Scott County Nursing Center Facility I.D. Number: 0004234 Date of Survey: 11/19/2003 Complaint Investigation “A" VIOLATION(S): The facility shall have written policies and procedures governing all services provided by the facility which shall be formulated by a Resident Care Policy Committee consisting of at least the Administrator, the advisory physician or the Medical Advisory Committee and representatives of nursing and other services in the facility. These policies shall be in compliance with the Act and all rules promulgated there-under. These written policies shall be followed in operating the facility and shall be reviewed at least annually by this committee, as evidenced by written, signed and dated minutes of such a meeting. All employees, except student interns, shall attend in-service training programs pertaining to their assigned duties at least annually. These in-service training programs shall include material regarding the facility’s policies, skill training and performing their duties effectively. The in-service training sessions regarding personal care, nursing and restorative services shall include material concerning prevention and treatment of decubitus ulcers (commonly known as bed sores). In-service training concerning dietary services shall include material concerning effects of diet in treatment of various diseases or medical conditions and the importance of laboratory test results in determining therapeutic diets. Written records of program content for each session and of personnel attending each session shall be kept. AN OWNER, LICENSEE, ADMINISTRATOR, EMPLOYEE OR AGENT OF A FACILITY SHALL NOT ABUSE OR NEGLECT A RESIDENT. (Section 2-107 of the Act) 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) A FACILITY ADMINISTRATOR, EMPLOYEE OR AGENT WHO BECOMES AWARE OF ABUSE OR NEGLECT OF A RESIDENT SHALL ALSO REPORT THE MATTER TO THE DEPARTMENT. (Section 3-610 of the Act) 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. (Section 3-611 of the Act) These Regulations are not met as evidenced by: Based on record review, interviews and review of the facility's abuse policy and procedure, the facility failed to ensure seven residents (R5, R3, R4, R16, R11, R10, R14) were not subjected to mental distress. The facility also failed to ensure there was not a physical altercation between R3 and R9 which resulted in R9 biting R3. This includes: a) R5 who is known to not like anyone in her room observed rolled up blankets placed in her bed to simulate someone was in the bed. This caused R5 to become upset and angry. b) R4 who is known to be afraid of dogs was told there was a dog outside to keep her from leaving the building. R4 was in bed and E28 (Certified Nurse Aide), who was down on the floor, barked like a dog. R4 was told her panty hose, panties, and socks were sniffed by E53 CNA (Certified Nurse Aide) when they were taken off. R4 was told staff were partying at her house, and two staff were married with the male being an alcoholic and abusive to the wife, knowing this behavior is occurring would upset the resident as it is against her religious beliefs. R4 was asked by Z15 CNA, "How am I going to explain to your daughter that you're pregnant?" c) R16, a cognitively impaired resident, had Z15 (Certified Nurse Aide) put powder on her face, had her lights dimmed, and then E11 (Licensed Practical Nurse) was called in to look at R16. d) R11 would be reading and a staff member would turn off her light without anything being said to her which would upset her very much. R11 believed taking her medication, at the same time daily, would help her medical condition, but E11 (Licensed Practical Nurse) would consistently tell R11 to wait when she would go up to the medication cart and request it. This upset R11 very much. e) R10 who worries about injuring her legs and has poor circulation had E53 (Certified Nurse Aide) place ketchup in his hand and show it to R10 which made R10 believe it was blood and R10 had sustained an injury. f) E28 (Certified Nurse Aide) put a sheet over herself and shook a fly-swatter at R14 and told him to be quiet. g) R3 and R9, who had been aggravating each other had no intervention by staff until R9 bit R3. R3 had a fan placed by E11 so that the air would be on her after she expressed she was cold. R3 also was squirted, in the face, by E53 using a feeding syringe. Through the facility's investigation it was noted that E53 would wet small pieces of paper towel, roll it up in a ball and flick it at R3. Findings include: 1. R5's current clinical record documents that R5 was admitted to the facility on 7/8/96 with diagnoses, in- part, as follows: "Peripheral Edema, Gout, Renal Insufficiency, Hiatal Hernia, Arterial Sclerotic Cardiovascular Disease and Anxiety". R5's Minimum Data Set dated 11/4/03 assessed R5 to have no loss of short term or long-term memory and is independent in making decisions. R5's nurses notes dated 9/19/03 7:45 a.m. and 8 a.m. document R5 to be very defensive because R5 was gotten up early to take a shower. R5 was upset and tearful when talking with E11 (Licensed Practical Nurse). R5 stated "I was told to keep my mouth shut et my eyes pealed". R5 was interviewed by the surveyor during tour on 10/24/03 and acknowledged that she was aware of all of the teasing the staff was doing to the residents. R5 became very anxious and did not want to discuss the teasing by the staff. R5 was fearful Z17 would move her to a different facility. E2 (Quality Assurance Officer) interviewed R5 and Z17 on 10/26/03, and it was noted that R5 stated that "staff has joked with her and at times R5 did not think it was funny". R5 acknowledged that E53 (Certified Nurse Aide) played a joke on her with blankets in her bed that made her (R5) think someone was in her bed. Neither R5 nor Z17 thought it was funny. E2 interviewed Z17 and documented that Z17 was aware of the incident and Z17 knew that the incident was meant as a joke. Z17 advised that it was not very funny to play the above joke on an 80-year-old women. In Interview of E53 on 10/30/03 and E29 on 10/29/03 in the administrator office/conference room, E53 acknowledged that E29 rolled up two bath blankets and handed the bath blankets to E53. E53 placed them in R5's bed which was bed #4 of a four-bed room and was next to a window. E29 pulled the curtain back and turned the lights on so R5 could see her bed from the doorway and before she got to her bed. E65 (Certified Nurse Aide) was interviewed on 9/15/03 and stated that around 5 a.m. the next morning, R5 approached E65, in tears, retelling the event the previous evening that E53 (Certified Nurse Aide) had played a trick on her and that it scared her. Interview of Z4 (former Administrator) on 11/04/03 by telephone at approximately 5:32 p.m. confirmed that Z4 was made aware of the blanket/pillow incident the next morning (could not recall a date). Z4 states E53 was given a verbal counsel. Z4 acknowledged that she did not document the incident as she felt there was no intention for abuse. E53 apologized to R5 after it was noted that R5 was upset over the blanket/pillow incident. Interview of E51 (former Director of Nurses) on 11/04/03 per telephone, at approximately 1:25 p.m., confirmed that E51 was made aware of the blanket/pillow incident with R5 the following morning and that she was informed that E53 was given verbal counseling. E51 was not aware of any documented investigation. E51acknowledged that R5 was upset over the blanket/pillow incident. 