MOUNT SAINT JOSEPH Facility I.D. Number 0005520 Date of Survey:09/26/2002 Notice of Violation:11/18/02 Annual Survey "A" VIOLATION(S): The facility’s 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. The facility shall notify the Department of any incident or accident which has, or is likely to have, a significant effect on the health, safety, or welfare of a resident or residents. Incidents and accidents requiring the services of a physician, hospital, police or fire department, coroner, or other service provider on an emergency basis shall be reported to the Department. 1) Notification shall be made by a phone call to the Regional Office within 24 hours of each serious incident or accident. If the facility is unable to contact the Regional Office, notification shall be made by a phone call to the Department’s toll free complaint registry number. 2) A narrative summary of each serious accident or incident occurrence shall be sent to the Department within seven (7) days of the occurrence. The facility shall also immediately notify the resident’s family, guardian, representative, conservator and any private or public agency financially responsible for the resident’s care whenever unusual circumstances such as accidents, sudden illness, disease, unexplained absences, extraordinary resident charges, billings, or related administrative matters arise. AN OWNER, LICENSEE, ADMINISTRATOR, EMPLOYEE OR AGENT OF A FACILITY SHALL NOT ABUSE OR NEGLECT A RESIDENT. (Section 2-107 of the Act) A FACILITY EMPLOYEE OR AGENT WHO BECOMES AWARE OF ABUSE OR NEGLECT OF A RESIDENT SHALL IMMEDIATELY REPORT THE MATTER TO THE FACILITY ADMINISTRATOR. (SECTION 3-610 OF THE ACT) A FACILITY ADMINISTRATOR WHO BECOMES AWARE OF ABUSE OF A RESIDENT SHALL IMMEDIATELY REPORT THE MATTER BY TELEPHONE AND IN WRITING TO THE RESIDENT’S REPRESENTATIVE. (Section 3-610 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) EMPLOYEE AS PERPETRATOR OF ABUSE - WHEN AN INVESTIGATION OF A REPORT OF SUSPECTED ABUSE OF A RESIDENT INDICATES, BASED UPON CREDIBLE EVIDENCE, THAT AN EMPLOYEE OF A LONG-TERM CARE FACILITY IS THE PERPETRATOR OF THE ABUSE, THAT EMPLOYEE SHALL IMMEDIATELY BE BARRED FROM ANY FURTHER CONTACT WITH RESIDENTS OF THE FACILITY, PENDING THE OUTCOME OF ANY FURTHER INVESTIGATION, PROSECUTION OR DISCIPLINARY ACTION AGAINST THE EMPLOYEE. (SECTION 3-611 OF THE ACT) Based on interview of staff, record verification, review of incident reports, and allegation investigation reports, the facility failed to:
Findings include: 1. R8, per her Admission/Discharge Sheet, is a 58 year old female whose diagnoses includes Profound MR and Aphasia. Per review of the facility's Incident Reports, on Monday 7/29/02, E12 (Hab Aide) reported to E15 (RN) that on Sunday 7/28/02 at approximately 2:45P.M./3P.M. she witnessed the following: E7 (former Hab Aide) held R8 "forcefully against the wall in the shower room. R8 moved her head banging her head on the wall twice, (on both sides of her head above ears). Staff (E7) also cleaned R8's legs and groin area with a large brush that is used to clean shower tubs." Administration was made aware of E7 abusing R8 at approximately 4P.M. on 7/29/02, per review of a FAX transmittal sheet dated 7/30/02 (addressed to Illinois Department of Public Health). Per review of R8's nursing notes, the facility received a call from R8's day program 7/29/02 at 11:30A.M. that R8 had an emesis. At approximately 3:30P.M. nursing assessed R8 and noted a small discolored spot above right knee and bumps were felt on scalp area. At 5:35P.M. R8's physician was notified and orders were received to send R8 to the emergency room for evaluation due to head injury. R8 was then transported to the hospital via ambulance. R8 returned to the facility at 11:40P.M. with a diagnosis of contusions to the head (per hospital report and E3 the Director of Nurses). E1 (Administrator) investigated the 7/28/02 incident in which E7 abused R8. The investigative packet provided the following information: On Sunday 7/28/02 at approximately 3:45P.M./4P.M., E7 took R8 to the shower room. R8 had an episode of fecal incontinence and needed to be cleaned. E7 used a cleaning brush and soap to clean R8. The cleaning brush is used for cleaning bath tubs. E7 claimed the feces was hardened on R8's body and that is why it was necessary to use the cleaning brush. E7 forcefully held R8 against the wall at which time R8 hit both sides of her head against the wall. E1 concluded, in her investigation, "... this incident may not fit the DPH (Department of Public Health) definition of abuse, it is an incident of gross disregard for the dignity of the resident." On 9/20/02 at 1:15P.M. E1 provided a written statement confirming E7 was terminated 8/1/02. E1 stated the facility did consider this incident to be abuse. 