Emerald Park Health Care Center
Facility I.D. Number: 0040816
Date of Survey: 10/17/2003
Complaint Investigation and Special Licensure Survey
The facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and
psychosocial well-being of the resident, in accordance with each resident=s comprehensive assessment and plan of care.
Adequate and properly supervised nursing care and personal care shall be provided to each resident to meet the total nursing and
personal care needs of the resident.
Objective observations of changes in a resident=s condition, including mental and emotional changes, as a means for analyzing and determining care required and the need for further medical, nursing or psychosocial evaluation and treatment shall be made by nursing staff and recorded in the residents medical record.
Personal care shall be provided on a 24-hour, 7-day-a-week basis.
All necessary precautions shall be taken to assure that the residents=environment remains as free of accident hazards as possible. All nursing personnel shall evaluate residents to see that each resident receives adequate supervision and assistance to prevent accidents.
The DON shall oversee the nursing services of the facility including:
Overseeing the comprehensive assessment of the resident=s needs, which include medically defined conditions and medical functional status, sensory and physical impairments, nutritional status and requirements, psychosocial status, discharge potential, dental condition, activities potential, rehabilitation potential, cognitive status, and drug therapy.
All exterior doors shall be equipped with a signal that will alert the staff if a resident leaves the building. Any exterior door that is supervised during certain periods may have a disconnect device for part-time use. If there is constant 24-hour-a-day supervision of the door, a signal is not required.
AN OWNER, LICENSEE, ADMINISTRATOR, EMPLOYEE OR AGENT OF A FACILITY SHALL NOT ABUSE OR NEGLECT A RESIDENT. (Sections 2-107 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)
This REQUIREMENT is not met as evidenced by:
Based on resident and staff interviews, review of medical record, incident reports, and review of facility abuse policy, the facility failed to prevent one resident (R5) from continuous witnessed verbal and mental abuse from staff (E3), failed to do a comprehensive investigation of allegations of abuse and injuries of unknown origin for 1 resident (R5), and failed to report abuse allegations to proper authorities.
1) On 10/6/03 during the initial tour on the 2nd floor, surveyors were informed during a confidential resident interview, that the resident had witnessed E3 (Resident Care Service Assistant) pull off R5's wig and throw the wig up on top of the fan at the nurses station while staff were present. The resident stated that the nursing staff did not intervene during the wig tossing.
During an interview with E6 (LPN- p.m. supervisor) on 10/6/03 at 4:15 p.m. when questioned by surveyor if E6 ever witnessed E3 do anything mean to resident, E6 responded:
"There is a 2nd floor confused resident (R5), E3 made fun of R5 a few weeks ago. E3 pulled off R5's wig and made snide remarks. When I saw E3 doing it I did not think it was abuse. I talked to E3 about it and he never did it again." E6 stated she did not report E3's actions to anybody.
On 10/8/03 during the daily status meeting, E1 provided the surveyors this undated statement hand written by E6. "This writer observed a social service aid make an inappropriate remark to a female resident take that wig off or straighten it out. This writer spoke to staff members about remark. He then apologized to resident and this writer." E6 did not state during her interview with surveyors that E3 had apologized to R5, E6 had stated that E3 had, "teased the resident".
On 10/7/03 in R5's room during interview with R5, surveyor asked R5 if any staff were ever mean to R5, R5 responded: "The night man of security snitched off my wig and is always teasing me about my wig. It makes me mad and I get agitated."
On 10/8/03 at 1:40 p.m. per phone interview with E3, surveyor asked E3 if he teased R5 about her wig, E3 made the following statement: "I was always teasing R5 about her wig, take the wig off. You wouldn't like the wig because it was an ugly wig." E3 also stated R5's wig had disappeared and was asked by R5 if E3 had taken the wig, E3 denied taking R5's wig.
2) Review of R5's clinical record revealed R5 is a 42-year-old with diagnoses that includes Schizoid-Affective Disorder and Seizure. Review of current Minimum Data Set reveals R5's cognition is moderately impaired and that she has limited vision.
Review of nurses noted dated 3/11/03 at 7:00 a.m. revealed R5 was noted ambulating with slow gait and noted with right side of head and face very swollen, right jaw swollen and hard to touch. Documentation include that when R5 was asked what happened R5 responded "that man did it." Further review revealed R5's physician was notified and R5 was transferred to hospital emergency room and admitted with diagnosis of Intercranial Hemorrhage.
Review of physician consultant notes (Z13) dated 3/14/03 reveal R5 was admitted to hospital CAT Scan of the brain on 3/11/03 showed benign perimesencephalic hemorrhage on the right and a swelling in the right temporal scalp and by the right orbit, consistent with post-traumatic change.