2. Review of R4's current clinical record documents R4's admission as 11/20/02 with diagnoses, in part, as follows: "Congestive Heart Failure; Alzheimer Disease; Depression; Bladder Spasms and Arthritis". R4's Minimum Data Set dated 8/14/03 documents R4 to have a Short and Long-Term Memory deficit. R4 is assessed to be moderately impaired for decision-making. R4 is assessed to be easily distracted, periods of altered perception or awareness of surroundings, R4 is usually understood and at times R4 understands, has persistent anger with self and others and, anxious. R4 requires supervision or extensive assistance for activities of daily living and has moderate pain less than daily. R4's resident assessment protocol dated 8/14/03 documents that R4 "yells at staff & other residents - gets angry/agitated with noisy residents." Z15 (Certified Nurse Aide) was interviewed on 10/30/03 at approximately 12:24 p.m. Z15 recalled that the facility had a procedure in place that when the exit doors were not alarmed, that the residents would be told that there were "dogs outside, don't go out there" and the residents would turn around and come back into the facility. Z15 acknowledged that R4 was one of the residents that was deterred in this manner from leaving the building. Z15 acknowledged it was well known that R4 is fearful of dogs. Interview of E6 (Laundry Supervisor) on 9/29/03, at the facility, noted that E6 observed Z15 to tell R4 that there was a big black dog outside the door." I hope it doesn't get in, it's big enough to eat us all up." R4 stated "Oh, I hope it doesn't get in here". E6 acknowledged that Z15 said she "wouldn't let the dogs get R4 or anyone". E6 acknowledged everyone knows R4 is petrified of dogs. E6 acknowledged this incident was approximately six to eight months ago. E15 (Licensed Practical Nurse) was interviewed on 10/28/03, in the administrators/conference office at approximately 1:10 p.m. E15 stated that the concern of mental abuse was brought to the attention of the management through the "chain of command". E15 stated he believed that Z15 and E53 knew that what they were doing was abusive when they saw the reactions of R3, R4, R5 and R10. E3 (Acting Director of Nursing) was interviewed on 10/29/03 in the facility. E3 acknowledged she was charge nurse on a 3-11 shift and observed E28 (Certified Nurse Aide) from the door way in R4's room, under R4's bed, down on her knees, getting R4's turban from under the bed. E3 heard E28 say "I feel like a dog" and heard her "bark like a dog." E3 acknowledged she told E28 to get up and stop that. E3 observed R4 attempt to get out of bed to chase the dog away. E53 (Certified Nurse Aide) was interviewed on 10/30/03 at approximately 11:23 p.m. in the administrator/conference office. E53 acknowledged a "year or so ago" E53 was picking up R4's soiled clothing and R4 wanted to know what E53 was doing. E53 stated "picking up clothes" and R4 stated "Sniffing Panty Hose". A couple of days later R4 called E53 a"Panty Hose Sniffer". E22 (Certified Nurse Aide) was interviewed on 9/19/03 at approximately 2:30 p.m. by telephone, and stated Z15 (Certified Nurse Aide) would tell R4 "you know when we take your panties off to go to bed that E53 (Certified Nurse Aide) sniffs them." R4 responded "He (E53) had better not" R4 gets quite upset. She will double up her fists and pound the table". E22 acknowledged E53 and Z15 would giggle at R4's actions. E22 (Certified Nurse Aide) stated she had not observed the "sniffing of panty hose" but had heard Z15 (Former Certified Nurse Aide) talk about it in the break room with other staff. Z15 CNA (Certified Nurse Aide) was interviewed on 10/30/03 at approximately 12:24 p.m. in the administrators/conference room. Z15 stated that before Christmas of 2002, Z15 was putting R4 to bed and was changing R4's clothes including her "knee Highs". Z15 informed R4 that she needed new hose for Christmas because one of the knee highs had a runner. R4 wanted her knee highs put into her shoes so she could put them on the next day. Z15 acknowledged she needed to have her knee highs sent to the laundry so they don't smell. R4 said, "Are you kids smelling my panty hose?" Z15 acknowledged that she got tickled and laughed and told R4 "For God sakes you don't think we would do that". Z15 left the room and went outside for a break and told E53 (Certified Nurse Aide) about the conversation with R4. E15 (Licensed Practical Nurse) was interviewed on 9/16/03, 9/29/03 and 10/28/03. E15 stated that E53 (Certified Nurse Aide) and Z15 (Certified Nurse Aide) were overheard telling R4 that E15 and Z15 (Certified Nurse Aide) were married. R4 was told E15 was an alcoholic and beat Z15. R4 was told when she went to bed there were parties at her house (R4's room) where there was beer drinking and dancing on the tables. E15 stated that R4 would become very upset due to her religious beliefs. E15 stated R4 would become agitated and would refuse to take medications from him. Z20 (Certified Nurse Aide) was interviewed on 9/15/03 at 1 p.m. by telephone, and stated that Z15 (Certified Nurse Aide) was observed/heard in May 2003, telling R4 "How am I going to explain to your daughter that you're pregnant?" E11 (Licensed Practical Nurse) was interviewed on 10/30/03 at approximately 8:43 a.m. in the administrators office/conference room. E11 stated that R15 and R18 would complain of being bloated and raise their tops and say "Look, I think I am pregnant". E11 stated that she probably said "Oh, you took your birth control pill." 3. During an interview of E29 CNA on 10/29/03 at 4:00 p.m. in the Administrators office conference area she stated that one evening, between 7:00 