Shady Oaks West Facility I.D. Number:0040527 Date of Survey: 12/04/2003 Annual Investigation An appropriate, effective and individualized program that manages residents’ behaviors shall be developed and implemented for residents with aggressive or self-abusive behavior. Adequate, properly trained and supervised staff all be available to administer these programs. The facility shall provide all services necessary to maintain each resident in good physical health. These services include, but are not limited to, the following: Nursing services to provide immediate supervision of the health needs of each resident by a registered professional nurse or a licensed practical nurse, or the equivalent. Residents shall be provided with nursing services, in accordance with their needs, which shall include, but are not limited to, the following. The DON shall participate in: Periodic re-evaluation of the type, extent, and quality services and programming. Modification of the resident care plan, in terms of the resident’s daily needs, as needed. AN OWNER, LICENSEE, ADMINISTRATOR, EMPLOYEE OR AGENT OF A FACILITY SHALL NOT ABUSE OR NEGLECT A RESIDENT. (Section 2-107 of the Act) These regulations are not met as evidenced by the following: Based on observation, interview and file verification, the facility failed to ensure that staff implemented measures to protect one individual (R5) from harm, including harm from self-injurious behaviors. Specifically, staff neglected to implement R5's behavior intervention program, allowing him to repeatedly inflict heavy blows to his face, resulting in soft tissue injury. 1) R5 is a 21 year old male whose diagnoses include Profound Mental Retardation, Anxiety, Impulse Control Disorder NOS, Cerebral Palsy, Blindness - Unspecified Loss, and Seasonal Allergies, per his IPP (Individual Program Plan) of 09/15/03. R5 was observed in his home from 3:30 - 7:10 PM on 11/24/03 and intermittently throughout the survey. R5 was seated in the living room and was observed to forcefully hit himself on the right side of his head and in his face repeatedly without any staff intervention or redirection. For example, at 3:40 PM on 11/24/03, R5 hit himself 6 - 8X. Two direct care staff were nearby, as well as the QMRP (Qualified Mental Retardation Professional), none of whom intervened. At 3:47 PM, R5 hit the left side of his head 4X, followed by hitting his right side 3X - no intervention observed. At 3:52 PM, R5 hit himself approximately 12 - 15X, accompanied by loud vocalizing and moaning - no intervention observed. At 3:55 PM, R5 hit himself approximately 20X, removed his protective leather helmet, hit himself 5X on the right side of his face, replaced his helmet and hit himself again 3X. E6, E7, E8 and E9 were in/out of the living room or in the attached activity and dining areas throughout this time period, never intervening. Surveyor noted that R5 hit himself with such force as to enable others to hear him from nearly anywhere in the home, e.g. from the hallways or kitchen areas. Surveyor observed R11 tell R5 to "Stop" several times, without success. R5 continued this self-injurious behavior throughout the evening until he fell asleep on the couch in the living room at approximately 7:05 PM. With the exception of E6 telling R5 to stop hitting himself once during the dinner meal, no interventions or redirection was observed. Per file review, R5 has a Behavior Management Program (BMP) dated 10/02/03 which states that when R5 "begins to make loud vocalizations staff will ask him what he needs and encourage him....to communicate. ...If behavior escalates, staff will verbally prompt him to calm down...., will lead him to a less stimulating and safe environment,....should guide his hands away from his head while speaking in a firm but calm tone,...should ask for assistance from other staff if they are unable to calm him..., or page the program director for further guidance." Per interview with E3 (Administrator) on 11/24/03, R5 remains home all day as the facility has been unable to find an adult day program to accept him due to his severe maladaptive behaviors. Per E3, there is one direct care staff in the home during the day whose primary responsibility is housekeeping after all the other residents leave in the morning. This staff person also is responsible for working with R5, according to E3. R5 was observed intermittently throughout the day on 11/25/03. At approximately 10:15AM, he was observed sitting in R9's bedroom, listening to the radio. From time to time he would hit himself 3 - 5X in the face, and then rock from side to side in time with the music. No staff were in the vicinity. E10 (Direct Support Staff) was interviewed on 11/25/03 regarding whether or not she had received any instructions on what to do with R5 while he was home. E10 stated she wasn't told anything specifically, so she tries to find things that he seems to enjoy doing such as listening to the radio while she cleans the house. E10 stated she had been told by the previous QMRP that R5's blindness was a result of his severe self-injurious behaviors in the past. E10 stated R5's behaviors "are hard to deal with - he really needs a 1:1" but the facility is not able to provide that for him. E10 stated that R5 damaged his helmet about 2 -3 months ago by pulling the chin strap apart. E1 was interviewed on 11/25/03 regarding R5's use of the helmet. E1 stated she was aware that R5 could remove his helmet but she "seem(ed) to remember that the Human Rights Committee didn't want the helmet to be fastened because that would be restrictive." Surveyor described to E1 the evening observations of 11/24/03 and asked what R5's behavior management program (BMP) was. E1 stated she was not sure and would have to look at the program but she was sure that staff should have intervened to stop him from hitting himself. On the morning of 11/26/03, R5 was observed sitting on the couch in the living room. The right side of his face, including the eye and cheek areas were very swollen and reddened. Surveyor asked E1 and E2(LPN) what had happened to R5. Neither knew the cause of the injury as it had not been observed. According to E2, R5 was being sent to the local hospital emergency room for evaluation of the injury. Both E1 and E2 speculated that the injury was caused by R5's self-injurious behaviors. At approximately 3 PM on 11/26/03, E2 informed surveyor that R5 had been evaluated in the emergency room and he was diagnosed with a "soft tissue trauma" injury which did not require further treatment. B) Based on observation, interview and file verification, the facility failed to ensure that three of three women residing in the facility (R1, R3, R6) were given birth control injections based on an actual need. Also the facility failed to obtain informed written consent for the administration of birth control injections for three of three women residing in the facility (R1, R3, R6). 1. R3 is a 35 year old female whose diagnoses include Profound Mental Retardation, Spasticity, Diabetes Insipidus - nephrogenic, Hypertension, Legally Blind, Retinitis, Rubella Syndrome, Gastritis and Anxiety, per the Physician's Order Sheet (POS). R3 was observed throughout the survey to be essentially non-verbal and socially isolative, avoiding contact with her peers and staff. Review of R3's POS revealed she receives Depo-Provera contraceptive injections of 150 mg every three months. E1 and E5 (Qualified Mental Retardation Professionals - QMRPs) were interviewed on 11/26/03 regarding the reason for this medication being given. E1 was asked if R3 was sexually active or had a medical condition that warranted its use. E1 responded "No, not that I know of - she's always been on it since I've worked here." E1 and E5 stated that R3 will not tolerate using feminine hygiene products and will not wear a diaper during her menses so perhaps this was the reason. E1 and E5 were asked if R3 had ever received desensitization training to teach her tolerance of feminine hygiene products or diapers before the Depo-Provera was ordered. Both E1 and E5 said they didn't know with certainty but thought she had not. 2. R1 is a 33 year old female whose diagnoses include Moderate Mental Retardation, Hypertension, Anemia, Cerebral Palsy, Rheumatoid Arthritis, GERD, Esophagitis and a history of Epilepsy, per her POS. R1 was observed throughout the survey to be wheelchair-dependent and unable to move her lower body without two-person assistance. She is fully able to verbally express herself and to make her wants/needs known. Per the POS, R1 was receiving Depo-Provera injections of 150 mg every three months until 03/07/03, when they were discontinued. E1 (QMRP) stated during interview on 11/26/03 that R1's mother requested the injections be discontinued as she (the mother) reportedly felt that the shots contributed to R1's anxiety or nervousness, as well as weight gain. E1 stated that as far as she knew, R1 had never been sexually active, had not expressed an interest in being sexually active, nor did she have any problems with her menses that would support the need for the Depo-Provera. E1 stated she understood that all women were prescribed this medication when they were admitted unless they were already receiving birth control when they came in. E1 stated she wasn't sure why the Depo-Provera was prescribed. On review of the Physician's Progress Notes for the past year and of the current Physical Examination of R1, surveyor was unable to find any supporting documentation for the need for this medication. 3. Another example includes R6. 4. During interview with E1 and E5 (Qualified Mental Retardation Professionals - QMRPs) on 12/01/03, E1 was asked if she had obtained written consent from the guardian of R3, authorizing the administration of the Depo-Provera injections. E1 responded, “No, I don’t have consent right now because I didn’t know I should.” E1 stated that R1, R3, and R6 had all been receiving these injections when she began employment at the facility more than two years ago and she never questioned the reason for them receiving this medication. E5 stated she believed it was an agency-wide practice to give Depo-Provera shots to any woman of child-bearing age and didn’t think it was considered risky or restrictive. Both E1 and E5 agreed during interview that any form of birth control has attendant risks associated with their use. Review of R3's record confirmed there was no consent for the administration of the Depo-Provera. Other examples include R1 (whose injections were discontinued at the request of her guardian in 03/2003, according to E1) and R6. C) Based on observation, interview and file verification, the facility failed to ensure that four of four individuals in the sample (R1, R4) and at least one additional individual (R5) received consistent, ongoing training and services as described in their IPPs (Individual Program Plans) and Weekly