During review of nursing notes and incident report dated 3/11/03 with E1, E1 stated she did not do an investigation into R5's allegation of a man hitting her or R5's injuries of unknown origin, and did not notify IDPH regarding allegations of abuse or unknown injuries. The incident report documents that R5 did not have a change in level of consciousness, was observed with very edematous right side of face, right jaw puffy and right eye closed and did not require hospitalization. The incident reports states, "Unknown origin".
Review of facility policy for report of abuse and neglect requires the following procedure by facility and staff: For all allegations of resident abuse, neglect, mistreatment, corporal punishment, involuntary seclusion, misappropriation of resident property and/or funds, or, injuries of unknown origin, the following steps are to be adhered to:
1) All employees are to immediately report the allegation to his/her supervisor and the Administrator.
2) The Administrator is to organize a team to promptly and thoroughly investigate all allegations. A written report of the investigation will be maintained by the facility.
The facility and staff in failing to follow the facility abuse policy has placed R5 at risk for continuous verbal and mental abuse by E3.
Based on interviews, record reviews and policy review, the facility failed to:
Findings include the following:
R3 was a 44 year old male who was readmitted to the facility August 7, 2003. R3 had the following diagnosis: Seizures, Hernia, Diabetes, Depression, Anemia, Ulcers, Chest Pain. R3 had been observed by staff and other residents drinking alcoholic beverages to the point of losing consciousness. R3 was physically carried by E3 (Resident Care Services Assistant) up to his room on the second floor October 3, 2003 and was not monitored or assessed by nursing staff. R3 was found by another resident around 3:00a.m. and was noted by staff to be in full arrest. Paramedics arrived and transported R3 to the hospital where he was pronounced dead.
R4, the resident who found R3 unresponsive was interviewed on October 7, 2003. R4 stated that R3 had been drinking earlier in the evening and that E3 (Resident Care Services Assistant) was observed by R4 taking R3 to his room. R4 stated that he went to R3's room early in the morning to see if R3 was okay. R4 stated that he touched R3 chest and that R3 had no breath and touched R3's hand and, "it was cold as ice". R4 stated he went and got another resident, R15. R15 went into the room and then got the nurse, E16. R4 stated that R3 would drink as much as he could and that he would drink until he ran out of money. R4 stated, "R3 gets drunk everyday."
R15 was interviewed on October 6, 2003. R15 stated that R4 had come to his room and asked him to go to R3's room because R3 did not look good. R15 went to R3's room and thought that R3 was dead so he went and got E16 (night nurse). R15 saw the staff place R3 on the floor and stated during the interview that "he had rigor mortis". R15 stated that when the staff lifted his arms, "the whole body moved". The paramedics came and took R3 away.
E16 (night nurse on duty October 3rd) stated during interview of October 7, 2003 that she was given report that R3 had been drinking and had been involved in an altercation. E16 stated during rounds between 11:30p.m. to 12:00a.m. that she noted R3 in bed and that his television was on. E16 stated that she did not enter the room but observed R3 from the doorway. E16 did not take vital signs or monitor R3 in any way. At about 3:00 a.m. R15 came to the nursing station and told her that R3 was "dead". E16 went to the room and checked R3's breathing by putting her head on R3's chest. E16 stated that R3 was "cold" and that she went to the nursing desk and called E6 (nursing supervisor). E16 stated that she got the crash cart and moved R3 onto the floor and started cardio pulmonary resuscitation. The paramedics arrived and took over. E16 stated, "It's not unusual for R3 to get drunk. Not every night but he is a regular".
E6 (night shift supervisor) was interviewed on October 6, 2003. E6 stated that at about 3:30a.m. E16 had called her to come up to the second floor. E6 stated that the resident was non responsive with "cold hands, but warm torso". A code was called and the facility started cardio-pulmonary resuscitation (CPR). E6 stated that they continued until the paramedics arrived. E6 stated that she had worked a double shift that night (3p.m. to 11p.m. and 11p.m. to 7a.m.) and had heard that earlier in the evening that a few residents including R3 had been drinking alcohol and were intoxicated. E6 also stated that staff had told her that R3 was "passed out" on the first floor in another resident's room. E6 stated that E3 (Resident Care Services Assistant) had taken R3 back up to the second floor.
E6 stated that during the afternoon shift both E1 (Facility Administrator) and E18 (Director of Nursing) were still in the building and aware of the drunken behavior. E6 stated that E4 (second floor afternoon nurse) was in charge of R3 after he was brought up to the second floor. E6 admitted that she did not assess or take vital signs on R3 when she was notified that he was passed out because his charge nurse would do this.