p.m. and 7:15 p.m., E53 CNA went to give R16 her nutritional snack. E29, E57 CNA's, and another aide (could not remember who), could see R16 from the hall. Z15 CNA asked them when R16 was put to bed "was she all right" and grinned. Z15 was asked why and E53 stated "she does not look right." Her bed light was turned on. Z15 was laughing, and R16's face was covered with a white powder that made her look like a ghost. E11 LPN came to the room and asked "what did you guys do?" Z15 stated she and E57 had put the powder on her. E57 stated she had done nothing. E11 told Z15 to wash off the powder and left the room. E11 did wash the powder off of the resident's face. E29 stated there "was no reaction" from R16. She was" just laying there, resident does not move much, has brittle bones, and is transferred with a mechanical lift." During interview of E11 LPN on 10/30/03 at 8:43 a.m., in the Administrators office conference area, she stated she was passing medication and was at her medication cart, when Z15 asked her to look at R16. R16 had powder on her face. E11 laughed a little as did the resident. E57 and Z15 were in the room. E11 stated she did not ask how R16 got powder on her face. Z15 wiped the powder off. E11 stated there may have been another resident in the room but she did not remember. E11 stated the incident was not documented or reported as she saw no harm. During interview of Z15 CNA on 10/30/03 at 12:24 p.m., in the Administrators office conference area, she stated she put powder on R16's cheeks and forehead and she washed it off. Z15 stated R16 giggled when she washed the powder off. During an interview with Z21 on 11/04/03, by telephone at 1:10 p.m., Z21 stated R16 would not have liked to be the subject of teasing or joking. Z21 stated R16 is a very sweet person and would be upset if she was used in any way as a joke or any teasing. Z21 stated she had not been informed of this incident occurring to R16, and stated again the resident would not like being used for a joke at all, as it would upset her. Review of R16's clinical record showed diagnoses, in-part, of Osteoporosis, Anemia, Organic Brain Syndrome, and Seizure Disorder. Review of the 09/10/03 assessment documented, in-part, that R16 has a long and short-term memory deficit, is moderately impaired cognitively, understands and is understood, is extensive to total assist with activities of daily living except for eating and has crying and tearfulness up to five days per week, and repetitive physical movements daily or almost daily. Review of the care plan, dated 09/10/03, for R16, showed a goal to reduce episodes of anxiety. 4. a. In interview on 10/29/03, E22 CNA stated E11(LPN) turned the lights off in the foyer, when R11 was reading a book. E22 stated R11 went to E51 (former Director of Nurses) and told her of E11 shutting the lights off and E51 put up a note not to turn the lights off. During an interview of E18 RN on 10/28/03, E18 stated E11 would turn the lights off in the foyer when R11 was reading. During an interview of E11, LPN on 10/30/03, she stated residents would ask for the over head lights to be turned off in the television area. She would then turn the lights off and ask R11 to read in another area which she would not do. The facility's investigation of this incident documented that E11 told them she did turn the lights out on R11 and had a problem taking care of her. She was hard to take care of. b. E15 LPN was interviewed on 10/28/03 at 1:10 p.m. in the Administrators office/conference area. E15 stated R11 would go to the medication cart to get her medication and there was never any problems with R11 if she received them. E15 stated E11 LPN would tell R11 to go and sit down, when she went to the medication cart and requested her medication. Instead of giving her medication, E11 would tell her this continuously. E15 stated R11 was afraid her Tardive Dyskinesia would get worse and would start wringing her hands when she did not receive her medication. R11 liked it the same time every day. E15 stated R11 left the facility because of E11. E11 was counseled by E51 over the differences she had with R11. E11 stated she always gave R11 her medication within the required time frame. c. Z8 Party responsible was interviewed on 10/29/03 at 12:58 p.m. by telephone. She stated she moved R11 from the nursing home to another nursing facility because "she was going down hill" and "deteriorating mentally." There were not many residents she could talk to. She stated R11 was "doing excellent now." Z8 stated R11 was "upset over there" because a nurse would turn the lights out while she was trying to read. Z8 stated the nurse seemed to like to "aggravate". d. R11, Z8 stated she felt it was "emotional abuse." Z8 stated she reported this to the Director of Nurses (E51) and she stated there has to be give and take because some don't want lights on when watching television. Z8 could not remember the nurses name. She said she would recognize her if she saw her but it had been a few months since R11 was moved. R11 was transferred to another facility in May, 2003. 5. R10's current clinical record was reviewed. It documented that R10 was admitted to the facility in 1992 with diagnoses of Cardiovascular Accident with Left Hemiparesis, Arthritis; Gout, Chronic Peripheral Vascular Disease, Anxiety, and History of Hemorrhagic Wounds of Bilateral Lower Extremities. R10's Minimum Data Set dated 8/12/03 documents R10 to be independent in decision-making and has no problems with long and short-term memory. R10 is non-weight bearing, refuses gait belt use with transfers, is a total lift of two (2) direct care staff, and feeds self with set-up. R10 was interviewed on 10/30/03 at approximately 10:50 a.m. in the residence small lounge area. R10 stated that E36 (Certified Nurse Aide) refused to assist her with her eye glasses and assuring her slip was pulled down. E36 would tell R10 that she could do more for herself if she would try. R10 stated this occurred last year. E36 is "short in tolerance of R10's needs". R10 stated that she has a left side deficit and needs help in her activities of daily living because she can do just so much with her right side. R10 stated she informed E36 that she was going to tell E51 (Director of Nurses). R10 stated E36 told R10 to go ahead and tell E51 and call the State. R10 stated that she has very frail, thin skin of the lower extremities. At times, just touching them would cause a skin tear and she would bleed. The skin tears do not heal easily and she has been treated by the wound clinic. R10's lower extremities