Emerald Park Health Care Center
Facility I.D. Number 0040816
Date of Survey: 7/10/02
AN OWNER, LICENSEE, ADMINISTRATOR, EMPLOYEE OR AGENT OF A FACILITY SHALL NOT ABUSE OR NEGLECT A RESIDENT (Section 2-107 of the Act)
Based on staff and resident interviews and review of medical records (R3, R10) and the facilitys policies and procedures the facility has failed to:
- Ensure one resident (R3) was free from physical and mental abuse and unreasonable confinement on 6-27-2002, by not allowing R3 to leave the office during a unjustified intimidating interrogation by E12 (security guard). R3 asked to leave the room, E12 prevented R3 from leaving when E12 blocked the door, pushed R3, and put him in police hold. This action of E12 resulted in R3's mental anguish in R3 needing medication to help R3 calm down after the incident.
R3's diagnoses includes: Schizo affective disorder, Hypertension and Chron's disease. R3 was admitted to the facility on 6-17- 2002.
During the survey on 7-2-2002 at 1:30 p.m., in the admissions office, surveyors asked R3 if he had any problems with E12, a facility Security guard, during 5-11p.m. shift? R3 told surveyors that he had written about his problems with E12 on incidents happening on 6-20-2002, 6-21-2002, and 6-27-2002 and gave these written statements to E2, the Director of Nursing (DON), when she returned to work on 7-1-2002. This was confirmed by E2.
Interview of R3 and review of written statement confirm the following, R3 was having a conversation with E13, (1st floor nurse), and R10, at 9:00p.m. on 6-27-2002 in the hallway near the dining room. "We were talking about R10 telling other girls to stay away from me. E13 told R10 that wasn't right for her to say."
E12 approached them and told them he was going to question them. R3 told surveyors that..... "This made me (R3) really scared because I didn't know what they would say about me."
R3 further told surveyors that E12 took R10 aside and questioned R10 and told R3 to stay there. E12 took R3 into the Director of Nurses office with a nurse by the name of E8, (supervising nurse 1st floor). R3 related that E12 kept giving R3 the "evil eye" and telling R3 to stay away from the girl (R11) upstairs.
E12 kept telling R3 to "look into his eyes when I talk to him and listen to him."
E12 further told R3 that he could go to jail if R11 screams rape. R3 told E12 okay I will leave R11 alone but right now I want to excuse myself from the room. R3 went to the door. E12 ran in front of R3 and pushed R3 back and told R3 you're not going anywhere until he finished talking.
R3 told E12 he had enough and walked to the door again. E12 then pushed R3 with both arms and said, " Do I think I'm a tough guy." E12 told R3 that R3 can call the state if he wants to because they can't do anything.
R3 walked to the door again and E12 said f--- this s and put R3 in a police hold and R3 screamed for E13 to come and get him.
E12 further told R3, "If I think I'm a tough guy we can take it outside."
E13 came into the room, and told E12 that what he was doing to R3 was wrong. R3 was extremely upset and had to be given a shot of Ativan."
During the same 7-2-2002 interview and again on the 7-8-2002 11:30 a.m. in the Admissions Office with R3, R3 told surveyors that E14, the 1st floor charge nurse 3-11 shift, was present in the room with R3 and E12 at the time of the 6-27-2002 altercation. E8 had left the room before E12 started to harass R3.
Interviews of E2 and E3 (assistant director of nursing) and E15 (director of social services) revealed a code yellow (the facility code for all male response to an emergency behavior) was not called on 6-27-02. Therefore E12 should never have intervened.
E14 during interview with surveyors on 7-2-2002 told surveyors that she was asked by E12 to be a witness to E12 asking R3 some questions about a conversation he was having with a female resident. E12 did block the door to prevent R3 from leaving when R3 had become upset with the questioning. E12 did put his hands up in a bear hug to stop R3 from leaving the room. E14 went so far as to demonstrate on one of the surveyors the behind the body grip that E12 used on R3. E14 proceeded to tell surveyors that E12 should not have done this. E14 told surveyors the resident should have been allowed to leave the room if he wanted to because this is the residents right to do so.