E7 (first floor afternoon nurse) was interviewed October 6, 2003. E7 stated that at about 4:15 to 4:30p.m. she was passing medications and found R3 passed out in another resident's room. E7 stated that she could not wake R3 and she called E3 to come and get R3. E7 stated it was a pattern for R3 to get drunk. E7 stated that she just tried to make sure that the residents were safe and they did not hurt each other. E7 stated that its nothing new for residents to be drinking and she did not know if the residents had been paid, but whenever the resident got paid there was increased drinking.
E18 (Director of Nursing) was interviewed October 7, 2003. E18 stated she was present when E3 carried R3 upstairs. E18 stated that E3 carried R3 over his shoulders up to the second floor. E18 stated that she asked E3 why he was carrying R3 over his shoulder. E18 stated that E3 did not respond to the question. E18 stated that she heard R3 snoring and that she had informed E6 (nursing supervisor) about R3's condition. E18 admitted to not checking on R3 because she thought the charge nurse on second floor would monitor him. E18 stated that R3 drank on regular basis, and that R3 would be intoxicated two to three times per week. E18 stated that the nursing department should check on residents at least every two hours when they are drinking, but did not give any specific details about how to monitor the residents. E18 stated there is no monitoring policy or procedure, but did state that the physician was notified of residents who were intoxicated and agitated.
E4 (second floor afternoon nurse) was interviewed by phone October 7, 2003. E4 stated she had asked R3 if he had been drinking that day before she gave him afternoon medication at about 4:00 to 4:30p.m. E4 also stated that R3 had a history of drinking and getting drunk and that she would not administer medications to a resident who was drunk. E4 stated that she was called about 5:15 p.m. or so about R3 being drunk and passed out on the first floor. E4 saw E3 carrying R3 over his shoulder into his room. E4 stated that she checked on R3 about 5:30 to 5:45p.m. and he was in bed snoring, so she sent his supper tray back to the kitchen. E4 stated that she did not take vital signs or assess the resident in any way. E4 stated that she gave R3 some Tylenol about 9:15p.m. because R3 had complained of shoulder pain. E4 stated that she had called Z1 (medical doctor) about an earlier incident involving R3. E4 stated that "I did not tell the doctor about R3 drinking".
Z1 (attending physician) was interviewed by phone October 7, 2003. Z1 stated he was informed of R3 being drunk and "I told them [meaning nursing staff] to let him sleep it off". Z1 stated that this was R3 usual customary behavior and that the staff should monitor R3 every hour to ensure that he was still in bed and sleeping. Z1 stated that, "I am not concerned about the alcohol use, 40% of the young male population in nursing homes drink and sleep it off, I go to 25 different nursing homes and it is very common." Z1 was asked again to define monitoring of a resident who has been drinking. Z1 responded that he meant to check the resident at least every hour to see if he/she was still in bed. Z1 also stated that he had refused to sign the death certificate after the Emergency Room had called because R3 had been involved in an altercation in which he fell and hit his head. Z1 stated that the nurse had told him the resident was fine but he was concerned about the fall and the resident's death.
Z4 and Z10 (paramedics) were interviewed by phone October 6 and October 14 about R3. They were called to the facility for full arrest and found R3 to be in full arrest and staff were preforming CPR. Both Z4 and Z10 stated that R3 had rigor mortis and that they were unable to intubate due to the rigor. R3 was pronounced dead upon arrival to the hospital. A review of the South Cook County EMS Report Form confirms Z1 and Z10's statements.
Surveyor reviewed Z11 (Investigator of Evergreen Park Police Department) report concerning R3's death. The report indicated that R1 (roommate of R3) had witnessed R3 being put to bed by E3 and that R3 had been intoxicated. Surveyors attempted to interview R1 who would not discuss the incident. R1 stated he, "didn't want to tell anything". Attempts were made to interview R16 and this resident did not want to discuss the incident but confirmed that R3 had been drinking that evening.
Surveyor was unable to interview R8 (resident present when R3 was found intoxicated), but R8 had been discharged to the hospital and was not available for interview.
R6 (resident on the second floor) was interviewed October 9, 2003. R6 stated that she observed E3 carrying R3 to his room on Friday. R6 stated, "it looked like there was no life in him". R6 described R3 as being lifeless with his arms dangling and being carried by E3. R11 also witnessed E3 carrying R3 to his room.