were observed to have a wrapped type dressing in place. R10 stated that E53 frightened her one night when E53 assisted R10 to bed. E53 asked R10 to look at his hand after he had lifted her legs and there was blood in the palm of his hand. R10 stated that she was frightened, had tears, and was very stressed because she knew she would bleed very easily. Then E53 said "it's okay it is only ketchup". R10 stated E30 (Certified Nurse Aide) was present with E53. R10 stated she does not enjoy being teased that way. A written report, by E53, documented E36 (CNA) was present and was assisting R10 to bed when he put ketchup in his hand. The report documented R10 to be alert, and in a poor mood. R10 was identified to be picky about every thing. E53 had a packet of catsup in his pocket from lunch. E53 squirted some of the ketchup into his hand and showed it to R10 after putting her to bed. R10 said "Oh My" and asked E53 if "that came from her leg?". E53 said "No just catsup". E53 stated that the above incident occurred either December of 2002 or January of 2003. E53 has been employed by the facility since 1/31/01. 6. Review of R14's discharge record documents that R14 was admitted to the facility with diagnoses as follows: "Hypertension, Gastro Esophageal Reflux Disease, Chronic Organic Pulmonary Disease, Peripheral Vascular Disease, Urinary Retention, Abdominal Aortic Aneurysm, Pulmonary Cancer, and Anxiety." R14's September nurses notes documented R14 to be in severe pain, hurting all over, yells out, then doesn't want anything. R14 expired 9/16/03. E3 (Charge nurse/Acting Director of Nursing) was interviewed on 10/24/03. She stated E22 (Certified Nurse Aide) had put a sheet over her head and obtained a fly swatter from R17 and stuck her head in R14's doorway to scare R14. E3 stated that R14 would holler, wanting some one to be with him. R14 was in a room at the end of the hall across from R17's room. R17 would get upset over R14 hollering, and would go to R14's doorway and shake the fly swatter at him and tell R14 to be quiet. E22 was interviewed on 10/29/03 at approximately 5:35 p.m. in the administrators office/conference room. E22 stated she was aware of the "sheet incident with R14. E22 was made aware of the incident during break. She did not observed it. The incident occurred approximately two months ago. R14 did not like jokes. He was a very serious man. The facility's Employee Action/Discipline report for E28 (Certified Nurse Aide) dated 10/28/03 was reviewed. It documents E28 being on suspension for putting a sheet over her and looking like a ghost and entering R14's room while on duty on the 11-7 shift. It was signed 11/03/03. 7. a. E15's LPN (Licensed Practical Nurse) written statement dated 10/26/03 was reviewed. It documented he moved residents R3 and R9 apart because R9 was biting R3. The statement documented there were several residents trying to get through a very small spot. He moved these residents so a possible skin tear could not happen. E18, RN (Registered Nurse) was sitting at a table in the main dining room talking to other residents. R3 was yelling. E15 looked over and R9 was biting R3's hand. E15 moved these residents away from each other and went outside to leave. E15 told E11, the nurse working the north hall. E15 stated to E11 he saved her a skin tear and explained what he did to move the residents through the small open area. He then stated R9 was biting R3. E15 stated E18 stated "Well She deserved it she was making fun of him." During an interview of E11, LPN on 10/30/03, she stated R3 and R9 were sitting in the foyer area. R9 would yell and R3 would mock him. E11 was standing at the medication cart facing the small dining area and heard R3 yell "he bit me." E11 stated she went over to check R3's arm and nothing was there. When asked by surveyor why the two residents were not separated before a physical altercation ensued, E11 stated she should have separated the two residents earlier and did not know why she did not. She separated the residents after the biting incident. She did not document the incident because there was no injury. E11 stated she "probably did say she deserved it as she had been mocking him for some time." She stated she was at the medication cart when she made the statement. E2 was interviewed on 11/05/03. She stated E11 told her she was out on break when R9 bit R3. She also stated that E15 separated the residents, and informed her of the incident. A counseling document for E11 dated 10/30/03 was reviewed. It documents, in part, that R3 "should have been separated from" R9 "instead of her being allowed to aggravate him all day as reported. Residents should be removed from other resident's local if a problem might occur due to aggravation." b. E22, CNA, was interviewed on 10/29/03. She stated E11 LPN placed R3 in the foyer under the ceiling fan and R3 complained of being cold. She stated E11 placed R3 under the ceiling fan just to aggravate E54 (Activity Director). She stated R3 did not like the fan because she was cold all of the time. She stated E11 and E54 received a one day suspension for getting into a verbal altercation in front of residents over the fan issue. During an interview of E29, CNA, she stated E11 placed R3 under the ceiling fans and R3 complained of being cold. E29 stated E54 and E11 "got into it" over R3 being placed under the fan and were both suspended one day by E51 (Director of Nurses). During an interview of E11 LPN on 10/30/03, she stated R3 was at the coffee table one morning and she pulled her back to let residents in. Both ceiling fans were on and blowing air at her. E11 stated R3 never stated she was cold but told E54 she was cold. She also stated to E54 that she had not had anything to eat or drink and had been wanting to go to the bathroom for a couple of hours. This happened about 8:00 to 8:15a.m. E11 corrected R3 by saying to her and E54 she had eaten, had drank coffee, and she had not been asking to go to the bathroom. Yelling ensued between E11 and E54. E11 told E54 maybe she should take care of R3 if she did not think they were doing a good job and then excused herself and went outside the building. E11 stated she offered to leave, because she reported to Z4 she had lost her temper. The Administrator (Z4) told her no that E51 would deal with it tomorrow. The next day E51 suspended her and E54 for one day. This incident happened May 6, 2003. Review of the facility's investigation report documented that E11 stated she placed R3 under the fan because she had a problem taking care of this resident. She was hard to take