IMPERIAL OF HAZEL CREST
Facility I.D. Number: 0040402
Date of Survey: 01/10/2003
INCIDENT REPORT INVESTIGATION OF 12/14/2002
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 thereunder. 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.
The facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psycho social 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.
The DON shall oversee the nursing services of the facility including:
An Owner, Licensee, Administrator, employee or agent of a facility shall not neglect a resident.
These requirements are not met as evidenced by:
Based on review of facility incident report, review of R1's record, staff, resident and other interviews, and review of the facility policies on Drug and Alcohol,Resident Pass Policy, and R1's signed Drug and Alcohol Behavior Contract, the facility failed to:
(1) Properly supervise one resident, R1, with behaviors that included: a) both a history of, and admission of current drug and alcohol use, b) possible involvement in criminal activity in the community, c) refusal to follow the facility policies regarding alcohol and drug use, and pass privileges.
(2) Effectively intervene with drug screening (as required in its own policy) after R1 admitted to drug/alcohol use while a resident of the facility,
(3) Revise treatment interventions developed for R1 after it became apparent that the interventions originally developed were ineffective,
(4) Develop a care plan which addressed R1's noncompliance with facility requirements/policies, and abstinence from the use of drugs/alcohol, and
(5) Restrict R1's access to the community after local police made several attempts to question the resident about home invasions, and burglaries in the surrounding community.
These known behaviors of R1, and the facility's failure to follow it's own policies regarding pass privileges, and drugs/alcohol use, put residents in the facility, and persons in the community at risk for harm.
The findings include:
1). The facility submitted an incident report to the Illinois Department of Public Health (IDPH) dated December 16, 2002, which stated that on December 15, 2002, the local police had escorted R1 to the police station for questioning, and the following day, December 16, 2002, the facility was informed by the police that R1 had been "arrested under suspicion of burglary/homicide and would not be returning to the facility." To date R1 remains in police custody.
2). When interviewed, Z1 (police) stated that they had received information that R1 had been responsible for a home invasion and murder that had occurred in the area on December 14, 2002, and based on that information the police escorted R1 to the police station for questioning on December 15, 2002. Z1 informed the surveyor that while in custody, R1 not only confessed to that home invasion and murder of
December 14, 2002, but to an earlier home invasion in the same building the previous month.
3). When interviewed, Z2 (police) informed the surveyor that the police had been to the facility several times the previous month November, 2002, to question R1 about a similar home invasion but was always informed that the resident was out of the facility. On November 19, 2002, the police were finally able to question R1 about that home invasion; the resident denied being responsible at that time, but did later admit responsibility for it.
According to staff interviews, R1 resided on the first floor.
During confidential interviews, E3, E4, E5, E8, E10, and E11 spoke to this surveyor and stated the following:
1) E3 stated that she observed R1 under the influence of drugs/alcohol "high" many times. That the local police were at the facility in the past looking for R1 for questioning regarding purse snatchers in the community. Stated that the facility doesn't monitor residents while they are out of the facility on pass; that they have no way of knowing that residents are where they say they are going to be.
2) E4 stated that she had been aware of R1's use of illegal drugs; that his eyes would be glassy, and that he sometimes wouldn't let you enter his room or he'd be agitated but would refuse to give urine samples for drug testing. Additionally, E4 stated that R1 would often threaten physical abuse to others, but would not carry it out. E4 stated that the facility doesn't monitor residents while they are out of the facility on pass.
3) E5 stated that she suspected R1 was using drugs because he would often sweat a lot and because of his agitation and behavior. R1 would argue with other residents; E5 had to calm the resident many times. Additionally, E5 stated that the local police had been to the facility in the past looking for R1.
4) E6 stated that she had heard that R1 was a person who liked to party (drink). E6 denied R1 receiving any nursing care at all. E6 also stated that she had heard that R1 would climb out of his bedroom window. E6 admitted that the facility would not be able to actually monitor whether or not a resident was compliant with medications or their behavior while they were on pass; that the facility doesn't know where a resident actually goes while on pass. Regarding R1, E6 stated that the facility would trust that he would be where he said he would be, even though he had a history of drug and alcohol use, and a current history of noncompliance with these substances, as well as noncompliance with the facility's policies.
5) E8 stated that on December 14, 2002, at approximately 8P.M.-8:30P.M. she saw R1 walking around on the first floor smoking room; he was loud, angry, and "acted crazy", and a few minutes later saw him walking towards the door of the lobby. On December 15, 2002, E8 again saw R1 "acting crazy" by laughing to himself, walking back and forth, talking to himself. E8 stated that no staff intervened.
