c) During the survey, in a confidential resident interview, one resident confirmed that two nurses are not nice to [R] and E18 is one of them. The resident stated that E18 threatened to not give medications to him/her and made him/her wait 45 minutes before giving the medications. The resident did not want to be identified and stated, "I'm afraid she'll [E18] find out and turn on me." d) E2 stated in an interview on 06/20/03, at 9:30 a.m. that she was not aware of the allegation of verbal abuse involving R20 and R21 until 05/23/03 when she talked to E4, E13 and E19. E2 confirmed that the allegation of verbal abuse occurred in the evening on 05/22/03 and that E18 worked the entire twelve-hour shift. This is reflected on the May 2003 schedule. e) An allegation of physical abuse was made by R15 and reported by staff to a nurse, but the nurse failed to report the allegation to anyone. The allegation made by R15 that he had been hit by someone was never investigated. Review of the nurses notes confirm an allegation of rough treatment made by R15 was documented. However, no investigation was conducted. 2) Seclusion Incidents: Staff failed to immediately report two allegations of involuntary seclusion of R1 and R19. The nurse blocked R19 in a small sitting room with a recliner chair for a couple of hours, with R19 calling for help to get out of the room. The same nurse then blocked another resident (R1) in the small sitting room with a recliner chair, with R1 yelling and screaming to get out of the room. Specifics to these allegations are: E4 stated in an interview on 06/26/03, at 4:03 p.m. that R19 was very "wound up" and kept coming into the nurse’s station, getting on E18's nerves. E4 stated that E18 said that she would fix her (R19), so she couldn't get in the nurse’s station. E4 then saw E18 put R19 in the sitting room and block the opening of the room with a recliner chair. E4 confirmed that R19 was in the sitting room, blocked in with the recliner chair for a couple of hours. E4 stated that R19 sat in the [adult enclosed rolling ambulator] and talked and said things like, "Honey, come here and help me.” E4 could not remember the date when the incident occurred and confirmed that she did not report the involuntary seclusion to anyone. E4's written statement that is dated as received by E2, DON on 05/24/03 state, "She [E18] blocked [R19] in the lounge room so she couldn't get out.” The June 2003 physician order sheet confirms that R19 has a diagnosis of Dementia with agitation. The M.D.S.(Minimum Data Set) dated 02/27/03 and 05/30/03 confirm that R19 has long and short term memory problems with impaired decision making ability. R19 has many behaviors including: repetitive verbalizations; unrealistic fears; crying; wandering; verbal and physical abusive behaviors. a) E7's written statement, dated 05/26/03, confirms the following information: "On another occasion, date not known, she [E18] had put a resident [R1] into a little room off of the nurses station and blocked the doorway with the recliner-I tried to take her [R1] out because she was yelling and screaming-Nurse [E18] had told me to put her [R1] back into the room and let her work herself down until she became tired. I did until she left the floor then I took her [R1] out, let her use the bathroom and gave her something to eat and drink." E7 confirmed in an interview, on 06/26/03 at 3:50 p.m., the accuracy of the written statement dated 05/26/03. E7 stated that she couldn't remember the exact date of the incident but thought it might have been a couple of weeks prior to 05/26/03. E7 confirmed that she did not report the incident to anyone at the time it occurred. T The June 2003 physician order sheet confirms that R1 has a diagnosis of Dementia with agitation and Anxiety. The M.D.S. dated 04/21/03, confirmed that R1 has a short-term memory problem and impaired decision making ability. R1 has behaviors including; wandering; inappropriate social behavior and repetitive physical movement. 