care of. Review of the 10/30/03 documentation for "Counseling" with E11 documented in-part that E11 was having a "hot flash." She turned on a fan to stay cool and had R3 "in the same area." E11 "knows that R3 is very sensitive to cool temperatures." E54 "shut off the fan and an argument ensued." Review of E51's written documentation showed that she received a phone call at home about an incident that took place between two employees. E11 and E54 got into a yelling episode in the sitting area next to the nurses station. E13, LPN (Assistant Director of Nurses) heard E11 and E54 yelling loudly in front of the residents about one certain resident sitting directly under a fan without a sweater on. E54 was yelling at E11 about not paying attention to a certain resident's needs or wants, and that E11 purposely mistreats that resident and she doesn't get coffee or treats when the other residents do. E54 accused E11 of isolating this resident from other residents, singled out this resident, and coerces other staff to mistreat this resident. When E51 returned to work on 05/07/03, E51 talked to E11, E54, and E13. She gave E11 and E54 a one-day suspension without pay. E51 documented "I have looked into these accusations of mistreatment to this one resident. On several occasions I have never found any supporting evidence of any type of mistreatment." When interviewed, E51 stated the resident referred to is R3. c. Review of the facility investigation documented that E53 CNA squirted R3 in the face with water that had been placed in a feeding syringe. The facility interviewed E29 CNA and she informed them that E53 CNA would fill feeding syringes with water and squirt them at residents to make them think it was "snot." This happened approximately two months ago. E29 also informed the facility that E53 would sometimes wet paper balls and throw them at residents including R3. He also would put sanitizing gel on his hands and then act like he was sneezing and flick his hands around residents including R3. d. During interview of E29 on 10/29/03 at 4:00p.m. and according to the interview she gave to the facility, she stated R3 rang the call light because she thought she had wet the bed. When E28 CNA and E56 CNA came into the room and found that she had not wet the bed, they said to her "Liar, Liar pants on fire". e. Review of R3's clinical record showed diagnoses that include: Brain Tumor with Craniotomy, and Hallucinations. Review of the 09/05/03 quarterly assessment showed, in-part, that R3 has a long and short-term memory deficit, is moderately impaired cognitively, is extensive assist to total assist with activities of daily living, is continent of bowel and bladder, has hallucinations of people being there when they are not, slaps-hits-bites-kicks during care, and uses a reclining chair; has periods of restlessness. f. R3 was interviewed on 10/28/03. This interview confirmed that R3 is blind, has poor hearing, and denied any abuse. g. Review of R9's clinical record showed a diagnosis of Alzheimer Disease. Review of the 07/16/03 assessment documented, in-part, he has a long and short-term memory deficit, is severely impaired cognitively, sometimes understood/understands, was physically abusive four to six days but less than daily and behavior is not easily altered, had daily socially inappropriate/disruptive behavior which was not easily altered, was dependent for most activities of daily living, and had a history of biting which was being tracked on the behavior form. R9 passed away in September of 2003. Based on record review and interviews it was determined that abuse was not reported immediately. When abuse was reported the allegations were not investigated and/or thorough investigations were not done. The facility did not ensure the potential for further abuse would not occur as the alleged perpetrators of the abuse were not removed from the facility until an investigation was thoroughly conducted. The facility failed to report the alleged abuse immediately to the State Agency. The facility failed to address an evident systemic problem of abuse to protect residents. The facility failed to have ongoing training of their abuse policy and procedure and failed to do annual staff evaluations to determine training needed so each staff person could be competent in their duties and/or responsibilities. This includes: I. a) R5 who is known to not like anyone in her room had rolled up blankets placed in her bed to denote someone was in the bed. This caused R5 to become upset and angry. During interview it was stated three staff were involved in this incident but only one staff person had anything said to them by the Administrator. The incident was not reported immediately. No investigation was done of the incident to determine who was involved. b) R4 who is known to be afraid of dogs was told there was a dog outside to keep her from leaving the building. R4 was in bed and E28 (Certified Nurse Aide) was down on the floor, and barked like a dog. R4 was told her panty hose, panties, and socks were smelled, and sniffed by E53 when they were taken off. R4 was told staff were partying, at her house, and E15 (Licensed Practical Nurse) and Z15 (Certified Nurse Aide) were married with E15 being an alcoholic and abusive to the Z15, knowing this behavior is against R4's religious beliefs. During interviews it was determined not all incidents were reported or reported immediately and were not investigated thoroughly. c) R16, a cognitively impaired resident, had powder put on her face by Z15 (Certified Nurse Aide). Z15 dimmed the lights in R16's room, and then called E11(Licensed Practical Nurse) into the room to look at R16. During interviews, it was determined that the incident was not reported immediately and was not investigated. d) R11 would be reading and her light would be turned off without anything being said to her which would upset her very much. R11 believed taking her medication at the same time daily would help her medical condition. E11 (Licensed Practical Nurse) would consistently tell her to wait when she would go up to the medication cart and request it. This upset R11 very much. During interviews it was determined incidents were not reported immediately, and were not investigated. e) R10 worries about injuring her legs due to poor circulation. E53 (Certified Nurse Aide) placed ketchup in his hand. E53 then showed his hand to R10. R10 believed it was blood, and that she had been injured. During interviews it was determined no investigation was done and the incident was not reported immediately. f) E28 put