Benjamin Green-Field Residence
Facility I.D. Number: 0041582
Date of Survey: 08/07/2003
Follow-up to Survey of February 21, 2003
The facility shall notify the Department of any incident or accident which has, or is likely to have, a significant effect on the health, safety, or welfare of a resident or residents. Incidents and accidents requiring the services of a physician, hospital, police or fire department, coroner, or other service provider on an emergency basis shall be reported to the Department.
A narrative summary of each serious accident or incident occurrence shall be sent to the Department within seven (7) days of the occurrence.
The facility shall also immediately notify the residents family, guardian, representative, conservator and any private or public agency financially responsible for the residents care whenever unusual circumstances such as accidents, sudden illness, disease, unexplained absences, extraordinary resident charges, billings, or related administrative matters arise.
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)
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 as evidenced by:
Based on interview, file verification, and review of abuse investigative reports for two of three individuals (R2, R3) who were allegedly abused by staff, the facility failed to promptly notify the guardians or family members of the alleged incidents of abuse.
Per an investigative report dated 07/9/03, R2 and R3 were allegedly abused by staff on 06/15/03 and 06/19/03 respectively. The report does not indicate that guardians or family members of R2 or R3 were notified of the alleged incidents.
During interview with E1 (Administrator), E2 (Facility Investigator), and E12 (Director of Program Services) on 07/23/03, surveyor questioned if notification had occurred. E2 responded that he did not believe that had been done. E12 stated they would notify the guardians immediately, acknowledging that it would be after the fact but better than not at all.
Review of the records of R2 and R3 confirmed there were no progress notes or entries in the records related to the allegations of abuse or that guardians/family members had been notified.
Based on review of incident reports from 02/21/03 to present, and interview, the facility failed to ensure that two of three allegations of abuse were reported immediately to the administrator.
Per review of two abuse investigation files, surveyor noted that E4 (Direct Support Person - DSP) reported two incidents of alleged abuse to E6 (Qualified Mental Retardation Professional - QMRP) on 06/20/03. E4 reported that on 06/15/03, E5 (DSP) yelled at and threatened R2, which was classified by the facility as an incident of mental injury. E4 reported that on 06/19/03, E5 "dragged (R3) out of the building, pulling and pushing him and when he does not want to go up the bus she brings him back to the living room and pushed him to the couch to sit. When (R3) tried to stand up she said shouting on top of her voice as if she was fighting with someone 'Don't stand up, don't move, you understand me, don't move. Stay there till I tell you to do so. Don't move, understand me." According to the Investigation Report, this incident was classified by the facility as physical abuse.
Interview with E1 (Administrator) on 07/23/03 confirmed that both of these incidents were not reported immediately to her or to her designee (E3). The Investigation Report documented "that (E4) was hesitant to report the incidents because she had been redirected in the past for overstepping her boundaries, complaining about her coworkers and getting into disputes with them." E1 stated that she thought E4 felt she might get into trouble for talking about or reporting her peer and hence did not make the reports until five days after the 06/15/03 incident and 36 hours after the 06/19/03 incident.
The Final Report dated 07/09/03 documents The issue of late incident reporting (not within 24 hours) has been an ongoing issue at (the facility). It has been addressed on several occasions through retraining of all staff. It is recommended that the reporting procedure be reviewed at the next (facility) staff meeting. Also, management should consider designing a system that follows up on daily incidents and follow-up.
Based on interview and review of investigation information concerning three allegations of abuse, the facility failed to ensure that thorough, reproducible investigations were conducted in all three cases. The facility failed to interview and/or document results of interviews from all staff and all individuals about the conduct of the accused staff (E5, E7,and E8) after the investigators were told of additional inappropriate behaviors of the accused.
1. Per review of an investigation file of a verbal abuse incident reported on 04/15/03, it was alleged that E7 (Direct Support Person - DSP) "yelled and screamed at (R1) on 03/23/03 because she was not ready on time. (R1) also state(d) that (E7) told her she was not allowed to attend the dances anymore." R1 also stated, according to the investigation report, that E8 (DSP) threatened to throw away her food if she did not come out of her room when requested. According to the report, R1 stated during interview with E9 (Behavior Specialist) that "It's all my fault....Sometimes I get yelled at...They get mad at me" When asked "Who got mad?", R1 responded E7 and E8. E9 stated in her report of the interview that R1 "appeared to be scared and nervous and wanted to go back to work."
On review of the investigation information, surveyor noted that no other resident interviews had been conducted to determine if anyone else may have witnessed or heard the alleged interactions between R1 and E7 or E8. Other residents were not asked if they had experienced similar interactions with or treatment from E7 or E8. The only staff statements obtained were from E4 (DSP who escorted individuals to the dance on 03/23/03) and E7 and E8 (both of whom denied yelling at or threatening R1). E7 stated "he did not have any discussions with (R1) regarding the dance on 03/23/03."