3) R18’s fall: Staff failed to immediately report an allegation of neglect involving E18 not providing an accurate and ongoing assessment, not providing pain medication and failing to obtain prompt medical treatment for R18 following a fall. R18 fractured her hip in the fall. The facility failed to do a thorough investigation of the fall and care of R18 by E18, resulting in E18 being allowed to continue to work and provide direct resident care. Specifics to this allegation are: a) The April 2003 physician order sheet reveals that R18 has diagnoses of Congestive Heart Failure, Angina, Hip Fracture and Organic Brain Syndrome. The Minimum Data Set dated 03/04/03 confirms that R18 has short and long-term memory problems. b) An interview with E4, on 7/1/03 at 8:40 a.m., confirms that she and E18 were at the nurses station when they heard a "thump.” The "thump" was R18 falling out of the bed. E4 was present when E18 examined R18. E4 stated that she (R18) was moaning and E4 thought she (R18) was in pain. At that time, E4 stated that she thought there was something wrong with R18. E4 stated, "[E18] said she's [R18] just making a big deal, that she was faking it." E4 confirmed that after the fall, R18 was lying in bed moaning and crying out with pain whenever she moved. At 5:30 a.m., E19 tried to get R18 up as instructed by E18 and R18 screamed with pain. E18 then called the doctor and sent R18 to the hospital. The X-ray report dated 04/10/03 confirms an acute, comminuted, intertrochanteric fracture of the right femur. c) The written statements dated 05/24/03 and 05/23/03, by E4 and E19 confirm that R18 was allowed to lie in pain, moaning and crying until 5:00 a.m. when E19 tried to get her up, as instructed by E18. When E19 tried to get R18 up, she screamed in pain. R18's nurse notes dated 04/10/03 at 2:05 a.m. contain the following information: E18 and E4 heard what sounded like a resident falling. R18 was found lying on her back at the foot of bed. PROM's and ROM's are documented as negative for injury, along with good flexion and internal and external leg rotation. The next entry on the nurse’s notes is at 5:30 a.m. when the physician is notified of the fall. R18 was then transferred to the hospital at 5:45 a.m. on 04/10/03. There was no further assessment documented in the nurses notes. The April 2003 Medication Administration Record has no documentation that any pain medication was given to R18 following the fall. The nurse notes for 04/10/03 have no documentation of any medication being given for pain. Undated documentation titled "Investigation" of R18 incident of 04/10/03 but not dated confirms that E18 denied giving R18 anything for pain. When asked what happened, E18 stated "[R18] was found at the end of the bed and assessment done with no findings.” Z2 confirmed in an interview on 07/01/03, at 9:05 a.m., that R18 expired on 04/13/03 with the cause of death listed as Congestive Heart Failure and Arteriosclerotic Heart Disease. Z2 confirmed that initially the hip may not have been internally or externally rotated. When asked if staff would have been able to do range of motion to the hip, Z2 stated, "No, it would have been too painful.” 4) Investigation of Incidents/Allegations: Facility administrative staff did not immediately and appropriately act on the reported allegations of abuse and neglect by E18. Direct care staff related to surveyors that they were in fear for their jobs and this is the reason they failed to immediately report these allegations to the administrative staff. Specifics to these allegations are: i) Interviews: i) E1, E2 and E3 all gave false statements to the surveyor when asked about their specific knowledge relating to issues of abuse, by denying any knowledge of any abuse other than the gait belt incident involving R1. E1 stated in an interview on 06/18/03 at 9:10 a.m. that they had no allegations of verbal abuse. E1 denied knowledge of any type of abuse; to deny being aware of an investigation conducted by E2, and denied receiving the report e-mailed to her (E1) on 06/04/03 by E2. E1 stated in an interview on 06/20/03 at 9:50 a.m. that she knew that E2 had e-mailed her “stuff,” but she never received any e-mail from E2. E1 confirmed that she was not aware of any allegations of verbal abuse involving R20 until 06/18/03 and did not see E1's “stuff” until this AM (6/20). E1 confirmed in an interview on 06/24/03 at 4:05 p.m. that after receiving further information of a confidential resident interview confirming the allegation of verbal abuse from the surveyor on 06/19/03 at 2:10 p.m., no further investigation of the allegations was done as E2 had already investigated the allegations. E1 confirmed in an interview on 06/25/03 at 10:10 a.m. that she had never seen the document titled "Abuse Investigation Follow-Up Report" before 06/25/03 and requested a copy of the report. ii) E2 and E3, stated in an interview on 06/18/03 at 8:55 a.m. that they were not aware of any allegations of abuse. The only investigation either one was aware of, involved R1 and an incident with a gait belt being applied improperly. E2 stated in an interview on 06/20/03 at 9:30 a.m. that she started the