a sheet over herself. E28 would then shake a fly-swatter at R14 and tell R14 to be quiet. Interviews showed this incident was not reported or investigated. g) R3 and R9, who had been aggravating each other had no staff intervention until R9 bit R3. During interview, it was determined the nurse knew these residents were aggravating each other but there was no intervention until a physical altercation occurred. R3 had a fan placed so the air would be on her even though she expressed she was cold. During interviews, it was determined not all incidents were reported or reported immediately, were not investigated, and were not reported immediately. II. Review of the training records for the past two years showed no training had been done on the facility's abuse policy/procedure. No training was held for intervention to prevent abuse. III. Review of the personnel files showed no annual evaluations of direct care staff were being done. IV. Review of the time cards and personnel files of the staff who committed abuse or were alleged to have committed abuse, showed the last day staff was removed, until an investigation was done, was 10/30/03. V. During interviews it was stated some incidents of abuse were reported to E51(Director of Nurse) and/or Z4 (Administrator). They failed to do any investigations or to recognize they had a systemic problem. They failed to take corrective action in a timely manner. VI. The facility failed to notify the State Agency of the allegations of abuse. Findings include: I. a. R5 had a rolled up blanket and a wig placed on her bed as if there was someone in her bed. Staff knew she did not like anyone in her room. E53 (CNA) and E29 (CNA) placed the items in the bed while E35 (CNA) observed. This was also brought to E10 LPN's attention. This incident was not reported by any staff until the next morning when the resident mentioned, the incident, to a staff person. They informed Z4 (Administrator). No exact date was given for this incident but Z4 was appointed Administrator 02/18/03, began as Administrator 03/03/03, but did not actually do the Administrators job until 06/03 as E51 kept acting as Administrator until then. Interview of Z4 on 11/04/03 at 5:32p.m. by telephone. Z4 stated she spoke with R5 about the incident. Z4 stated she told E53 not to do it again. Surveyor asked her why the other two staff involved were not spoken to. She stated no one had brought it to her attention that anyone but E53 was involved. No investigation was done. b. R4 was told there was a dog outside, by Z15 (CNA) to keep her from exiting the building. E28 (CNA) was down on her knees in R4's room. E28 barked like dog. It was well known by all staff that R4 is fearful of dogs. R4, a year or so ago, was told by E53 and Z15 that her pantyhose smelled after she took them off. R4 was told E15 (LPN) and Z15 were married and E15 was an alcoholic and abusive to Z15. Beer drinking and dancing was going on in her home when she went to bed. Staff knew this behavior would upset the resident as it was against her religious beliefs. E15 heard these statements and told them not to say it again but it continued. Staff were aware the statement about the pantyhose was being made. Z15 stated, in 05/03, to R4 she did not know how she was going to explain to her daughter she was pregnant. During interview of staff none of the above instances were reported immediately and no investigations were done. Interview of E51 (Director of Nurses) on 11/04/03 at 1:25p.m. by telephone. E51 stated she knew nothing about the above incidents until the IDPH surveyor told her. Interview of Z4 (Administrator) on 11/04/03 at 5:32p.m. by telephone Z4 stated she knew nothing of the above incidents until the IDPH surveyor told her. Investigation was not began until after 10/23/03 when E51 terminated her employment. E53's last day worked was 10/20/03. Z15's last day worked was 10/20/03. Incidents with R4 had been going on for at least one year. Interview of E15 (LPN) on 10/28 and 11/05/03. E15 stated he had reported to E51 and did not feel she was doing anything about the report so when Z4 started he spoke with her about his concerns. He stated he had also spoken with a board member and twice with the Commissioners, but nothing was done. E15 stated Z3 (Activity Director) has also spoken to the Commissioners. c. During interviews, it was stated Z15 placed powder on R16's face sometime in the last year, dimmed the lights, and asked staff what was wrong with her (E57, E53, E29, E11). This incident was not reported until surveyors were asking questions in 10/03 so an investigation was not began until at least 10/24/03. d. R11 had the light turned out on her while she was reading by E11 (LPN). E11 would continuously not give R11 her medication when she requested it. Staff were aware of the nurse turning out the resident's light. E15 and E18 (RN) were aware of the medication issue, but no one reported the incidents immediately and no investigation was done. Interview of E15,and he stated he had reported the above incidents to a board member when reporting to E51 and Z4 did not bring resolution. Surveyors brought these incidents to the new Administrators attention. She counseled E11 on 10/30/03, in the morning, but did not suspend E11. An investigation was not done until concerns were again brought to her attention about an investigation not being done after the facility was first informed of the above by the surveyors. E11's last day worked was 10/30/03. During interview of the new Administrator, she stated E11 is being terminated but she has been unable to get a hold of her to inform her of that fact. On 11/13/03 the Administrator informed the surveyor she had gotten a hold of E11 by telephone and terminated E11's employment. R11 was discharged, from the facility, in May 2003. e. R10 is afraid of lower extremity injury. E53 (CNA) placed ketchup in his hand and reached down toward R10's legs. E53 then showed her the ketchup which scared R10 as she thought it was blood. This was witnessed by E36 (CNA). R10 had E36 to refuse to assist her in some activities of daily living. E36 told R10 she could do it herself which upset her as she was unable to do the things she needed done. This all occurred the end of December of 2002 and/or the first of January of 2003. These incidents were not reported thereby not investigated until the surveyors brought this to the facility's attention after 10/23/03. E53's last day worked was 10/20/03. f. E28 put a sheet over her head. E28 held a fly-swatter, and shook the fly-swatter at R14 telling him to be quiet. This