E10 (Psychiatric Rehabilitative Services Coordinator [PRSC] was interviewed and confirmed that R3 was "passed out" on the first floor at 5:00p.m. and that E7 (nurse) had called for R3 to be removed. E10 stated that E3 carried R3 up the stairs fireman style and that the nurse was aware that R3 was intoxicated and that he was in bed. E10 left the facility that evening at 6:00p.m. and R3 was still passed out.
E3 (Social Service Resident Assistant) was interviewed by phone October 8, 2003. E3 stated that he had been informed by E7 (nurse) that R3 was drunk. E3 stated he carried R3 upstairs via "fireman style". E3 described R3's condition as "awake but snoring". E3 admitted that R3 would drink, "any chance he could". E3 also stated there were other resident who regularly consumed alcohol in the facility. E3 stated that he had checked on R3 during rounds at 8:30p.m. and he was sleeping. E3 stated that when residents drank in the facility or were intoxicated he would, "let them sleep it off." E3 had no medical or professional psychiatric training.
E17 (Certified Nursing Assistant) stated that at about 2:30p.m. that she thought that R3 was drunk. E17 stated that she knew R3 was drunk by his behavior. E17 stated that a lot of residents drink alcohol and that they find bottles all the time.
E1 (facility administrator) and E2 (corporate nurse consultant) were interviewed on October 6, 2003. Both stated that R3's death was being investigated because Z1 (attending physician) would not sign the death certificate. E1 stated that Z1 is notified when residents are drinking but Z1 just tells them to give medications anyway. Z1 also at times does not promptly answer his pages and tells staff just to let residents sleep it off. E1 and E2 admitted that the facility lacked a specific policy for alcohol use and monitoring residents. E2 stated, "We cannot get the doctors to agree on a policy". Both indicated that the facility would suspend passes for those residents who had behavioral problems, but were unsure how R3 was able to obtain alcohol. E1 stated that R3 did attend his outside program on October 3, 2003.
Z3 (driver for outside program van) was interviewed October 9, 2003 and stated that he never stops the van. Z3 remembered R3 attending program on October 3 and that residents all had money from the program. Z3 stated he did not think R3 had been drinking yet that day, but at times he looked like he had been drinking. Z3 also stated that residents will try to get him to stop so they can go to the store after getting their money from program.
Z2 (psychiatrist) was interviewed by phone October 7, 2003. Z2 stated he was aware of R3's drinking behavior and that, "he has a long history of getting intoxicated and sleeping it off". Z2 also stated that he advised nursing staff to follow the directions of the medical doctor before administrating medications to an intoxicated resident.
Nursing staff failed to adequately monitor and assess R3 after he became intoxicated and lost consciousness and failed to adequately monitor a resident who had a known history of using alcohol and becoming intoxicated.
Based on observation, clinical record review, resident and staff interview, the facility failed to monitor one resident (R5) with known elopement behavior from leaving the facility through an unalarmed and unsupervised basement door. The facility also failed to provide continuous supervision to one resident (R5) who eloped from the facility.
The facility failed to supervise residents who ingest alcoholic beverages, failed to monitor residents who leave the facility on pass and become intoxicated, failed to monitor residents who routinely consume alcoholic beverages to ensure their safety and well being failed, and failed to develop policies and procedures for monitoring of residents who consume alcohol for five out 17 sampled residents (R10, R3, R8, R9, R4).
1) On 10/6/03 at 1:25 p.m., surveyors were walking north on Pulaski Avenue approximately one and a half blocks from facility, when surveyors observed one resident (R5) walking from an alley, east of the facility, then cross in the middle of a local side street. Surveyors observed R5 swaying and staggering while walking.
While surveyors continued walking, surveyors stopped and asked 2 unidentified people who were walking slowly down the street if they recognized the resident.
The people identified the resident as R5 and stated, "They'll get her." Surveyors observed R5 still staggering down the block while the staff walked towards her. Upon approaching the facility, the surveyors stopped two males (R13 and R17) and asked if they knew who the resident was. R17 stated it was R5 and started running after R5.
R13 was interviewed on 10/9/03 at 10:00 a.m. at the day program agency. R13 said that after speaking with the surveyors on 10/6/03 and having identified that it was R5 who was wandering out in the street, R13 returned to the facility to notify staff. R13 stated that R12 who was also walking down the street, stayed with R5 while R13 obtained staff assistance. Interview with R12 on 10/9/03 at 10:20 a.m. at the day program agency confirmed that he remained with R5 while R13 went back to the facility to get help.
During the daily status meeting on 10/6/03 with E1(Administrator) and E2 (RN consultant), surveyors reported seeing R5 staggering down the street. E1 responded that they would check out the incident regarding R5. During daily status on 10/7/03, E1 stated that staff thinks R5 got off the van after returning from the day program and wandered out in the street.
