Statement of Violation

Woodbine Nursing Home, LLC

Facility I.D. Number: 0044446
6909 West North Avenue
Oak Park, Il 60302

Date of Survey: 5/22/03

Annual Licensure Survey

"A" VIOLATION(S):

ABUSE AND NEGLECT

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.

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.

This requirement is not met as evidenced by the following:

Based on review of facility Concern/Complaint log, facility abuse policy, resident and staff interview, the facility failed to: 1) develop and implement an Abuse Policy that ensures a comprehensive investigation of all allegations of abuse, neglect or mistreatment of residents; 2) investigate allegations of abuse to determine whether or not actual abuse occurred; 3) report allegations of abuse to the physician, the family or guardian and IDPH; 4) report the final determination to proper authorities; and 5) failed to take necessary corrective actions for 5 residents (R12, R13, R14,R15, R16) with documented allegations of abuse.

Findings include:

1) Review of the facility's Policy and Procedure for Abuse and Neglect indicated that the policy does not ensure that a complete investigation will be done for all allegations of abuse or neglect.

According to Items 4 and 5, the charge nurse or abuse prevention coordinator will determine whether or not the allegation will be investigated. The policy does not include any indication that all allegations will be investigated and reported.
Item 7 in the policy states that the physician, the administrator and the resident representative are notified only when the charge nurse or abuse prevention coordinator determine that a full investigation should be conducted.
Item 9 indicates that IDPH is notified only when the facility determines that abuse actually occurred.
Item 10 states that the abuse prevention coordinator, "will exercise reasonable care to assure both residents, staff and others involved in the investigative procedure will be free from harm during the investigation." The policy and procedure does not address the necessity of removing staff when there is an allegation of abuse that involves them.
Review of the individual "Concern/Complaint Response" forms indicate that the alleged abusers were not removed from duty pending investigation. R13 and R14 were not able to identify their alleged abusers and there is no indication that the facility attempted, by investigation, to identify who they were.

2) Review of the individual "Concern/Complaint Response" forms indicated that the facility failed to do a comprehensive investigation of the allegations of abuse for all 5 residents (R12, R13, R14,R15, R16). There is no indication that any final conclusions were determined or that any corrective actions were taken.

3) Review of the complaint log indicated that all 5 residents (R12, R13, R14, R15, R16) were alleged to have been abused by facility staff. There were no evidence that initial reports of the allegations were sent to IDPH for all 5 residents. There was no final report sent to IDPH for R12, R14, R15, or R16. There was one report sent for R13 on 5/6/03 regarding and incident on 4/28/03, however there was no specific conclusion determined. There is no documentation that families or guardians were notified of the allegations. There is no evidence that the allegations were reported to the physician for R12, R13, R15 or R16.

4) Review of the "Concern/Complaint" forms and the "Concern/Complaint Response" forms indicate that there was no final determination based on investigation for all 5 residents (R12, R13, R14,R15, R16). The investigation for R13 stated that there were 9 interviews done, however there was still no final determination.

5) Review of the "Concern/Complaint" forms and the "Concern/Complaint Response" forms indicate that there was no corrective action taken to ensure that allegations of abuse would be promptly identified addressed and acted upon. The allegation for R16 was an observed instance of mistreatment by staff. The 3 staff involved (E6 and E10 - CNAs and E8 - LPN) were counselled. That was the extent of the corrective action. There was no evidence that there was any inservice education for staff related to situations of abuse or suspected abuse.

Specific examples:

On 4/9/03 R16 was observed being forced into the shower by nursing staff, according to the "Concern/Complaint" form. The resident was observed by E3 (Activity Director) and E11 (Activity Staff) to be screaming and crying and trying to brace herself in the doorway as 3 staff E6, E8 and E10 tried to push her into the shower room. The report goes on to say, "Resident was terrified. She has a history in concentration camps and a fear of shower rooms." Other staff observed without intervening. E3 and E11 intervened and removed the resident. There is no documentation to indicate that this incident was reported to the family, the physician or IDPH. There is no indication that the staff observed as perpetrators were suspended pending investigation. There is no indication that any formal investigation was conducted. There are no documented interviews. According to the "Concern/Complaint Response" form, the CNAs were counseled on proper technique and approach and it was placed in their personnel files. There is no documentation to indicate that the facility handled this situation as an observed abuse.
On 3/26/03, according to the "Concern/Complaint" form, R12 reported to E8 that on the previous day E9 insisted that the resident get out of bed (she was not due to get up until the next day) and E9 rubbed rubber gloves on the resident's face. The report states that when R12 told E9 that she had been up yesterday and that she shouldn't get up again until the next day, that E9 told her she was, "getting up anyway". The report goes on to say that when R12 told E9 to change her gloves after personal care (before putting on the resident's socks) that E9, "took the gloves and rubbed them over the resident's face." The report also states that this incident was witnessed by E12. The extent of the facility response to this allegation is limited to interviews of the 3 staff named by the resident - they simply state that it did not occur. There was no "Concern/Complaint Response" form completed to address the facility response. There is no documentation to indicate that this incident was reported to the family, the physician or IDPH. There is no indication that the staff observed as perpetrators were suspended pending investigation. There is no indication that any formal investigation was conducted. There is no indication that there was a conclusion based upon investigation.
On 10/02/02, according to the "Concern/Complaint" form, R15 complained that the CNA who worked the overnight shift on 9/30/02 and 10/1/02, "cursed at her and called her names." The resident further stated that the CNA said, "After being off for 3 weeks I have to come back to your ugly face!" The report goes on to say that the resident was very upset and wants to make sure she is not cared for by this CNA again. There was no "Concern/Complaint Response" form completed to address the facility response. There is no documentation to indicate that this incident was reported to the family, the physician or IDPH. There is no indication that any formal investigation was conducted. There are no documented interviews. There is no indication that there was a conclusion based upon investigation.
On 4/29/03, according to the "Concern/Complaint" form, R14 was observed to have a deep bruise on her upper left forearm. R14 went on to say that, "she asked the CNA to be careful with her arms, but the CNA pressed her arm to the siderail. Resident states CNA was either 'nervous or angry'." There is no documentation to indicate that this incident was reported to the Office of State Guardian (OSG) or IDPH. There is no indication that any formal investigation was conducted. There are no documented interviews. There was no "Concern/Complaint Response" form completed to address the final facility response. There is no indication that there was a conclusion based upon investigation.
On 4/28/03 at 6:30p.m., according to the Nurses' Notes, R13 was noted by E13 (CNA) to have a dark discoloration on the left, lower arm and the area was slightly raised. The resident stated, "one of the girls handled me quite roughly today." The facility completed the "Alleged/Suspected Abuse Report Form" 2 days later on 4/30/03. There is no documentation to indicate that this incident was reported to the family, the physician or IDPH (Initial Report). The Investigation Report is dated 5/6/03 and states that it was faxed to IDPH. This report states that 9 staff members were interviewed and that none of these interviews, "resulted in information that would lead to the identity of a staff member who may have inappropriately transferred the resident." There is no documentation of the specific interviews and no documentation of the investigation.

E3 and E4 stated in interview on 5/20/03 that facility has not followed up on allegations of abuse, or removed involved staff from direct care. E1 verified in interview on 5/20/03 that no staff have been suspended during the investigation regarding R13 or R12. E1 stated he did not consider abuse occured with R16 and therefore did not suspend staff nor notified IDPH.