Facility I.D. Number 0039958
Date of Survey:07/05/02
Notice of Violation:10/11/02
The facilitys governing body shall exercise general direction of the facility, and shall establish the broad policies and procedures for the facility related to its purpose, objectives, operation, and the welfare of the residents served.
Sufficient staff in numbers and qualifications shall be on duty all hours of each day to provide services that meet the total needs of the residents. At a minimum, there shall be at least one staff member awake, dressed, and on duty at all times.
The facility shall provide training and habilitation services to facilitate the intellectual, sensorimotor, and effective development of each resident in the facility.
There shall be evidence of training and habilitation services activities designed to meet the training and habilitation objectives set for every resident.
Physician services including a complete physical examination at least annually and formal arrangements to provide for medical emergencies on a 24-hour, seven-day-a-week basis.
Nursing services to provide immediate supervision of the health needs of each resident by a registered professional nurse or a licensed practical nurse, or the equivalent.
A resident who becomes unmanageable shall promptly be examined by a physician or a psychiatrist. A psychologist and members of other appropriate professional disciplines should be consulted, as necessary.
Residents shall be provided with nursing services, in accordance with their needs, which shall include, but are not limited to, the following: The DON shall participate in:
Periodic reevaluation of the type, extent, and quality of services as part of the total habilitation program.
Direct care personnel shall be trained in, but not limited to, the following:
Detecting signs of illness, dysfunction or maladaptive behavior that warrant medical, nursing or psychosocial intervention.
Basic skills required to meet the health needs and problems of the residents.
First aid for accident or illness.
Sufficient, appropriately qualified nursing staff shall be available, which may include licensed practical nurses and other supporting personnel, to carry out the various nursing service activities.
Records of significant behavior incidents, reactions to any family visits and contacts, attendance at programs, and leaves from the facility.
AN OWNER, LICENSEE, ADMINISTRATOR, EMPLOYEE OR AGENT OF A FACILITY SHALL NOT ABUSE OR NEGLECT A RESIDENT. (Sections 2-107 of the Act)
1) Per interview with Z3 (DT - (Day Training) General Manager) on 06/27/02 at 8:30 A.M., Z3 stated that R1 had a maladaptive behavior at that facility on 05/29/02 or 05/30/02. Z3 stated that R1 had arrived to work with "a knot on her head." Z3 stated "E2 (QMRP/Qualified Mental Retardation Professional) from the facility had called before R1 arrived to DT and stated that she had a behavior. R1 became upset when she was removed from the bus for a doctor's appointment. R1 began beating her head on the brick wall on the front porch of the facility." Z3 stated she had observed the knot to R1's head. Z3 demonstrated the action of R1 to the surveyor and stated that "R1's knot was located to the right side off to the center back of R1's head. The knot was visible because of the bruising and because R1 has thin hair." Z3 stated R1 had been examined by the DT nurse (Z4).
Per interview with Z4 (DT Licensed Practical Nurse/LPN) on 06/27/02 at 8:40 A.M., Z4 confirmed that R1 had arrived at Day Training on 05/29/02 or 05/30/02 with a slightly elevated area to the back of her head with purple bruising.
Per review of the written statement completed by Z4 on 06/27/02, Z4 documented: "... At approx (approximately) 9:30 A.M. as I was entering the office, Z3 relayed a message to me from E2 at (Facility name). Z3 stated that E2 had called to make me aware that R1 had a (maladaptive) behavior this A.M. and that they were aware of the raised area to the back of her head that was a result of her behavior. Upon leaving the office, R1 entered side door with (Facility) staff member. She immediately showed me the back of her head. I saw swelling to back of cranium with red/purple discoloration beginning... She was taken to the Group Room 1 and seated after showing Z3 the trauma to the back of R1's head. Ice was then applied to the area for approx. 20 min. (minutes). In this time Tylenol was given to help alleviate discomfort..."