On 10/7/03 at 2:00 p.m. on 2nd floor in R5's room, surveyor asked R5 how she got out of the facility the day before. R5 stated, "I go down the basement stairs and out the door cause its' not alarmed." After interview, the surveyor observed R5 wandering down the hallway and go to the door leading to the basement and open it up. R5 was stopped by E9 (LPN).
Upon interview with E9 (2nd floor LPN) on the 2nd floor at 2:07 p.m., E9 pointed out that only two of the doors marked "Exit" which lead out to the street are alarmed. The other two doors without exit signs share an open landing leading to the basement. The surveyor pointed out that alarm pads are present on these doors, E9 stated, "They don't use them." E9 stated that residents are monitored by staff at the desk.
During interview with E9 on 10/8/03 at 9:30 a.m., E9 stated he was having a cigarette in the facility parking lot on 10/6/03, when E9 stated he was informed by R13 that R5 was walking down the street. E9 stated that R5 was brought back to facility by R12. E9 stated he was the nurse on the 2nd floor where R5 resides and was not aware that R5 was not in the building.
On 10/07/03 at 2:09 p.m., the surveyor walked down the stairs leading to the basement. The surveyor observed an exit door at the south end of the building which leads out to the facility parking lot. The red light on the alarm was on. There was no staff present at the door. E14 (Rehab Nurse) opened the door of the rehab room (across from the exit door) and asked the surveyor if help was needed. Surveyor asked E14 if the alarm to the door was on. E14 stated, "No, the red light indicates the alarm was off." E14 stated sometimes staff will turn the alarm off for deliveries or things. E14 then proceeded to reset the alarm to the basement exit door.
Review of R5 clinical record reveal R5 was admitted to facility in May, 2002. R5's diagnoses includes Schizoaffective Disorder and Seizure Disorder. Review of Minimum Data Set of July 2003 reflects R5's cognition as moderately impaired and has a wandering behavior. R5 is also legally blind. Review of nurses notes from the following dates reflect R5's previous wandering behavior and elopements:
Review of Psychiatric evaluation and treatment plan dated 7/2/03 documents "that while at nursing home, the patient became delusional and uncontrollable. The patient attempted several times to run out into traffic nearly missed being hit by a car."
Review of R5's comprehensive care plan dated 7/5/03 does not address R5's elopement behavior. The care plan does address the fact that R5 is at risk for injury due to poor eyesight and bumps into people and objects.
Review of a facility policy in R5's clinical records indicated "Residents are not allowed in basement without a staff member. Therefore, all departments will be accountable for scheduling and providing escorts for all residents who have any activities in the basement."
Review of the facility policy regarding missing residents and elopements indicated that all residents will be assessed for behaviors or condition that put them a risk for elopement and these issues addressed in the care plan. The environmental preventive measures for elopement include electronic monitoring device, door alarms on facility exits and or staff supervision either by visual contact or by video camera of facility exits. At no time shall any of these monitoring device be turned off without the continual supervision of the appropriate exit. It indicated that residents identified with behaviors that may result in a safety concern which include wandering and history of elopement, to be placed on the "Resident Safety concern List." The residents who are at risk for safety concerns who leave the facility property shall be accompanied.
2. The facility failed to monitor and supervise residents who consume alcoholic beverages and become intoxicated to ensure their safety and well-being. During the survey, staff and other residents were able to identify residents who routinely use alcoholic beverages. E1 (Administrator), E18 (Director of Nursing) and E2 (Corporate Nurse Consultant) all admitted that the facility does not have a policy or procedure for supervising residents who consume alcoholic beverages. The facility lacked a policy for supervising residents who leave the facility and become intoxicated and a policy for supervising residents who obtain a monetary reward for attending an outside program. Specific residents identified by the survey team are as follows:
a) R3 was noted to be intoxicated to the point of losing consciousness on October 3, 2003. Staff did not assess or monitor R3 during the evening and R3 was found non responsive on October 4, 2003 and later pronounced dead. R3 had a history of using alcoholic beverages and becoming intoxicated. R3 was not supervised by the facility to ensure his safety and well-being.
b) R10 has a history of alcohol abuse and on August 13, 2003 was observed in bed bleeding from the mouth and a change in level consciousness. Resident was noted to be lethargic and hostile and was transferred to the hospital emergency room and was transferred back to the facility the same day with a diagnosis of Alcohol Intoxication. E1 stated that the resident had been out on pass and had returned to the facility and was later found intoxicated and needing emergency treatment. The facility failed to adequately supervise this resident with a known history of alcohol abuse.