was observed by E22. This incident was not reported until surveyors brought it to the facility's attention after 10/23/03. E28 was suspended 10/28/03 and allowed to return to work on 11/03/03 after the facility's investigation was completed. E28 had been counseled, and had attended two in-services on abuse. g. R3 had a fan placed so that the air would be on her. R3 expressed she was cold. R3 was placed under a fan by E11 (LPN) and this was known by several staff members. Z3 (Activity Director) and E11 had a verbal altercation partly over the fan issue. Z4 (Administrator) was aware of this incident at the time. Z4 took no action and told E11 that E51 would take care of the situation when she returned. E51 returned the following day and suspended both employees for one day without pay. E53, during interviews, was found to have placed water in a feeding syringe and squirt the water at residents including R3. E53 would wet small pieces of rolled up paper towel and throw them at residents including R3. E28 and E56 stated "Liar, Liar pants on fire" to R3 when she believed she had been incontinent but she had not been. The above incidents were known by staff but no one reported these incidents until interviewing them in October and November of 2003 to complete an investigation on abuse allegations. II. During interviews, it was stated the facility's governing body was made aware of some of the abuse allegations. The governing body did not ensure the staff alleged to have perpetrated the abuse were removed from the facility. They failed to ensure an investigation and/or thorough investigation was completed. They failed to address an evident systemic problem of abuse. After the facility was informed of the IDPH findings on 10/02/03, they still allowed the alleged perpetrators to work. III. Review of the employee personnel files, it was noted that none of them had annual evaluations. IV. Interview of E51 (Director of Nurses) on 11/04/03 at 1:25p.m. by telephone. E51 stated she had not done evaluations for two and maybe three years. V. Interview of Z4 (Administrator) on 11/04/03 at 5:32p.m. by telephone stated, she did not know of any abuse so she could not have notified the State Agency. After an IDPH surveyor brought abuse issues to the facility's attention, 10/02/03, there was no investigation done. Based on interview, it was determined the facility's governing body did not ensure the facility's policy and procedures, on abuse were being followed.
Interview of E15, LPN (Licensed Practical Nurse) on 09/16/03, 09/29/03,10/28/03 and 11/05/03 stated that he reported to E51 (Director of Nurses), and Z4 (Administrator), about hearing Z15 (Certified Nurse Aide) and E53 (CNA) telling R4 when her panty hose were removed they smelled. Also telling R4 they have beer parties at her home when she goes to bed and dance on the tables. E15 stated Z15, CNA, falsely told R4 he was married to Z15 and E15 (LPN) was an abusive, alcoholic husband who beat her. E15 stated R4 would become upset after hearing these things and would become agitated and refuse to take medications dispensed by him. E15 stated he told Z15 and E53 he never wanted to hear them say these things again. Interview of E15 on 10/28/03 stated he reported the panty hose incident and other issues to Z24 (Advisory Board member). E15 stated on 11/05/03 that he informed Z24 that R11 left the facility because R11 had her light turned off while she was reading and was not receiving her medication when she went up to the medication cart. He informed Z24 he heard E28 (CNA) barked like a dog at R4. E15 stated Z24 seemed concerned. Z24 stated something should be done. Z24 would discuss it and see what could be done. E15 thought she meant she would discuss it with the Commissioners. E15 also stated that he had told Z4 about the concern involving E11 and R11 when Z4 began working at the facility. E15 further stated that he spoke to all three Commissioners (Z25, Z26, Z27) twice, once shortly after June 5, 2003 and again just prior to E51 terminating her employment (10/21/03). E15 stated he met with all three Commissioners in their office at the Courthouse. On the second visit, Z3 (Activity Director) accompanied him. E15 stated he informed them of everything that he had informed Z24 of and some additional things that were going on between him and the former Director of Nurses. E15 stated he brought his concerns/complaints to the attention of management per the chain of command: Director of Nurses, Administrator, Board, and Commissioners. E15 stated that he and Z3 (Activity Director), and Z18 (former Assistant Activity Director), E22 (CNA), E29 (CNA) have all talked to the Board members about the concerns of abuse/mistreatment. Interview of Z4 (Administrator) on 11/04/03 stated the staff rolling up blankets or pillows and placing in R5's bed was brought to her attention the morning after it happened. She spoke with the resident and to E53 (CNA) who placed the pillows/blankets, and told him not to do it any more. When asked why she did not speak with the other two staff persons involved (E29,E35), she stated no one told her anyone else was involved in the incident. No investigation was done. During interview, she stated she had heard rumors of a staff person putting a sheet over their head. Z4 did not do an investigation to see if the rumor was valid. She stated a resident across the hall from R14 would hit his table with a fly-swatter. A staff person would tell him to be quiet. Z4 stated Z24 did bring a concern to one board meeting and believed the concern was that the residents were not getting the total care needed which involved R3 not being toileted. She stated she observed a few days and the resident was being toileted. Z4 could not remember any other concerns brought to her attention by the Board and none by the Commissioners. Interview of E19 (Social Service Director) on 09/15/03 at twelve noon. E19 stated that she had reported to Z4, 09/05/03 that R5 had stated a CNA "balled her out" for using the bathroom in the mini dining room, and the same CNA had done this to her before. E19 stated that Z4 said she would take care of it. No investigation was done into this concern/complaint by the resident. Interview of E19 on 11/05/03, E19 stated she had presented a letter to the Board and a Commissioner (Z25), at the board meeting in October of 2003. The letter asked for E51's resignation. The letter also mentioned the repeated verbal abuse of Z3 by E51. Interview of E2 (LPN) on 11/05/03 stated that Z24 told her she was always getting telephone calls about the