Per interview with E1 (Administrator) on 06/27/02 at 9:12 A.M., stated that R1 had a maladaptive behavior on 05/30/02. E2 (QMRP) was present during this interview and stated "R1 was sitting down and bumped her head only. I did call DT. I felt her head. I did not see anything on her head." E2 confirmed during this interview, that no neurological check was done on R1 after hitting her head. E2 stated "I didn't feel that this was needed."
Record review and interview with Z1 (Bus Driver), E2, E3 and E4 (Direct Care Staff) on 06/27/02 confirmed that R1 was removed from the bus on 05/30/02 at about 9 A.M. for an appointment with the audiologist. R1 became upset after being removed from the bus. R1 sat down on one the benches on the front porch of the facility. R1 struck the back of her head an undetermined number of times during this tantrum incident. R1 was not continuously monitored by staff during this behavioral incident.
Per interview with Z1(Bus Driver) on 06/27/02 at 10:05 A.M. Z1 stated that "R1 got on the bus about 9 A.M. on 05/30/02. Z1 stated "I have to keep a manifest, so I know the exact day they removed R1 from the bus. Staff came to get her off (the bus) and she threw a tantrum. R1 got off the bus, went up the ramp and sat down in the seat. R1 started banging her head against the brick wall. E2 was standing there while R1 hit her head at least twice with force. This was upsetting to me." Z1 stated that E3 and E4 (facility staff) were also present on this date when this incident occurred.
Per interview with E3 (Direct Care Staff) on 06/27/02 at 9:20 A.M., E3 stated that he had been on duty on 05/30/02 when R1 had her behavior. E3 stated "R1 was screaming so loud and was so upset while sitting on the porch, that she shot her teeth (dentures) out of her mouth. R1 was really upset." E3 stated that he left R1 and went inside the facility to get help. E3 stated that "R1 was inside the facility by the time I got someone." E3 stated that he did not see R1 bang her head against the brick wall and was not aware of a knot on R1's head. E3 stated that "I heard about a week later while talking with E6 and E7 (Direct Care Staff) that R1 had a big bruise on the back of her head from this incident."
Per interview with E4 (Direct Care Staff) on 06/27/02 at 11:50 A.M., E4 stated that she was on duty on 05/30/02. E4 stated "I saw her (R1) hit her head on the back of the wall. She hit the center back of her head. R1 hit her head on the brick wall with enough force that I was concerned." E4 stated that E2 was present and she thought E2 checked her. E4 stated "I didn't document because I thought E2 would document. E2 should have documented."
Per interview with E2 on 06/27/02 at 1 P.M., E2 stated that R1 got off the bus mad on 05/30/02. E2 stated that R1 got off the bus and sat down in the chair by the driveway. E2 stated that she then went inside and talked with the audiologist. E2 stated that she did not remember anyone being outside monitoring R1. E2 stated that when she came back outside, R1 was sitting on the bench and the bus was gone. E2 stated that she saw R1 "bump" her head. E2 stated that she "unsure" as to how hard R1 hit her head. E2 stated that she would have to check R1's behavior program, when asked by the surveyor if R1 was to be left unattended during a behavior.
E4 was interviewed again on 06/28/02 at 4 P.M., due to staff's statements identifying that R1 had been left unsupervised during her temper tantrum on 05/30/02. During this interview, E4 stated that she had gone back in the facility during R1's behavioral incident. E4 stated that when she returned E2 was with R1. E4 stated that R1 was really mad and was clenching her fist and throwing her head back. E4 stated that she thought "R1 hit her head twice", but wasn't sure. E4 stated "R1 was screaming and E2 asked for help to bring her in." E4 stated that when she took R1 to Day Training, "I saw the red patch". E4 stated that she had informed DT staff about the area to R1's head while at Day Training.