c) R8 was noted on October 3, 2003 to be passed out in his room. R8 has a diagnosis of Alcohol Abuse. Staff interviewed identified R8 as a regular consumer of alcoholic beverages. R8 also attends an outside program in which he receives money for participation. The facility failed to supervise R8 with financial matters and failed to supervise resident when noted with alcohol consumption.
d) R9 is 34 year old resident with diagnoses that include Bipolar Disorder. According to the MDS dated 7/16/03, this resident has no identified behavior problems. R9 was noted by staff on September 27, 2003 at 1:40p.m. to be "extremely diaphoretic, nodding, and responsive to tactile stimulation, was combative at times with confusion." The physician was notified and R9 was transported to the emergency room where R9 was placed on a ventilator. Review of the hospital records reveal that R9 had "acute respiratory failure on mechanical ventilation secondary to change in her mental status because of alcohol and marijuana intoxication." R9 has a history of substance abuse. Surveyor interviewed R9 who stated that she bought the alcohol with the money she obtained from attending outside work program. The facility failed to provide R9 with adequate programing and Psychiatric services to deal with alcohol use and failed to provide supervision for money provided by outside program. Failed to supervise R9 after return from pass.
e) R4 is 42 years old with diagnoses that include Schizophrenia and Depression. Based on interview with E16 - night nurse (confirmed by E3 - Resident Care Services), R4 becomes intoxicated on a regular basis. On interview on 10/08/03, R4 confirmed that he had been intoxicated in the past (including Friday, 10/10/03), but that he had not had a drink in two days. The Minimum Data Set (MDS) dated 9/23/03 indicated that the resident has no behavioral symptoms. The resident's care plan identifies a history of alcohol abuse and the objective is limited to the resident maintaining sobriety while a resident of the facility. There are no specific interventions identified to address episodes of intoxication. R4 stated that he attends the RBPC day program. He attends for four hours daily and the program consist of playing cards, playing pool and attending a group at the end of the day where they discuss various topics (i.e. HIV). R4 also stated that he receives money for attending the outside program. The facility has failed to adequately supervise R4 to ensure his safety and well-being. R4 also takes prescribed psychoactive medications (Seroquel, Paxil) and a sleeping medications that should not be taken with alcohol.
Based on direct observation, record review, staff and resident interviews, the facility failed to provide a program of specialized rehabilitative services for those residents with a mental illness as evidenced by the facility's failure to: 1) Provide in house programming for residents with a mental illness; 2) Integrate and evaluate specialized rehabilitative services with outside programs; 3) Address the specific nature and complexity of residents with a history of substance abuse; 4) Provide programming for resident's with substance abuse issues; 5) Identify specific behavioral issues and identify appropriate interventions;
6) Provide programming and discharge planning to assist residents with re-integration into the community;
7) Prevent residents from engaging in behavior that was harmful to themselves.
3. There is currently no full time Social Worker employed by the facility to establish, facilitate and monitor programs. There are four PRSCs (Psychiatric Rehabilitation Services Coordinators ).
4. The care plans of residents do not document the specific interventions related to individual behaviors. There is no indication that there is any monitoring and evaluation of episodic incidents as they relate to resident progress or lack of progress (i.e. E18 (DON) stated during interview on 10/7/03 at 2:55p.m. that R3 was intoxicated 2 to 3 times per week. The frequency and severity of R3's intoxication was not addressed on the care plan - only the fact that he became aggressive when he was drinking. The nurses' notes and social service notes do not address the frequency and severity of his intoxication). On interview on 10/08/03, E5(PRSC) confirmed that there is no formal tracking of episodes of maladaptive behavior (i.e. elopement or intoxication). When asked how progress or lack of progress was measured, he stated, "You kind of just know."
5. There is no documentation of any formal discharge plans or programs designed to assist the residents back into the community.
6. The facility has no in-house program that is focused on rehabilitative services for MI residents. E5 (PRSC) was interviewed on 10/07/03 at 1:20p.m. He provided a list of in-house groups that are scheduled. According to the list there are a total of four groups scheduled in a week and each group lasts 30 to 60 minutes. The groups are as follows:
E5 confirmed that these are the only scheduled programs in the facility. He also stated that specific residents are not assigned to the groups - the groups are open to anyone who wants to attend. There is no attendance record for these groups and there is no documentation of participation in these groups.
According to facility records there are 104 residents who attend programming outside of the facility. However, the programs are only half a day and there is no integration of services between the outside agency and the facility.