2. R16, per her Admissions/Discharge Sheet, is a 63 year old female whose diagnoses includes Profound MR, Blindness, Dysphagia and Recurrent Aspiration Pneumonia. R16, per her 9/02 Physician's Order Sheet (POS), is on a puree diet with pudding-thick liquids and needs assistance with feeding. Per review of a 7/28/02 abuse investigation (involving E7 and R8), an Employee Warning Form was noted. The form, dated 5/30/02, documented E7 received a written disciplinary warning regarding a 5/25/02 abuse incident involving R16. E7 received a written warning due to being "verbally offensive" to R16 and pinching her nostrils to get her to eat. E13 (volunteer) provided a written statement, dated 5/25/02, of her observations of E7 abusing R16. The statement included the following information: On Saturday 5/25/02 at approximately 8A.M., E13 was walking down the hallway towards the north side of Angel Guardian cottage when she heard, "open your mouth! open your mouth!" "The voice was loud and sounded quite frustrated and angry, so I hurried down the hall to see what was wrong." "... I witnessed E7 take hold of R16's nose, by pinching her nostrils together, and then pushing her head back (by use of R16's pinched nose) and then forcefully shove a spoonful of thickened milk into R16's mouth." E13 intervened and then pushed R16 (in her wheelchair) into the living room. E13 first made R16 more comfortable in her wheelchair, "... (one leg hanging off chair, blanket on floor, body leaning to one side)." As E13 was assisting R16, "E7 yelled from the kitchen, 'she needs to go to bed now.'" E13 responded, "R16 needs to sit-up for at least one hour to digest her food ... do not lay her down." E1 was interviewed 9/18/02. E1 stated this 5/25/02 incident was not reported immediately to the Administrator and was not investigated. E1 stated this incident was looked at for disciplinary purposes with E7. E1 then stated the incident should have been looked at as abuse. 3. R17, per her Admission/Discharge Sheet, is a 59 year old female whose diagnoses includes Profound MR and Blindness. Per review of a 7/28/02 abuse investigation (involving E7 and R8), an Employee Warning Form was noted. The form, dated 5/3/02, documented E7 received a verbal disciplinary warning regarding a 5/2/02 incident involving R17. E7 received a verbal warning due to, "Failure to treat residents with dignity/respect. Was verbally offensive and loud to resident on May 2, 2002. Co- worker complained to supervisor, as she witnessed the incident." E1 (Administrator) was interviewed on 9/18/02. E1 identified R17 as the client. E7 (former direct care staff) was "verbally offensive" and also loud to R17 on 5/2/02. On 9/18/02, E1 was interviewed. E1 stated this incident (5/2/02) was overlooked - it should have been handled as abuse. 4. R13 is a 68 year old female with diagnoses of Severe Mental Retardation. R13 is verbal, utilizes a wheelchair, and needs assist with ambulation and transfers at all times. (Per Physician's Order Sheet of 8/29/02.) Per review of the facility's incident reports, the Accident, Illness, Seizure and Documentation Report form of 4/08/02 indicated, "On 4/08/02 it was reported to me that resident had 2 small bruises on her upper left arm. Upon speaking with resident, she reported that staff pinched her." E5, Housemother of Angel Guardian Cottage (who wrote the Accident Documentation Report), on 9/18/02 at 9:30A.M. stated that she was unable to recall who reported the incident to her. "I spoke to R13 who told me E7, former direct care staff, pinched her and showed me the finger- size purple bruises." Review of photographs dated 4/08/02 at 5:25P.M. indicated R13's left inner arm with 2 circular finger-sized bruises. E5 continued to state, "I spoke to R13 who told me E7 (former direct care staff) pinched her. E7 punished her. R13 showed me the finger-size purple bruises." E5 further stated, "We tracked it down through conversation with R13 and E7 that it occurred on 4/06/02 around 8:00A.M. when she was in her room at breakfast time." Review of Narrative Notes Statement of 4/06/02 regarding R13's behaviors at 7:35:A.M. and 8:35A.M., written by E7 (the alleged employee perpetrator), indicated R13 was crying, yelling and screaming in the day room and refusing to eat breakfast, therefore, E7 escorted R13 back to R13's bedroom....."I helped her back to her chair asking her if she was going to behave herself and come back to the day room, when she picked up her cereal bowl and was going to throw it at me. I took the dishes away and let her sit in her room like she wanted." Interviews with E1, Administrator, and E5, Housemother, on 9/18/02 indicate no one other than R13, the alleged abused individual, and E7, the alleged employee perpetrator, were interviewed. E1 stated, "During the interview with E7, we felt it was inappropriate holding, though E7 doesn't remember doing anything to cause bruising." 