DYBALL SUNSHINE HOME
Facility I.D. Number 0031021
Date of Survey: 10/17/02
The facility shall notify the residents physician of any accident, injury or significant change in a residents condition that threatens the health, safety or welfare of a resident, including, but not limited to, the presence of incipient or manifest decubitus ulcers or a weight loss or gain of five percent or more within a period of 30 days.
Each residents medical record shall contain the following:
Nurses notes that describe the nursing care provided, observations and assessment of symptoms, reactions to treatments and medications, progression toward or regression from each resident's established goals, and changes in the residents physical or emotional condition.
An ongoing record of notations describing significant observations or developments regarding each residents condition and response to treatments and programs.
The residents record shall include information regarding the physicians notification and response regarding any serious accident or injury, or significant change in condition, as required by Section 350.1220(m) of this Part.
AN OWNER, LICENSEE, ADMINISTRATOR, EMPLOYEE OR AGENT OF A FACILITY SHALL NOT ABUSE OR NEGLECT A RESIDENT. (Sections 2-107 of the Act)
RESIDENT AS PERPETRATOR OF ABUSE. WHEN AN INVESTIGATION OF A REPORT OF SUSPECTED ABUSE OF A RESIDENT INDICATES, BASED UPON CREDIBLE EVIDENCE, THAT ANOTHER RESIDENT OF THE LONG-TERM CARE FACILITY IS THE PERPETRATOR OF THE ABUSE, THAT RESIDENTS CONDITION SHALL BE IMMEDIATELY EVALUATED TO DETERMINE THE MOST SUITABLE THERAPY AND PLACEMENT FOR THE RESIDENT, CONSIDERING THE SAFETY OF THAT RESIDENT AS WELL AS THE SAFETY OF OTHER RESIDENTS AND EMPLOYEES OF THE FACILITY. (Section 3-612 of the Act)
Based on interview and file verification, the facility has neglected to provide adequate supervision for an individual with known special needs and neglected to provide adequate supervision to prevent physical altercations resulting in an environment of fear in the facility for 3 of 15 individuals residing in the facility who have verbalized fear (R1, R2, R8) with the potential to affect all.
R15 is a 60 year male who functions at a moderate level with diagnoses that include Intermittent Explosive Disorder, Diabetes and Seizure Disorder. R15 is ambulatory and verbal.
Per file verification of the Individual Program Plan (IPP) of 5/23/02, R15 was admitted to the facility on 06/13/01 from the home of his cousin where he had resided temporarily after his father required nursing home care. R15 had always resided at home with his parents prior to that time.
Per interview with E1, Resident Service Director (RSD) on 10/10/02 at 10:30 A.M. R15 seemed to make a good adjustment to the facility until about 2 months after he was admitted. E1 stated, "About 2 months after he was admitted, sometime in August (2001), he began to have aggressive behaviors."
Per review of the ICAP of 05/07/02, R15 displays the following Problem Behavior Categories:
Hurtful to others--one to 6 times a week, rated as extremely serious; a critical problem. Disruptive behavior of interrupting or yelling--one or more times an hour, rated as not serious. Socially offensive behavior of picking nose--one or more times an hour rated as not serious. Uncooperative behavior, refusing to do chores/not following instructions--one to 6 times a week, rated as not serious.
Per file review of the Behavior Plan of 04/24/02, the short-term objective for R15's behavior plan is "To maintain socially acceptable behavior not to exceed 10 incidents of physically aggressive behaviors monthly.
1. During prime time (R15) may earn a plus for no physically aggressive behaviors (3 P.M.- 9 P.M.). During A.M., from wake up to departing to work and returning from work, (R15) will earn a plus. On weekends pluses will be awarded by shift, one for days and one for evenings.
Penalties: In the event that any targeted behavior occurs then penalties or fines will be initiated per the following:
A. PLUS DENIED: If a physically aggressive behavior occurs, a minus will be given and (R15) will be denied money for a soda the following day.
B. If behavior re-occurs or a new behavior enters on the same shift after the initial penalty, then two pluses will be charged
C. The continuation of behavior or third incident per shift will result in a 5 plus penalty earned.
D. Any incident of fighting, combative, or assaultive behavior will result in forfeiture of outing with guardian.
E. Apart from the reinforcement schedule, any behavior that is inappropriate shall be addressed through routine procedures:
a. Direct (R15) to discontinue the physical aggressive behavior.
b. Attempt to distract (R15) and direct him toward a task, chore, or area calling attention away from the incident or cause.
c. Attempt to remove or separate (R15) from the cause of the problem area particularly if it continues to perpetuate the undesired behavior.
d. If necessary physically come between and separate (R15) from the situation.
e. It will be necessary to evaluate the cause, reaction, intervention, and outcomes of all incidents and to record them in the residents record."
Per file review of the IPP, R15 has baseline data of 23 incidents of targeted behavior per month between 6/02 to present. Targeted behaviors included at that time physical aggression towards peers and staff which included hitting and slapping among others and throwing water and hot coffee.
Per file review of facility nurse notes, the following incidents of physical aggression by R15 are documented beginning in March 2002:
3/9 "Walked into living room slapped female peer on butt! Then ran off and laughed."