7. According to the facility list, 13 residents attend a day program at the Illinois Behavior Center, Inc. The residents are scheduled to attend for four hours, five days per week. According to the program information this agency is Partial Hospitalization Program (PHP). The information provided indicated that the treatment team was comprised of a psychiatrist, psychologists, clinical nurse specialists, social workers, occupational therapists, expressive therapists, and addiction counselors. On a visit to the contracted agency on 10/9/03, it was observed that there were at least 24 residents in attendance (as observed in the morning group with others throughout the building playing pool and engaged in other activities) and 12 were from this facility.
While observing the program from 9:30a.m. to 11:30a.m. on 10/09/03, it was noted that there was no psychiatrist, no psychologist, no nurses, no social workers, no occupational therapists, no expressive therapists and no addiction counselors. Upon arrival there were three staff (1 CNA and 2 activity aides) and 1 bus driver in the building. E5 (the CNA) was in charge and is listed on the agency information sheet as being a contact for the agency. E5 refers to herself as the supervisor. E6 (Building Manager) was not present, but arrived about 30 minutes later. The activity aides were having the residents go into one of the group rooms for coffee and a snack. E5 stated that there would be a group starting at about 9:50a.m. She stated that they usually conduct the groups twice with half of the residents each time. She stated that the group lasts about 45 minutes and covers topics such as depression, behavior management, and schizophrenia. She further stated that sometimes they watch a videotape as the group activity. It was observed that the group on 10/9/03 was viewing a video tape that was titled, "Schizophrenia: Surviving in the World of Normals". This videotape was of a doctor who was standing at a podium and addressing what appeared to be other health care professionals. He was addressing statistics regarding the comparison of numbers of residents who reside in a state hospital with the numbers from the previous year.
E6 (Building Manager) was interviewed on 10/9/03 in his office at the agency. He stated that the focus of the program was as a "full service outpatient psychiatric facility". He further stated that the program was centered around a psychotherapy model and that it also included diversional activities. He stated that Z9 (physician) provided the program plans and that he actually oversees the program. He stated that Z9 is there every day, however he was not there on 10/9/03 and E6 stated that he did not know why he was not there. Review of the individual program plans indicated that all residents have the same approach - 45 minutes of group therapy per day and 15 minutes of individual therapy per day. E6 stated that the individual therapy is done only on an as needed basis. E6 also confirmed that the residents are paid every Friday and the payment is based solely on attendance.
The "Psychotherapy Progress Notes" for R3 from 7/21/03 to 9/10/03 were reviewed. The documentation is limited to general comments about whether or not he participated - there was no specific information related to the needs of the resident. For example, on 8/11/03 the Group Topic was "Chemical Dependence" and the note stated, "Good concept of being chemical dependent. Good thought process in expressing ideas." On 9/9/03 the Group Topic was also "Chemical Dependence" and the note stated, "Has no concept of chemical dependence and poor thought of expressing his ideas". In addition, some of the topics for group therapy lack relevance to the psychotherapeutic needs of the residents. Examples are as follows:
9. Specific examples include but are not limited to:
R3 was a 44 year old resident with diagnoses that included Schizoaffective Disorder (per the psychiatrist note). There was no diagnosis of substance abuse, however, the "Psychiatric Rehabilitative Services Note" dated 9/3/03 stated that the resident had a history of alcohol abuse. The resident's care plan identified the history of alcohol and drug abuse, however the objective was related to dealing with his anger and frustration when he was intoxicated. The care plan did not list any specific interventions regarding situations when the resident was intoxicated. The MDS dated 9/3/03 did not identify any behavior problems though it was documented in nurses notes and the "Psychiatric Rehabilitative Services Notes" that the resident would become belligerent and aggressive when he was intoxicated. The "Social Work Services Progress Notes" document episodes of intoxication on 6/3/03, 9/4/03, 9/19/03 and 9/22/03. The Nurses' Notes document episodes of intoxication on 8/20/03, 8/23/03, 9/22/03 and 10/3/03. Z2 (Psychiatrist) on phone interview on 10/7 /03 stated that R3 had a history of getting drunk and sleeping it off. Z1(Medical Doctor) on phone interview on 10/7/03 stated that drinking was R3's "usually customary behavior." On interview on 10/7/03, R4 stated that he was a friend of R3 and that R3 would get drunk every day. He further stated that if R3 had $10.00 he would drink $10.00. R15 and R11 also confirmed on interview on 10/6/03 that R3 would drink alcohol frequently. On 10/ 3/03, R3 was noted to be intoxicated at approximately 4:30p.m. (interview of E10); at 5:00p.m. he was noted to be passed out and was carried to his room by E3. R3 was observed at 3:15a.m. to be unresponsive with no vital signs by R4 and R15 who then notified the nurse. CPR was initiated and R3 was sent to the hospital where he was pronounced dead on arrival.