investigation of another incident and when interviewing staff became aware of problems with E18. E2 confirmed that she began the investigation on 05/23/03. E2 stated due to illness she finished her investigation at home and e-mailed her recommendations on 06/04/03 to the Administrator. E2 stated that her recommendation was that E18's employment be terminated. E2 confirmed that she found out on 06/20/03 that E1 did not receive the allegations. E2 stated that she did not know that E1 had not received her report, so she assumed she E1 was talking about all the allegations. E2 stated that she believed what the CNA's were telling her as she had no reason not to believe them. E2 confirmed in an interview on 06/24/03 at 4:30 p.m. that when she returned to work, E1 told her the finding was not founded. On 06/20/03, at 11:05 a.m., E2 confirmed that E18 was suspended from work on 05/23/03. On 06/21/03 when E18, was allowed to return to work and the facility failed to thoroughly investigate these allegations of abuse. The facility was made aware of this information (from the confidential resident interview) but allowed E18 to continue work and provide direct care to the residents. The facility failed to thoroughly investigate the additional allegations of verbal/mental abuse by not further interviewing staff, residents, resident's families and visitors. iii)E3 confirmed in an interview on 07/09/03 at 10:45 a.m. that E2 and E23 had informed her (E3) on 05/23/03 of "other" allegations of abuse involving E18. E3 confirmed that she told E2 and E23 to only look at the specific issue that was brought up which was the gait belt incident. b)Investigation: i) E2 confirmed in an interview on 06/25/03 at 11:55 a.m. that when she investigated the involuntary seclusion allegations involving R19 and R1, she talked to E7, E19, E4, E13, E17 and E5 but did not talk with any other staff, residents, families of residents or visitors. E2 confirmed in an interview on 6/24/03 at 5:00 p.m. that after receiving further information about a confidential resident interview confirming the allegations of abuse, involving R20 and R21, that she talked to E5 and E17, CNA's and R22 but did not talk with any other staff, residents, families of residents or visitors. E3 confirmed in an interview on 6/24/03 at 4:05 p.m. that she had done no further investigation of the verbal abuse allegations involving R20 and R21 ii)Undated and unsigned documentation titled "Investigation" of R18 incident of 04/10/03, but not dated or signed, contained the following information: (1) Information unclear. No witness. The rumor was that two CNA's watched resident fall. (2)Called [E18] on 04/10/02 and she gave the following information: No external rotation, no shortening of leg. Resident denied pain, no facial grimace. E18 denied giving R18 anything for pain. When asked what happened E18 stated, "[R18] was found on the floor at the end of bed and assessment done with no findings.” (3) Spoke with [E19] in passing about the incident with [R18], and he stated, 'I don't know' while raising hands in the air. (4)R18's roommate was unable to recall the incident. iii)The report contains no documentation that anyone talked to E4 or interviewed E19 other than in passing. There is nothing in the investigation documentation to indicate that the nurse notes in R18's record were reviewed for the time when the fall occurred, what time the doctor was notified and whether there was any further assessment done after the initial assessment. There is no conclusion documented on the investigation form. C) Report of Facility Investigations: A document titled "Abuse Investigation Follow-Up Report" dated 06/03/03 was given to surveyors. i) The first page of the report (the “Findings”) was given to the surveyor by E2, DON on 06/24/03 at approximately 5:00 p.m. The second page of the report (the “Recommendations”) was given to the surveyor by E2 on 06/20/03. This report contains the following information: (1)Date initially reported: 05/23/03. (2)The findings were as follows: 3 (a)There is a report of using the sitting room as a 'playpen' to confine residents and prevent them from wandering in the halls. 3 (b)CNA's report that they would request her [E18] help with a resident or the resident would make a request for pain medication or cough medication and she would not come to help. She would often state, 'I don't care or so what'. She would threaten residents to behave or she would not give them their medication. 