6) E10 (staff) stated that R1's attendance at the Relapse Prevention Group was sporadic; he would either be on pass in the community, or would refuse to attend. E10 stated that while he never actually saw R1 use drugs, his behavior was sometimes that of one who was under the influence of drugs or alcohol; that he'd once smelled liquor on the resident. According to E10 he had no idea why R1 was at the facility, because other than medications, nothing was really done for him; that the resident didn't even really attend the groups as required-he could have lived at home.
7) E11 (staff) stated that R1 would be out of the facility for days at a time (on pass).
When interviewed regarding R1's noncompliant behavior, E15 (Regional Director of Mental Health) stated that no real sanctions had been applied to the resident's behavior. As stated by E15 "We counsel them and provide programming, but no progressive types of sanctions or enforcement is done." E15 admitted to the surveyor that the facility's policy on drugs and alcohol and restriction of pass privileges was not followed by the facility in regards to R1.
E16 (Clinical Director Mental Health) was interviewed regarding R1. As stated by E16, the resident was in the Stress Relief Group which meets twice weekly on Wednesday and Friday, and the Relapse Prevention Group which meets twice weekly on Sunday and Thursday nights. R1 was not in any other groups, although he was welcome to attend. E16 stated that R1 was on his second infraction (for not following policies related to drug and alcohol use). E16 admitted that the resident was not issued a 30- day pass restriction as a result. E16 stated that if a resident is noncompliant with facility policies, they should not be allowed out on pass. Additionally, E16 was unable to provide evidence of the resident's following the Drug/Alcohol Policy and Contract and of the facility's enforcement of this policy for R1.
When interviewed, R2 (R1's roommate) informed this surveyor that he had seen R1 leave the facility via their room's window in the past; and that R1 would usually return to the facility through the same window. R2 stated that prior to this incident with R1, the room window was able to be opened "pretty much all the way." R2 stated that sometimes at night R1 would be complaining of not having any money, but the next morning would "be flashing a lot of bucks." R2 stated that he had been questioned by the local police about R1 stealing money and women's purses.
While in the facility, this surveyor requested a complete copy of R1's record. When presented with the record of R1, facility administrative staff including E15(Regional Director of Mental Health), E16,
(Clinical Director of Mental Health), E17 (Administrator), E18 (Director Clinical Services), and E19
(Director of Operations) assured the surveyor that the copy of R1's record presented to the surveyor was in fact complete, and that there was not any missing documentation.
Review of R1's facility record revealed that the resident was admitted on May 29, 2002 with diagnoses that included Major Depression, Mild Neutropenia, and Mild Hypertension. R1 did have a physician's order "May go out on pass w/meds & instructions." R1's record contained multiple entries verifying that the resident was out on pass, sometimes for days on end.
Nursing Notes of July 5, 2002, documented "Resident out on pass till Sunday July 7, 2002 with family; August 19, 2002; resident remains out on pass with medications; August 20, 2002, resident remained out on pass during the night; out on pass with medication." Other dates in which R1 was out of the facility on pass were: August 22, 2002, August 23, 2002, August 26, 2002, August 27, 2002, August 28, 2002;
September 3, 2002, September 4, 2002, September 6, 2002, September 12, 2002, September 14, 2002, September 16, 2002, September 17, 2002, September 18, 2002, September 20, 2002, September 22, 2002, September 23, 2002, September 24, 2002, September 26,2002, October 6, 2002, October 7, 2002,
October 21, 2002, October 22, 2002, October ,28,2002, November 3, 2002, November 4, 2002,
November 7, 2002, November 8, 2002, November 9, 2002, November 10, 2002, November 11, 2002, November 12, 2002, November 13, 2002, November 14, 2002, and Dec. 11, 2002, December 12, 2002, December 13, 2002, December 14, 2002.
Social Service notes for R1 were reviewed for the dates May 29, 2002 through December 28, 2002, and documented the resident's frequent passes out of the facility, sometimes for days at at time as well as his noncompliance with group attendance, and his suspected/admission of drug/alcohol use. One entry, that of October 22, 2002, documented that the resident did give a sample for drug/alcohol testing, but when this surveyor contacted the area laboratory used by the facility to test specimens, the surveyor was informed that the lab had not received any samples for this resident for any toxicology or drug/alcohol testing.