5. An incident report for 3/25/02 shows the facility was neglectful in using an unauthorized restraint to keep an individual in her room at night. The incident was discovered when R24, a 57 year old woman with diagnosis of Profound Mental Retardation (according to the Individual Program Plan, dated 11/13/01), fell over a gate placed in her bedroom doorway by staff to prevent her from leaving her room during the night. A memo from the psychologist dated 3/25/02 and an interview on 9/19/02 verified that the gate was used to keep R24 in her room at least two documented times on 3/25/02 and in November 2001. 6. Review of incident reports and allegation investigation reports showed that after 6 allegations of abuse had been made, the alleged perpetrators (E7, E8 and E10) had been allowed to continue working with clients in those cottages. The abuse allegations were the following: E7 physically abusing R13 on 4/8/02, E7 verbally abusing R17 on 5/2/02, E7 verbally/physically abusing R16 on 5/25/02, E7 physically abusing R8 on 7/28/02. E8 physically abusing R14 on 2/14/02. E10 physically abusing R15 on 4/16/02. The clients who live in Angel Guardian, St. Mary's and St. Joseph's cottages that were placed at risk while the allegations were taking place are the following: R1, R8, R11, R13-17, R19. R21, and R's 25-67. Based on interview of staff, record verification, review of incident reports, and allegation investigation reports, the facility failed to notify guardians of 4 allegations of abuse (physical and/or verbal abuse of R16, 17,14 ,15) and an injury of unknown origin (R18). Findings include: 1. Per review of the allegation investigation dated 2/14/02, R14 reported to E11 (Behavior Specialist) on (Wednesday) 2/13/02 that on Sunday night (2/10/02), E8 (Housemother on St. Mary's cottage) had choked her. Per record verification of the Admission and Discharge Record and the Physician's Order Sheet, R14 is a 47 year old verbal, ambulatory female who has a diagnosis which includes Mild Mental Retardation and Down Syndrome. Review of the investigation showed E9 (Director of Psychology) gave a statement on 2/14/02 which reported that R14 said E8 was upset because R14's closet was messy, and that E8 had choked her and had hurt her throat. Per review of the investigation and per record verification of R14's chart, there was no documentary evidence to show that R14's guardian had been notified of this allegation of abuse. Per interview on 9/18/02, E1 (Administrator) said that she had not notified the guardian of this allegation. Per interview on 9/19/02, E3 (Director of Nurses) said that usually the nursing department does notify the guardian of significant events, but that in this instance, neither she nor the other nurses were aware of this allegation of abuse. E3 concluded by saying that the nursing department had not notified R14's guardian about this allegation. 2. Per review of the allegation investigation dated 4/16/02, R15 reported to E17 (a staff driving R15 to a doctor appointment) that E10 (habilitation aide on St. Joseph's cottage) had hit her. Per record verification of the Admission and Discharge Record and the Physician's Order Sheet, R15 is 34 year old verbal, ambulatory female who has a diagnosis which includes Moderate Mental Retardation. Per review of the investigation and per record verification of R15's chart, there was no documentary evidence to show that R15's guardian had been notified of this allegation of abuse. Per interview on 9/18/02, E1 (Administrator) said that she had not notified the guardian of this allegation. Per interview on 9/19/02, E3 (Director of Nurses) said that usually the nursing department does notify the guardian of significant events, but that in this instance, neither she nor the other nurses were aware of this allegation of abuse. E3 concluded by saying that the nursing department had not notified R15's guardian about this allegation. 3. Per review of incident investigations, there were 2 other incidents of abuse that were not reported to the guardians. Per record verification, there was no documentary evidence to show that R16's guardian was notified of the abuse incident dated 5/25/02. Per record verification, there was no documentary evidence to show that R17's guardian was notified of the abuse incident dated 5/2/02. Per interview on 9/18/02, E1 confirmed that R16's and R17's guardians were not notified of the abuse incidents. 