nursing home. Z24 indicated that all she could do was pass the concerns on to the Commissioners, as the Board can only advise. Review of the facility's "POLICY ON ABUSE OR NEGLECT" showed documentation, in-part, "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 or if he is not available then to the Department." Review of another "POLICY ON ABUSE" showed the facility's procedure, in-part, is "a facility employee who becomes aware of resident mistreatment shall immediately report the matter to their supervisor regardless of the situation; any facility employee reasonable suspected ofmistreatment shall immediately be asked to leave the facility and shall be placed on suspension pending the outcome of the investigation, the charge nurse shall notify the Director of Nursing and the Administrator as soon as possible; the charge nurse or Director of Nurses shall notify the resident's physician; the Administrator shall have witnesses (if any) document date and sign a statement describing what they saw or heard. The charge nurse shall document the alleged incident in the residents' clinical record; the Administrator or Director of Nurses shall notify the family and/or resident's legal representative, and the Illinois Department of Public Health of the alleged mistreatment within 24 hours and shall follow-up with a written report within five (5) working days of the outcome of the facility investigation to the Department; if the alleged mistreatment is determined by the Administrator and Director of Nurses to be abuse or neglect appropriate action shall be taken to ensure the safety of the resident. The total governing body did not ensure the facility's abuse policy/procedure was followed in that no investigations were done when concerns were brought to their attention in reference to staff mistreating residents. When known abuse situations were determined the staff found to have caused/done the mistreatment were still allowed to work. The Commissioners or the Advisory Board did not ensure the Administrator was following the policy/procedure on abuse to ensure resident safety after they were aware of known instances of mental abuse. When allegations of mistreatment/abuse were brought to the governing body's attention the alleged perpetrators were not removed from direct care per the facility's policy/procedure. E53 and Z15 continued to work after it was known they had caused residents mental anguish. E11 was allowed to work after allegations of resident mistreatment was brought to the facility's attention and an investigation was not began. The governing body did not ensure residents confidentiality was maintained in that the Director of Nurses had placed the resident's identity key with the State deficiencies for anyone to read. The governing body did not ensure the facility's personnel policies on harassment were followed. Review of the facility's harassment policy showed documentation, in-part, the facility will not tolerate or condone any actions by any person which constitutes harassment of an employee; "Harassment is defined as unwelcome advances, requests for sexual favors and other verbal, written or physical conduct by employees or supervisors, where such conduct is either made an explicit or implicit term or condition of employment; used as the basis for employment decisions affecting employees; or has the purpose or effect of substantially interfering with an employee's work." Interview of E15, and he stated after he had spoken with the State surveyor that E51 accused him of giving a bad report to the State. E51 passed a petition around to get names to have him terminated from his employment. E15 stated E51 passed out the employee identity key when the State findings were issued and highlighted in yellow the names of staff who complained to the State, highlighted in blue the ones who had complaints, and circled two names (E22, E29) that denied something in the report. E15 stated if E51 did not like you, you were gone. During confidential interviews of staff it was stated a person had to be careful in what they said or did because if E51 did not like it you were gone. She would make it so hard that staff would quit or she would find a way to get rid of you. It was felt, by staff that E51 had to know passing the employee identity key to employees would cause dissension between many of them. Interview of E51 on 11/04/03 stated that she had passed a petition around to be signed so she could get E15 fired but few would sign it. During interview she stated she had not done evaluations of the staff for two years and maybe three. E51 stated she could not remember if an in-service on abuse had been done recently but upon hire each employee gets a copy of the abuse policy/procedure. The governing body failed to ensure evaluations were done annually on staff, as required, to ensure their competency in their duties/responsibilities and determine what training may be needed. The governing body failed to ensure continual training was provided to staff as review of the in-service records, for the past year, showed no training on abuse/neglect. The governing body did not ensure required Quality Assurance meetings were held and did not ensure the appropriate people were in attendance at the meeting held. During interviews and review of the facility's quality assurance meetings, it was shown the last Quality Assurance meeting held was in May of 2003; no content documented. The Quality Assurance meeting before 5/03 was in 10/02. During interview of department heads it was stated the last Quality Assurance meeting was in 5/03, and they could not remember when the one before that was held; all interviewed stated only the Administrator and department heads attended. Review of the "ADVISORY BOARD MEETING" minutes, for May, July, August, September, and October of 2003 showed no documentation of any concerns/complaints being addressed for May, July or August. In September, a concerned citizen representing employees was present to discuss the resignation of a former employee (E54). The Board went into executive session to discuss the resignations of E51 and Z4. There were six Board members, one Commissioner, and the Administrator present for this meeting. At the October 21, 2003 meeting "Twenty persons were present to address some problems among staff, residents, and asking for the resignation of the Director of Nurses." E19 "presented papers to the board outlining the complaints to read. Questions were asked and we told them we would look into it." There were four board members and one Commissioner present. |