The facility policy on Drugs and Alcohol requires that a drug/alcohol screen be completed if a resident is suspected of using drugs or alcohol. This same policy considers a resident as "Positive of drugs/alcohol if the resident admits to use (which R1 did on two separate occasions via the record), and if the resident refuses to submit to a drug/alcohol screen (which R1 also refused)." This policy also requires that the resident submit to random drug/alcohol screens and follow any and all treatment recommendations of the medical doctor and psychiatrist. R1 signed this policy on July 19, 2002 and on November 18, 2002, as well as signed the Drug/Alcohol Policy and Contract on July 19, 2002 and November 18, 2002, in acknowledgment of receipt and intent to adhere to this policy.
The facility also has a Resident Pass Policy which indicates that a resident's pass privilege may be changed or suspended under certain circumstances which included repeated violation of pass privileges or severe violation (returning late, not taking meds, using drugs/alcohol, or "if resident uses drugs or alcohol at any time.)"
R1's record contains numerous entries regarding the resident being out on pass, sometimes for several days, and even though there is repeated documentation of his noncompliance with attendance at groups, and admission of use of drugs/alcohol, the facility continues to allow R1 to go out on pass.
The facility was unable to provide the surveyor with the requested evidence or documentation of any attempts to effectively intervene in screening R1 for drugs/alcohol use and was unable to provide evidence/documentation of treatment revisions after it became apparent that the resident was noncompliant with the facility policies.
Staff interviews verified the documentation contained in R1's record regarding the resident's repeated passes into the community even though resident had admitted to drug/alcohol use, and was continually noncompliant with the facility's policy on drug/alcohol use.
Review of R1's record also revealed three separate occasions in which either staff suspected that the resident had been using drugs and/or drinking or the resident admitted to having been using these substances:
July 19, 2002 (resident admitted using drugs/alcohol) and refused to submit to drug screen, October 22, 2002, counseled by staff and gave urine sample and November 24, 2002, resident admitted to using drugs/alcohol.
Review of R1's care plan revealed that the facility:
1). Failed to address the resident's multiple and prolonged passes out of the facility.
2). Failed to address the resident's history of and admission of current drug/alcohol use.
3). Failed to address the resident's noncompliance with the facility's drug and alcohol policy
4). Failed to address the resident's medication compliance, both inside the facility and while on his frequent overnight passes.
5). Failed to address the resident's noncompliance with attendance at in-house treatment groups, such as the Relapse Prevention Group.
6). Failed to address any counseling regarding noncompliance of the facility's policy on drug/alcohol use.
The facility's Drug and Alcohol Policy specifically stated the following: #1). If a resident is suspected of or observed to be using drugs or alcohol, a drug/alcohol screen will be completed. #2). The resident will be considered positive of drugs/alcohol in any of the following circumstances: a) the resident admits to using drugs/alcohol, b) the resident refuses the drug alcohol screen. Further, the policy states that if a resident is considered positive for drugs/alcohol the resident must submit to random drug/alcohol screens, and must follow any and all treatment recommendation of the medical doctor and psychiatrist related to the drug/alcohol use. Finally, the Policy at #5) states that the resident may be issued a 30-day notice of discharge if the resident fails to successfully complete recommended treatment or is found again to be positive for drugs/alcohol.
Staff interviewed admitted to suspicion of R1 having used drugs/alcohol. The resident's record documents the resident's admission of drug/alcohol use and of his refusals to submit to drug screens and of his continued pass privileges despite failing to adhere to the policy.
Facility's Resident Pass Policy, #6) states that "Residents must adhere to all rules and procedures when signing out on pass, R1 via staff interviews and record review consistently violated this requirement without the facility following up or attempting to enforce the policy. Also, item #7) has two other requirements that R1 did not meet and facility did not enforce a) "If resident violates their pass privilege repeatedly or with a severe violation (returning late, not taking meds, using drugs/alcohol), b) If resident uses drugs or alcohol at any time" a resident's pass privileges may be changed or suspended.
The facility's policy titled House Rules, states that "Residents who have been approved for pass privileges must sign in and out of the facility." In/Out Sheets are located at the front door or nurses station with a staff member. The only documentation that the facility was able to provide regarding: R1's signing out of the facility was for the dates June 2, 2002, June 9, 2002, June 11, 2002 and November 28, 2002,
December 4, 2002, December 11, 2002 and December 13, 2002. The facility was unable to provide additional documentation of R1 having signed in/out of the facility as per policy requirement on any of the days that the surveyor was in the facility investigating this incident with R1, and even though repeated requests were made to review the sign in and out sheets for the months of October through December 15, 2002.