3/17 "Came into living room smacked female peer on butt. He stood there and laughed."
3/17 "Walked into dining room and dumped water down male peers shirt."
3/23 "Hitting peers all evening and pouring water on their heads."
3/30 "Walked up to female peer and smacked her on her butt. Walked away laughing, refused to apologize."
4/2 "Walked up to peer and smacked them"
4/11 "(R15) and male peer were in the kitchen. I heard the resident tell (R15) to stop hitting him."
4/12 "Had his hands on male peers shoulder pushing him, male peer was trying to get (R15's) hands off him."
4/24 "Walked up behind female resident and smacked her on the back."
4/28 "Walked up to male peer, grabbed him by the arm and shoved him. Refused to apologize and continued to laugh."
5/4 "Walked up to female peer and smacked her on butt."
5/5 "Walked up to male peer and dumped water down his pants. (R15) ran away and laughed. Refused to apologize."
5/5 "This staff was in kitchen cooking heard peer yelling. (R15) was choking male peer with fishing string. (R15) had the fishing string wrapped around male peers neck pulling!"
5/5 "Walked into TV room saw (R15) trying to push female peer off couch."
5/11"Since (R15) has been up this morning he has started in on female peer tell her she is in the doghouse now and he has been wondering how he can get her."
5/13 "When (R14) went to restroom I heard a loud smack and asked (R15) if he smacked peer and he said yes. I asked (R15) to apologize and he did and was laughing the whole time."
6/4 "This staff was in the kitchen this morning when I heard male peer yell and female peer said (R15) had hit other male peer. I asked (R15) why he did this and he had no answer only laughed in my face."
6/5 "This staff heard (R15) yelling at male peer. Other staff trying to calm down (R15) because he had already hit other male peer. (R15) kept yelling "I'll get even with him (meaning male peer)."
6/20 "Walked up to male peer in the dining room and slapped him twice across the face. This staff intervened but (R15) just laughed and laughed and kept saying 'I"ll do it again if I want."
6/21 "Hit a male peer 3 times on the workshop bus this morning."
6/25 "Was standing in the dining room, turned around and hit male peer twice-then turned and hit female peer once. (R15) was removed from the situation--but he just laughed and laughed."
6/27 "Has hit 2 peers this evening. He just walked up to female peer and slapped her for no apparent reason. Then he poured water on male peer's head, then hit him and scratched his arm."
6/28 "Staff heard male peer screaming, when I got to scene (R15) was pulling peer's hair."
6/30 "(R15) threw water on female peer."
7/1 "(R15) hit male resident. Staff intervened-did no good."
7/2 "(R15) hit 2 male residents."
7/3 "(R15) came up behind and hit male peer"
7/10"(R15) slapped a female peer on the butt this evening. Just laughed and walked away, would not apologize to peer."
7/4 "Walked into the dining room and hit female peer in back."
7/6 "Was sitting on porch and stood up throwing water that was in a glass into peers face"
7/6 "Walked into kitchen and punched a female peer in the lower back."
7/6 "Was sitting on porch and stood up and hit a male peer."
7/10"Walked into hallway and hit female peer on back."
7/13"Walked up to female peer and slapped her in the middle of the back"
7/13"Walked up to a male and female peer slapping both in the back."
8/1 "Slapped female peer."
8/1 "Hit female peer on the shoulder."
8/3 "Threw water in female peer's face."
8/16 "Suddenly threw water on a female peer then just laughed."
8/17 "Smacked male peer on bottom."
8/20 "Slapped female peer on the back."
8/20 "Walked up to female peer, smacked her on butt."
8/21 "Slapped female peer in the face."
8/22 "Slapped female peer on side of face and neck."
8/23 "Slapped female peer on bottom"
8/25 "Touching female's breast."
8/25 "Sat down next to female peer and started rubbing female peer all over her shoulders, chest, back and neck."
8/28 "Threw juice on peer and slapped female peer."
8/29 "Slapped male peer on butt."
8/29 "Slapped female peer on back."
8/29 "Slapped male peer in back of head."
8/29 "Slapped female peer in middle of back."
8/29 "Slapped female peer in the face."
8/30 "Tried to karate chop female peer in the neck."
8/31 "Walked up behind female peer and smacked her bottom."
8/31 "Smacked female peer on butt."
9/1 "Staff heard resident yell, staff went down to see what happened, resident holding ear. Staff ask if (R15) had hit him, resident stated "In the ear.'"
9/1 "(R15) has been very ornery today. He has tried to kick male peer, hit female peer and has constantly argued with female peer."
9/3 "(R15) came into dining room and slapped female peer on the butt."
9/4 "(R15) just walked up to female peer and slapped her across the butt."
9/5 "This staff went to get (R15) for his meds. I told him staff was asking for him. He said, I'm going to kill her. He said three times, I'm going to kill her."
9/7 "(R15) picked up a kitchen chair earlier tonight and hit a male peer with it. He was asked to apologize to peer but refuses and just laughed."
9/7 "During meds tonight (R15) walked up to male peer sitting at the table and for no apparent reason punched peer 2 times in face. (R15) also just before this incident smacked a female peer on the face open-handed and laughed at her."