Review of the facility's policy and procedures on "Head Injuries" identified that staff are to determine the base line condition of the resident (after the injury) by assessing level of responsiveness; determining presence of headache, double vision, nausea or vomiting; evaluate pupil size and reaction to light; measure blood pressure, pulse, respirations; evaluate motion and strength of extremities; and assess for injuries to other organ systems. Additionally, staff are to evaluate changes in resident's condition. Under the facility's policy on Trauma injuries, staff are to determine area and extent of injury; evaluate type of injury and if necessary for evaluation by the doctor and or Emergency Care facility; make note of type of injury, area involved, treatment given in Universal Note; and fill out an Incident Report.
Per file review, no documentation was noted of R1's injury sustained to the back of the head during her temper tantrum on 05/30/02.
Interview with E2 on 06/27/02 at 1 P.M., confirmed that she had not checked R1's vitals nor completed a neurological check after R1 hit her head against the brick wall on 05/30/02. E2 also confirmed that she nor any facility staff contacted the nurse or the doctor as per the facility's policy and procedures. E2 also stated that she did not remember if she told staff to monitor R1 after the incident on 05/30/02.
Per telephone interview with Z7 (Physician) on 06/27/02 at 11:43 A.M., Z7 stated that he was "not aware" of any injury R1 sustained to her head on 05/30/02. Z7 stated that in reviewing R1's file, he could not find record that the facility had contacted him or his nurse regarding R1 hitting her head. During this telephone interview, Z7 checked R1's record with his nurse. Z7 stated that he found nothing documented for 05/30/02 or for any other date regarding a lump or bruise to R1's head. Z7 stated "I would have expected the facility to call and then I could advise them. If R1 had a lump or bruising noted to her head, I would have asked to see her."
On 06/14/02, approximately two weeks after the incident on 05/30/02, R1 had an episode where she became unresponsive and appeared to have seizure like activity while at Day Training. R1 was sent by ambulance to the local Emergency Room and was admitted for monitoring for "Bradycardia with Arrhythmia" and "Syncope". R1 remained in the hospital until she was transferred on 06/20/02 to another hospital for neurosurgery.
On 06/15/02, a Neurological consultation was completed that identified R1's "unresponsiveness was most likely represented seizure activity secondary to cortical irritation from the subdural hematoma." Recommendations were also noted that identified that "the patient is to be watched closely for increasing symptoms. Hematoma most likely to be secondary to fall/trauma.... If at any time her symptoms increase a neurosurgeon consultation is recommended as there is current evidence of midline shift (brain shift) on CT (Computerized Tomography) scan..."
Review of the CT Scan report for R1 dated 06/16/02 identified a right sided subdural hematoma (mass of blood in a layer of the brain) (with both acute (acute (rapid onset) subacute (defined below) and subacute components)....There is also evidence of hemorrhage (bleeding) along the right tentorial edge." (Strong connective tissue supportive portions of the brain)
Per telephone interview with Z7 (Physician) on 06/26/02 at 4:04 P.M., Z7 stated that he had examined R1 at the time of her admission to the hospital. Z7 stated that he examined her scalp and found no laceration, contusions or evidence of trauma. Z7 stated that he had talked with the consulting neurologist, who had identified that the subdural hematoma was sub acute. Z7 defined sub acute as "trauma or injury that occurred two to six week ago."
On 06/20/02 another CT scan of the brain was completed on R1 that identified that as compared to the CT scan of 06/15/02, "there is interval increase in the size of the right subdural hematoma as well as interval worsening of the mass effect and shift of the lateral ventricle towards the left. There is again evidence of hemorrhage along the right tentorial edge. There is increasing dilation of the temporal horn of the left lateral ventricles which probably indicates impending obstructive hydrocephalus (fluid build up in the brain)." R1 was transferred on 06/20/02 to another hospital for neurosurgery. After surgery on 06/20/02, R1's condition continued to decline.
On 06/27/07 per telephone interview with Z8 (Hospital Personnel) at 2 P.M., Z8 stated that R1 remained unresponsive after surgery. Z8 stated "Yesterday R1 was removed off of the ventilator and recommendations made for hospice." Z8 stated "R1 will be transferred within the next 24 hours because there is nothing further the hospital can do."