A note of an interview with R1's mother on 04/16/03 documents that she had a phone conversation (date not specified) with E7, which was upsetting to her. The note states that R1's mother was told by E7 that R1 "did not want to go to the dance because she was not ready and that she never listens to him so he wasn't going to get involved."
The investigation states further that E7 "has a history of using an abrasive approach when communicating with participants and staff. In the past, he has used an inappropriate tone of voice and engaged in some inappropriate interactions.....it is recommended that (E7) be given 30-days to correct this matter..."
2. Per the investigation file presented to surveyor on 07/23/03 and interview with E1 (Administrator) and E2 (Director of Training and Staff Development and Facility Investigator), two allegations of abuse against E5 for incidents occurring on 06/15/03 and 06/19/03 were investigated together because the incidents were reported on the same date (06/20/03) and involved the same employee.
The incident of 06/15/03 alleges that E5 yelled at and threatened R2 while R2 was displaying inappropriate behavior.
The incident of 06/19/03 alleges that E5 physically abused R3 while escorting him to his workshop bus and subsequently threatened and pushed him upon reentry to the facility. Statements given by two of three staff witnesses (E10 and E11) corroborated that E5 tried to force R3 out to the bus but gave some discrepant details as to her method.
Statements were taken from a few of the residents (R1 - 6). R4 reported in part that E5 pushed R2 out of the room. R4 went on to say that "sometimes E5 is upset with me. She gets mad. Sometimes they get really pissed off. Oh boy." No further interviews were conducted with either staff or residents to determine if E5 behaved in an angry or intimidating manner at other times, as inferred by the statement of R4. The statement from R3 only documents that he "could recall no incident on 06/19/03." It does not explore whether he could provide information about E5's interactions with him at other times.
Surveyor interviewed R2, R4, R5, and R6 on 08/04/03, asking each of them if they ever heard staff yell at residents. All confirmed that sometimes staff get angry and holler at them. R5 stated that "sometimes (E5) gets mad at us. One time, she got mad at me because I had an accident (i.e. toileting accident)." R4 stated "sometimes they holler at us - they get angry or tired....I don't want to say the names - it's OK." R6 stated that "it's not a big deal - they just get mad sometimes and can't help it."
On interview with E2 on 7/23/03, E2 acknowledged that the Final Reports did not document all of his investigation efforts. E2 agreed that additional interviews should have been conducted, once general statements had been made regarding E5's behavior or interactions with residents.
Based on interview and review of abuse investigation case files, the facility failed to ensure that the accused perpetrators (E5, 7, 8) were prevented from having further contact with residents during the course of the investigations for three incidents of alleged abuse which occurred on 03/23/03, 06/15/03 and 06/19/03.
According to an abuse allegation investigation file, E7 and E8 were accused of verbally abusing and intimidating R1 on 03/23/03. This allegation was reported to the facility on 04/15/03 and an investigation was initiated the same day. There is no indication in the file that E7 or E8 were removed from duty or reassigned to an area in which they would have no further opportunity for unsupervised contact with residents during the course of the investigation.
A second abuse allegation investigation file documented that E5 was accused of physically abusing R3 on 06/19/03 and verbally abusing or mentally injuring R2 on 06/15/03. These allegations were reported to the facility on 06/20/03, at which time an investigation was initiated. The file does not document that E5 was prohibited from having further contact with residents during the course of the investigation.
Interview with E3 (Coordinator) on 07/23/03 confirmed that E5, E7 and E8 remained on duty throughout the investigations. During interviews with E1 (Administrator) and E2 (Facility Investigator) on 07/23/03, surveyor was informed that it was not the facility's practice to reassign or remove staff from duty while an investigation was being conducted. In fact, both E1 and E2 stated they were not aware that this was required by State and Federal regulations but acknowledged that it was a good idea to do so.
Based on review of abuse investigation files and interview, the facility failed to complete three of three investigations and the corresponding reports within five working days of the incidents.
According to abuse investigation case files, there were three allegations of abuse reported since 02/21/03.
One incident of alleged verbal abuse of R1 occurred on 03/23/03 and was reported on 04/15/03. An investigation was initiated on 04/15/03 but was not completed until 04/29/03, according to the Final Report.
An allegation of verbal abuse/mental injury to R2 by E5 on 06/15/03 was reported to the facility on 06/20/03. The same day a second allegation of physical abuse of R3 by E5 on 06/19/03 was reported to the facility. As both allegations were received on the same day and involved the same staff person, the facility conducted one investigation of both allegations, per interview with E2 (Facility Investigator). The Final Report of this investigation is dated 07/09/03.
During interview with E2, surveyor was told that E2 was aware that the reports were not completed within the prescribed time frame of five working days. E2 stated he had difficulty connecting with various staff members to obtain their statements due to off-days, vacations, etc. E2 stated that because the facility was reasonably sure that the allegations were not substantiated, he did not believe it was urgent to complete the reports within the five day time frame.