9/7 "(R15) smacked female peer on bottom ran away and laughed."
9/11 "(R15) was walking down hall as other peer was coming for breakfast and ran into male peer on purpose and started laughing. Then when I was shaving (R15) he told me he was going to run into everyone and knock them down and then started laughing."
9/11 "Went to see physician today. He said with all the behaviors (R15) has had and for him hitting a resident over the back with a chair that he needed admitted to the psychiatric unit."
9/21 "(R15) has been slamming doors, trying to lock people out of the house and he yelled at a peer and her visitor saying that the visitor isn't welcome here and to go home. He also smacked 2 male peers on the butt tonight"
9/22 "(R15) came into dining room after dinner and slapped female peer on the butt."
10/2 "Smacked female peer on butt."
10/4 "Hit male peer on PM shift."
10/5 "Hit female peer on butt."
Per interview with E1, RSD on 10/10/02 at 2:00 P.M., when surveyor asked to see the nurses notes and incident report of R15 hitting R1 across the back with a chair he had thrown, she stated, "I don't know. I can't find them."
Surveyors were not able to determine if the above incidents actually resulted in injuries to clients. No documentation as to the extent of injuries could be found and clients were never seen by the physician after the injuries, nor was the physician notified of any of the above incidents.
Per interview with E6, Physician, on 10/11/02 at 2:30 P.M., he was not notified of the above incidents. When asked if he had been notified of the incidents he stated, "I don't really remember these things here. I'll call (E1) and tell them to start documenting in their chart everything that's going on there I should be informed of."
Per interviews with clients, several of them are afraid of R15 (R1, R2, R8) and one has threatened to retaliate (R5) if R15 continues to aggress against him.. Per interview with R5, a 69 year old male on 10/9/02 at 11:05 A.M. when asked if he is afraid of R15 he stated, "I said to him if you hit me, you're gonna get the same treatment you gave me. He doesn't hit me anymore since then."
Per interview with R1, a 38 year old newly admitted client who is legally blind and deaf on 10/09/02 at 4:20 P.M., when asked if he was afraid of anyone in the facility he signed and wrote to surveyor that he was "a little bit afraid of (R15)." (R1 was hit with a chair by R15.)
Per interview with R2, a 43 year old female on 10/9/02 at 10:55 A.M., when asked if she is afraid of R15, she originally said she was not, then came to surveyor and said that she was. When asked why she had at first said she was not afraid she stated, "I didn't want to make you mad at me." She further went on to state she is afraid of R15 "Cause (R15) gets mad easy. He hits me on the butt and I'm afraid of him. I feel weird when he hits me. I stay away from him. I stay in my room."
Per interview with R8, a 51 year old female on 10/9/02 at 11:45 A.M. when asked if she is scared of anybody at home, R8 began crying and stated, "Yes." When asked who she is afraid of, she replied, "(R15), he's always hitting me on the butt. Hit me on the right jaw, too. Always hitting everybody. He's harassing me." When asked how long this has been going on, she stated, "Quite a while. He hits everybody. Hit my jaw when I got on the van. Hits me on the butt, hurts bad. Hit my boyfriend, too." When asked if R15 ever comes into her room, she stated "Yes, a couple of times." When asked what he does when he comes into her room, she stated "Jabbers and stuff. Hit my room mate, too, (R9, a 76 year old female). Always hits me on the butt when I try to get my newspaper on the dining table." When asked if she had ever told anyone that R15 is hitting her, she stated she tells the RSD "every time and she just talks to him. He won't quit for nothing. He hurt (R2) and the new guy too--hits everybody. Everybody's scared of him."
Per file review of facility nurses notes for 8/23/02, the RSD did speak to R15 on that occasion about his inappropriate behavior toward R8. The entry described a joint discussion with R8 and R15 and the RSD. "(R15) had smacked a female resident on the buttocks and she was very upset about the incident. (R15) said he liked her and was just playing with her. She told him in no uncertain terms that she did not like him touching her and it had to stop now. (R15) told her that he was sorry and would not touch her again. She told him she was engaged and didn't want to be touched. RSD talked with (R15) after resident left and explained to him under no terms it is OK to touch someone who doesn't want it. He said he understood but he had a big grin on his face."
Per file review of facility consultation notes, R15 was evaluated by the psychiatrist on an outpatient basis in July 2002 for aggression which had become "a consistent thing" and had an in- patient hospitalization in September after "patient held a chair off the floor and slammed it on the back of a blind resident at the same group home where he lives. Patient has been attacking other resident and has been increasingly aggressive and hostile." As a result of the September hospitalization, R15's medications of Tegretol and Xanax were increased and Seroquel, an antipsychotic was prescribed for R15.
Per interview with E1, RSD on 10/12/02 at 2:00 P.M., she stated the facility wants to keep R15 as a resident of their group home. E1 stated, "I know the behavior looks bad. I've been telling the Behavior Management Committee for months that we have a problem here. I've tried talking to (R15) but he just laughs. He seems to think his actions are just practical jokes. I don't know what else to do about him. We want to keep him as a resident here."