4. Per review of incident reports, it was found that 1 other guardian was not notified of R18's fractured finger, which was confirmed by X-ray results on 6/5/02. There was no documentary evidence to show that R18's guardian was notified of this injury of unknown origin. Per interview on 9/20/02, E3 (Director of Nurses) said that the guardian was not notified of the fractured finger. Based on interview and record verification, the facility staff failed to ensure the Administrator was immediately notified of 4 incidents of abuse: R8 (7/28/02), R16 (5/25/02), R17 (5/2/02) and R14 (2/14/02). The facility also failed to report the abuse of 2 clients, R16 (5/25/02) and R17 (5/2/02), and 2 allegations of abuse R14 (2/14/02) and R15 (4/16/02) to other officials (Illinois Department of Public Health) in accordance with State Law. Findings include: 1. R8, per review of her Admission/Discharge Sheet, is a 58 year old female whose diagnoses includes Profound MR and Aphasia. Per review of the facility's Incident Reports, on 7/29/02 E12 (Hab Aide) reported to E15 (RN) that on Sunday 7/28/02 at approximately 2:45P.M./3P.M. she witnessed the following: E7 (former Hab Aide) held R8 "... forcefully against the wall in the shower room." "R8 moved her head banging her head on the wall twice." Staff (E7) also cleaned R8's legs and groin area with a large brush that is used to clean shower tubs. On 7/29/02 R8 was subsequently sent to the emergency room where she was diagnosed with contusions (to the head). This incident of abuse occurred, as witnessed by E12, on Sunday 7/28/02 at approximately 2:45P.M./3P.M.. However, E12 did not report the abuse until Monday 7/29/02 at approximately 4P.M.. E1 (Administrator) was interviewed 9/17/02. E1 stated E12 did not report that E7 abused R8 (7/28/02) until 7/29/02. On 9/18/02 E1 stated E12 tried to contact the Administrator 7/28/02 (Sunday) but she did not know the right procedure. 2. R16, per her Admission/Discharge Sheet, is a 63 year old female whose diagnoses includes Profound MR, Blindness, Dysphagia, and Recurrent Aspiration Pneumonia. R16, per her 9/02 Physicians's Order Sheet (POS), is on a puree diet with pudding-thick liquids and needs assistance with feeding. Per review of a 7/28/02 abuse investigation (involving E7 and R8), an Employee Warning Form was noted. The form, dated 5/30/02, documented E7 (former Hab Aide) received a written disciplinary warning regarding a 5/25/02 abuse incident involving R16. E7 received a written warning due to being "verbally offensive" to R16 and pinching her nostrils to get her to eat. The 5/25/02 abuse incident occurred at approximately 8A.M., per E13's (volunteer) written statement. E1 (Administrator) was interviewed 9/18/02. E1 verified the abuse incident 5/25/02 was not immediately reported to the Administrator and it was not reported to IDPH (Illinois Department of Public Health). E1 stated this abuse incident of 5/25/02 was overlooked. The incident was not investigated because the incident was handled as a disciplinary issue, and not as abuse. She said it should have been identified as abuse. 3. R17, per her Admission/Discharge Sheet, is a 59 year old female whose diagnoses includes Profound MR and Blindness. Per review of a 7/28/02 abuse investigation (involving E7 and R8), an Employee Warning Form was noted. The form dated, 5/3/02, documented E7 (former Hab Aide) received a verbal disciplinary warning regarding a 5/2/02 incident involving R17. E7 received the verbal warning due to "Failure to treat residents with dignity/respect. Was verbally offensive and loud to resident on 5/2/02. Co-worker complained to supervisor, as she witnessed the incident." E1 (Administrator) was interviewed on 9/18/02. E1 identified R17 as the client E7 abused. E1 verified this abuse incident was not immediately reported to the Administrator and it was not reported to IDPH (Illinois Department of Public Health). E1 stated the incident was overlooked. The incident was not investigated and should have been handled as abuse. 4. Per review of the allegation investigation dated 2/14/02, R14 reported to E11 (Behavior Specialist) on (Wednesday) 2/13/02 that on Sunday night (2/10/02), E8 (Housemother on St. Mary's cottage) had choked her. Per record verification of the Admission and Discharge Record and the Physician's Order Sheet, R14 is a 47 year old verbal, ambulatory female who has a diagnosis which includes Mild Mental Retardation and Down Syndrome. Review of the investigation showed E9 (Director of Psychology) gave a statement on 2/14/02 which reported that R14 said E8 was upset because R14's closet was messy, and that E8 had choked her and had hurt her throat. Per review of the investigation, although R14 reported the allegation of abuse to