Schedules. Findings include: 1. R1 is a 34 year old female whose diagnoses include Moderate Mental Retardation, Hypertension, Anemia, Cerebral Palsy, GERD, Esophagitis, Rheumatoid Arthritis and History of Epilepsy, per her IPP of 01/27/03. R1 was observed throughout the survey to be wheelchair dependent and unable to independently move her lower extremities. She is verbal and fully able to express her wants/ needs/thoughts. Per R1's IPP, she is to receive daily ROM(range of motion) exercises, to be conducted at both the day program and her residence. The Program Form in her daily program book states these exercises should be conducted "Daily as scheduled." The Weekly Schedule states OT/PT exercises are scheduled to occur from 8:00 - 9:00PM. R1 was observed on 11/24/03 from 3:30 - 7:10PM in her home. She was put into bed at approximately 7:00PM and the lights were turned off. With the exception of being out of her bedroom during dinnertime, R1 sat in her wheelchair in her bedroom, watching TV. She was not observed to be provided the ROM exercises. R1 was interviewed on 11/24/03 and asked what she would be doing that evening. She stated "Nothing, I'll probably watch TV like I do every night. There's nothing else to do around here." E6 (Direct Support Staff) was interviewed on 11/24/03 and asked what was planned for that evening and she replied that most of the residents were already in bed but they might play Bingo later on. R1's daily care log for November was reviewed, which documented that R1 is put to bed most nights between 5:45 - 8:00PM. The daily care log for November also documents that R1 did not receive a bath on 15 of 25 days which staff recorded on. E1 (QMRP - Qualified Mental Retardation Professional) was interviewed on 11/25/03 regarding surveyor's observation that R1's ROM exercises were not done. E1 replied that sometimes staff do the exercises in the morning or at night during bath times. She stated she does not know for sure when these programs are done but when she was a direct care worker, she generally completed the ROMs during baths. D) Based on observation, interview and file verification, the facility failed to ensure that nursing services were effectively provided to prevent the skin breakdown or development of decubitus ulcers for three individuals who are wheelchair dependent (R2, R6, R10). 1. R2 is a 55 year old male whose diagnoses include Moderate Mental retardation, Dysphagia, Obliterans of lower extremities, Cerebral Palsy, Neurogenic Bladder, Dermatitis and Hypertension, per his Physician Order Sheet (POS). R2 was observed throughout the survey to be wheelchair dependent and unable to move his lower extremities without physical assistance from 1 - 2 staff. Except for brief toileting breaks when he was taken out of his chair, R2 was observed to be in his chair from morning to bedtime. On review of R2's nursing notes for the past year and of injury/incident reports, surveyor noted that R2 has experienced skin breakdown or decubitus ulcers on at least two occasions during the past six months. An 08/24/03 treatment nursing note documents "R groin area 2cm X 3cm open area excoriation, dr red Grade II...Tx done per order...rest of body clr..." A 05/25/03 nursing note states "Healing decub drsg of DuoDerm to R thigh wound superficial - appears reddened but clean. Also has Stage II wound to groin fold of scrotum area cleansed and Algreade (sp) dsg applied." Review of the quarterly nutritional note of 08/25/03 indicates that R2's "Decub felt to be d/t chronic excoriation rather than nutritionally compromised." The 11/24/03 note documents "He cont with wound on groin area - described as Stage II per chart. Nrsg reports it improves and then opens again..." During interview with E3 (Administrator) on 11/24/03, E3 stated that R2 has had persistent skin integrity problems in the groin and scrotum area due to contractures of the lower extremities. E2 (LPN) stated on 11/24/03 that R2's groin and scrotal skin is always excoriated and she has never personally seen this area to be fully healed. E2 stated "it gets better for a while and then reopens." 2. R10 is a 52 year old male whose diagnoses include Mild Mental Retardation and Cerebral Palsy. R10 functions adaptively in the Profound range of disability. R10 was observed throughout the survey to be wheelchair dependent and unable to move his lower extremities without staff assistance. Review of the nursing notes and treatment records for the past year showed that R10 has experienced Stage II decubitus or skin breakdowns at least six times since 12/02. For example, a nursing note dated 07/11/03 documents "2 open Stage II decubs - 1 R buttock 3cm X 3cm - 1 L buttock 2cm X 1cm. Seat cushion was improperly placed on w/c (wheelchair) - corrected." Other dates when skin breakdown/decubitus were recorded include 09/07/03, 09/01/03 (right buttock), 08/26-08/31/03 (right hip or side), 07/18/03 (area between buttocks), 12/05/02 (both buttocks). During interview with E2 (LPN) on 12/01/03, E2 stated that on at least two of the above occasions, the skin breakdown was caused by staff not correctly applying the removable gel cushion to R10's wheelchair. E2 stated staff were retrained twice to correct the problem and as far as she knew, there has not been a recurrence. 3. Another example of an individual who has experienced skin breakdowns (per nosing notes, attributed to friction from or improper application of disposable diapers) is R6. |