On 06/28/02, R1 was transferred to a local nursing home without prognosis for recovery. R1's Death Certificate identified that R1 expired on 06/30/02 at 5:55 A.M. with the immediate cause of death being identified as "Subdural Hematoma".
2) During the interview with Z2 (Day Training Staff) on 06/27/02 at 10:20 A.M., Z2 stated that she was "concerned about staff supervision" at the facility. Z2 stated that clients had been "observed outside of the facility by themselves."
On 07/02/02 at 8:15 A.M., R9 was observed outside sweeping the driveway of the facility. R5 was also observed on the front porch of the facility, pacing back and forth and self stimming with his hands. No staff were observed outside the facility.
Upon the surveyor's entrance to the facility, E4 and E5 (Direct Care Staff) were present in the living room. E5 informed the surveyor that E1 and E2 were not scheduled until about 9 A.M.. R3, R4, R6 and R7 were observed seated in the front living area of the facility. R8 was not present in the area.
At 8:25 A.M., R3 entered the QMRP office where the surveyor was present. R3 initially stood and looked around the room and then began moving towards objects and items in the room. The surveyor attempted to redirect R3 and sought out staff assistance. A staff member was observed sitting on the couch in the living room. The staff member appeared to be asleep. R4, R5, R6, R7 were observed present in the living area. R5 was observed pacing around the living room. R7 was observed with his arms crossed over his chest making movements with his mouth. No other staff were present in the living room. At 8:30 A.M., R3 returned to the QMRP's office and stood at the door. When the surveyor left the office at 8:45 A.M. the staff member was observed to still be sitting on the couch asleep. Clients were still present in the living room area. Surveyor then attempted to find another staff. Within minutes the surveyor located E4 in the kitchen pantry of the facility.
When the surveyor asked E4 to identify the person asleep on the couch, E4 stated the staff member's name (E6) to the surveyor. E4 then stated, "Should I wake her up?" E4 then yelled, "E6, you need to get up!" Interview with E5 on 07/02/02 at 10:05 A.M., E5 stated "She (E6) goes to sleep in the morning all the time."
At 8:53 A.M., E5 was observed sitting outside with R9. E5 stated that she had to stay with R9 because she has seizures and falls. When the surveyor informed E5 that R9 had been observed at 8:15 A.M. in the facility parking lot sweeping without staff supervision, E5 stated, "She's not supposed to be."
Per interview with E2 on 07/02/02 at 12:50 P.M., E2 stated that seven clients (R3, R4, R5, R6, R7, R8 and R9) do not leave the facility until about 9 A.M.
Record review identified that R3, R4, R5, R6, R7, R8 and R9 all function at a severe to profound level of mental retardation and requires staff assistance for most aspects of daily living skills. Review of the client's individual program plans identified that:
R3 requires monitoring and behavioral programming for PICA (eating in edibles) behaviors;
R4 requires monitoring for history of aggressive and self injurious behaviors;
R5 requires monitoring and behavioral programming for pacing behaviors;
R7 requires close monitoring and behavioral programming for "Rumination", "PICA" and "Rectal Digging";
R8 requires monitoring and behavioral programming for "Physical Aggression"; and
R9 requires close monitoring and supervision due to seizure activity and potential for falls and or injuries sustained during seizure activity.
Per review of the facility's policy and procedures on "Facility Staffing" identified that the facility shall provide sufficient direct care staff to conduct the resident living program to provide training in activities of daily living and the development of self help and social skills and to carry out the recommendations and plans for the treatment of each resident.
Interview with E1 on 07/02/02 at 2:05 P.M., E1 confirmed that E6 was on duty at the time that the surveyor observed her asleep on the couch. E1 also confirmed during this interview that E6 could not meet the client's developmental and or behavioral needs as identified per the facility's policy while asleep.