3 (c)The circumstances surrounding the fall of [R18] are questionable. All reports at this time would indicate that [E18] did not act in a timely manner, did not provide appropriate nursing assessment, did not administer pain medication, and did not obtain medical attention in a timely manner. 3 (d)When CNA's were questioned as to the untimely manner in which they reported these indiscretions to me they indicated that [E18] would make comments that she could get them fired, that we paid tall dollars for her, that she was in good with management, and that management would believe her over the aides. (2) The recommendations page has the following information: (a) Based upon interview with CNA's and the inconsistent responses by [E18] it would be my recommendation to sever all employment with [E18]. (b) Report findings to Department of Public Health. (c) Report findings to Department of Professional Regulations. (d) Re-inservice abuse policy to all staff. (e) Discuss with Administrator the untimely reports of staff and any discipline to be imposed. (f) Address any staffing changes that should be made. ii)On 07/09/03, another copy of the Abuse Investigation Follow-Up Report was given to the surveyor. This copy of the report has the following information at the top of the report: 1From: [E2]. 2Sent: Wednesday, June 04, 2003 9:09AM 3Subject: ABUSE INVESTIGATION FOLLOW. 4Text: "[E1], I am faxing the resident reports to you." E31 confirmed in interview on 07/10/03 at 10:00a.m. that the e-mail dated 06/04/03 from E2 was received, that she partially read the e-mail, realized it wasn't for her, and told E1 about it. E31 confirmed that she was instructed by E1 to print the e-mail and then delete it from the computer. E31 confirms that she folded the printed e-mail and placed it on E1's desk. E31 stated that E1 was present in the the office when she placed the e-mail on her desk. d) Staff that witnessed the neglect, verbal/mental abuse, and involuntary seclusion stated they were all afraid to report the allegations of abuse. Residents also expressed being afraid to report E18, fearing that E18 would find out that they had talked. Staff reported fear of retribution by the facility and from E18. E4, CNA E 31 confirmed Certified Nurse Aide) stated in interview on 06/18/03 at 11:15 a.m. that she did not report the allegation until 05/23/03 when the E2, DON called asking about E18, because E18 was going around saying that she (E18) had already gotten two other CNA's fired. ii) E13, CNA, stated in interview on 06/18/03 at 11:50 a.m. and 06/20/03 at 8:30 a.m. that she did not immediately report an allegation of verbal/mental abuse because, "A lot of us aides are scared of her (E18). The other CNA's won't say anything because they are too afraid". iii) The written statement dated 05/26/03 and signed by E7, CNA, states, "[E18's] response was always, I got two troublemakers off my shift and in fear of our jobs we held our tongue and did what she [E18] wanted". e) E18's personal file was reviewed and E18's contract was bought from a staffing agency in February 2003. E1 confirmed in interview on 06/18/03 at approximately 3:00 p.m. that the facility did buy E18's contract. i) E1 allowed E18 to return to work on 06/12/03 and work through 06/24/03 as scheduled, even though she had knowledge of E2's (DON) recommendations to terminate E18. E1 confirmed in interview on 06/24/03 at 4:05 p.m. that E18 worked 06/21, 06/22 and 06/23 and was not suspended from work because E2 had already checked into the allegations and "we were satisfied with the results". ii) Review of the April 2003 schedule confirms that E18 continued to work. Review of the May and June schedules confirm that E18 was scheduled for twelve hour shifts on 5/22/03, 6/12/03, 6/16/03 and 6/17/03, 6/21/03, 6/22/03 and 6/23/03. E2, DON confirmed in interview on 6/20/03 at 11:05 a.m. that E18 worked 5/22/03, was suspended on 5/23/03 and returned to work on 6/12/03. E2 confirmed in interview on 06/20/03, at 9:30 a.m. that she documented on the written statement signed by E4, "Already investigated and no problem" and that E4 "didn't work". E2 confirmed that she had investigated the allegation of neglect in the written statement and that E4 wasn't scheduled to work that night. Review of the April 2003 schedule confirms that E4 was scheduled to work 6:00 p.m. to 6:00 a.m. on 04/09/03. The Daily Assignment Sheet dated 04/09/03 confirms that E4 was scheduled on the second floor for 04/09/03. E22, Scheduling Coordinator confirmed in interview on 07/01/03 at 8:35 a.m. that E4 did work 04/09/03 and was to go down to first floor, but was pulled back up to second floor when another CNA was sent home ill. |