E13 told surveyor during a phone interview at 9:00p.m.on 7-2-02 that she was in the 1st floor corridor when residents told her that they have R3 in a room and he is screaming for you. E13 went to the Director of Nurses office, accompanied by E11. E13 could hear R3 yelling for her. E13 opened the door and at that point observed R3 extremely upset and asked E12 what are you doing in here with my resident? E13 asked E11 to take R3 to his room. E13 asked E12 why would they call R3 in the room? Why did E12 not come to me with the problem of my resident?
E13 told surveyor I told E12 he was wrong with what he did to R3.
E8 during interview with surveyors on 7-2-02 at 3:30p.m. told surveyors that she was making copies in the nursing office when E12 and R3 came into the room. "E12 did not talk in front of me, E12 then called E14 into the office and this upset the resident and I, E8 left the room."
Surveyors asked, "Why did you leave the room when you were the supervising nurse for the evening?" E8 responded to surveyors, "I leave everyone to do their own thing"
In a written statement of 7-5-2002, E8 documented..." I heard loud noises coming from the Director of Nurses office. I immediately went to where the loud noise was coming from. Opening the door R3 was stating "I want to get out of here I want to call my mother". Escorted to room by E11( Social Service) and E13.
E11 during phone interview on 7-3-2002 at 10:50 a.m. and written documentation of 7-3-02 that he came into the facility at 10:30 p.m. on 6-27-02 and heard shouting in an office. E11 knocked on the door and E12 was present and observed R3 in a rage, loud and disruptive. E11 accompanied R3 (with E13) to his room to reduce stimuli, and provided one to one counseling.
During interview with E3 on 7-2-02 in the p.m. in the Admissions office, E3 told surveyors she was present in the facility on 6- 27-02, when the occurrence took place. E3 was called down from the 3rd floor to give a PRN medication (Ativan 2mg IM) to R3. E3 then talked to R3 to quiet him down.
Interview with the Administrator, E1, on 7-2-02 at 3:30p.m. in the Admissions office, E1 told surveyors that the facility has had far less problems now since they have security guards and that all the surveyors have is a written statement of a resident. Surveyors shared with E1 that it was ascertained during staff interview that this occurrence did happen.
On 7-5-02 fax of written final incident investigation report by E2, E2 states" "Not a valid allegation." Staff was given inservice on Sensitivity Training." However there was no evidence of E12 attending this inservice.
Interview of E15, the Social Service Director, on 7-8-02 at 12:00 noon, E15 said that, "E12 called me the next morning (6-28- 02) about the incident. E12 did not write any written report I asked him to call me about all incidents. I previously had told E12 to keep an eye on R3, because R3 was going out on curfew. E12 over stepped his boundaries, I feel as though I might have contributed to it happening."
During interviews of 16 residents (R1,R3 through R17) on 7-2-02 and on 7-9-02 it was ascertained that E12 is bossy, has a habit of putting his hands on people, does room searches without any nurse, does body searches and invades a residents privacy, is rough, talks down to residents, uses profanity to residents, makes residents afraid of his presence and acts like he is the police officer.
In other written statements by R3 given to E2 on 7-2-02, R3 documents incidents of 6-20-02 and 6-21-02. R3 states that E12 and another staff (later identified by R3 as E16) brought R3 into the head nurses office, interrogated and harassed R3 about drug use in the facility. E12 threatened that R3 is going to be on his list. There is no evidence of any Code Yellow being called that generated E12 to approach R3 on these dates.
No evidence exists that the facility had in place the following:
No written qualifications for security personnel.
No training and/or ongoing inservices for security personnel.
No supervisor for security to report to.
No accountability for security personnel.
No written chain of command.
Security Job description did not define limitations of contact with residents.
No evidence of resident right policy followed.
No evidence Abuse Policy and Procedure Followed.