R9 is 34 year old resident with diagnoses that include Bipolar Disorder. According to the MDS dated 7/16/03, this resident has no identified behavior problems. R9 was noted by staff on September 27, 2003 at 1:40p.m. to be "extremely diaphoretic, nodding, and responsive to tactile stimulation, was combative at times with confusion." The physician was notified and R9 was transported to the emergency room where R9 was placed on a ventilator. Review of the hospital records reveal that R9 had "acute respiratory failure on mechanical ventilation secondary to change in her mental status because of alcohol and marijuana intoxication." R9 has a history of substance abuse. Surveyor interviewed R9 who stated that she bought the alcohol with the money she obtained from attending outside work program. The facility failed to provide R9 with adequate programing and psychiatric services to deal with alcohol use and failed to provide supervision for money provided by outside program.
On interview by telephone on 10/7/03, E16 (night nurse) identified R3, R4, R6, R7, R8, R10 and R15 as residents that are known to drink and become intoxicated on a regular basis. The facility has no protocol to identify and monitor residents who are suspected of being intoxicated.
R4 is 42 years old with diagnoses that include Schizophrenia and Depression. Based on interview with E16 - night nurse (confirmed by E3 - Resident Care Services), R4 becomes intoxicated on a regular basis. On interview on 10/8/03, R4 confirmed that he had been intoxicated in the past (including Friday, 10/3/03), but that he had not had a drink in two days. The Minimum Data Set (MDS) dated 9/23/03 indicated that the resident has no behavioral symptoms. The resident's care plan identifies a history of alcohol abuse and the objective is limited to the resident maintaining sobriety while a resident of the facility. There are no specific interventions identified to address episodes of intoxication. R4 stated that he attends the RBPC day program. He attends for 4 hours daily and the program consist of playing cards, playing pool and attending a group at the end of the day where they discuss various topics (i.e. HIV). On interview, R4 also stated that he is interested in being discharged and living on his own. He further stated that the social service department does not help much. There is no indication in his clinical record that R4 is being assisted with discharge.
R6 is a 48 year old resident with diagnoses that include Depression with psychotic features. Staff stated that she has a problem with intoxication on a regular basis, however this problem has not been identified and addressed. Based on interview with E16 - night nurse (confirmed by E3 - Resident Care Services), R6 becomes intoxicated on a regular basis. The resident's care plan does not indicate alcohol intoxication as a problem and there are no specified interventions. There was no documentation by social services from 12/02 to 9/03. There was one episode of intoxication documented in the nurses' notes on 9/28/03, but no other episodes documented.
R10 is a 49 year old resident who was identified by E16 as becoming intoxicated on a regular basis. According to the "Rehabilitation Potential Summary" dated 9/2/03, R10 "does not appear to desire to stop drinking. There are social service notes 5/19/03, 6/25/03, and 8/13/03 which describe incidents of intoxication. There are no interventions documented that identify the interventions to be used other than on 6/25/03 when the notes states that the resident was to lay down for safety purposes and that they would continue to monitor. The nurses' notes for 8/13/03 and the social service notes for 8/13/03 both document an episode of intoxication which resulted in facial injuries (resident stated that he fell). The social service note also documents that the resident took his banking money and walked to the Jewel grocery store where he bought two pints of Vodka and drank them. The "Psychiatric Rehabilitative Services Note dated 9/2/03 (less than a month later) stated that the resident was on Level 3 which allowed him to go out into the community independently. The care plan for R10 addressed the resident's alcohol abuse, however the interventions are limited to encouraging him to stop drinking and to attend Narcotics Anonymous/Alcoholic's Anonymous. There are no interventions related to attempts to prevent the resident from drinking or how to address him when he is intoxicated.
R8 is a 46 year old resident who was identified by E16 as becoming intoxicated on a regular basis and he has diagnoses that include history of alcohol abuse. The resident's care plan does not indicate alcohol intoxication as a problem and there are no specified interventions. The nurse's notes dated 10/3/03 at 4:40p.m. stated, "Resident found lying on floor in room. Slurred speech. No injury noted. Resident assisted to bed." There were no other interventions documented. The nurses' note dated 10/5/03 stated, "Resident states that on 10/3/03 he fell and scraped his left upper arm trying to pick up another resident off the floor." The wound was treated by nursing staff on 10/5/03.
R14 was interviewed on 10/9/03 at the day program. He stated that the is in a nursing home because he has problems with substance abuse. He further stated that it is difficult for him to get better because drugs and alcohol are always available.