E11 on (Wednesday) 2/13/02, the allegation was not reported to the administrator until 2/14/02. Per interview on 9/18/02 at 2:35 P.M., E11 said that he had not reported the allegation to the administrator. Per this same interview and per review of the investigation, E11 had instructed R14 to report the abuse to E9 on (Thursday) 2/14/02, because his understanding was that any allegations of abuse needed to be reported to the director of the psychology department. The investigation showed that R14 did speak to E9 on (Thursday) 2/14/02, and only then was the administrator notified of the allegation of abuse. E11 failed to report an allegation of abuse immediately to the administrator. Per review of the investigation and per record verification of R14's nursing notes, there was no documentary evidence to show that IDPH had been notified of this allegation of abuse. Per interview on 9/18/02, E1 (Administrator) confirmed that IDPH had not been notified of this allegation of abuse. E1 explained, "I thought that only incidents having serious outcome needed to be faxed to IDPH, and since the allegation of abuse could not be substantiated, we did not believe IDPH needed to be notified." E1 said she couldn't explain why E11 did not report the abuse allegation to the administrator, but that he should have reported it immediately to her. E1 said that as of 9/18/02, no staff had been formally re-trained or re-inserviced about reporting any abuse or neglect immediately to the administrator. 5. Per review of the allegation investigation dated 4/16/02, R15 reported to E17 (a staff driving R15 to a doctor appointment) that E10 (habilitation aide on St. Joseph's cottage) had hit her. Per record verification of the Admission and Discharge Record and the Physician's Order Sheet, R15 is 34 year old verbal, ambulatory female who has a diagnosis which includes Moderate Mental Retardation. Per review of the investigation and per record verification of R15's nursing notes, there was no documentary evidence to show that IDPH had been notified of this allegation of abuse. Per interview on 9/18/02, E1 (Administrator) confirmed that IDPH had not been notified of this allegation of abuse. E1 explained, "I thought that only incidents having serious outcome needed to be faxed to IDPH, and since the allegation of abuse could not be substantiated, we did not believe IDPH needed to be notified." E1 said that as of 9/18/02, no staff had been formally re- trained or re-inserviced about reporting any abuse or neglect immediately to the administrator. Based on interview of staff, review of incident reports, and allegation investigation reports, the facility failed to investigate 2 allegations of verbal/physical abuse (the physical/verbal abuse of R16 on 5/25/02, and the verbal abuse of R17 on 5/2/02), failed to investigate 2 injuries of unknown origin (R18's red, swollen hand on 6/3/02, and R18's fall on 6/4/02), and failed to interview key staff, or any witnessing clients for the investigations of 4 allegations of physical abuse (the physical abuse of R8 on 7/28/02, the physical abuse of R13 on 4/8/02, the alleged choking of R14 on 2/14/02, and the alleged physical abuse of R15 on 4/16/02). Findings include: 1. R8, per review of her Admission/Discharge Sheet, is a 58 year old female whose diagnoses includes Profound MR and Aphasia. Per review of the facility's Incident Reports, on 7/29/02, E12 (Hab Aide) reported to E15 (RN) that on Sunday 7/28/02 at approximately 2:45P.M./3P.M., she witnessed the following: E7 (former Hab Aide) held R8 "...forcefully against the wall in the shower room." "R8 moved her head banging her head on the wall twice." Staff (E7) also cleaned R8's legs and groin area with a large brush that is used to clean shower tubs. Nursing assessment of R8 notes, "A small discolored spot above Rt (right) knee, bumps on both side(s) of scalp felt." R8 was sent to the emergency room for further evaluation on 7/29/02 at approximately 6P.M.. R8's nurses notes of 7/29/02 11:30A.M., document a call was received from her workshop that she had an emesis. At 3:30P.M. on 7/29/02, per nursing notes, bumps were felt on scalp area. The physician was notified and R8 was sent to the hospital via an ambulance. R8 returned to the facility at 11:40P.M. 7/29/02. Diagnosis, per hospital report, was contusions (to head). E1 (Administrator) investigated the 7/28/02 allegation that E7 was abusive to R8. E1's investigation was completed 7/30/02. The investigation included the following: E7 washed R8 with a brush that is used for cleaning tubs. R8 had an episode of fecal incontinence earlier in the day and needed to be bathed. E7 stated she used a brush and not a shower chair because she would not have been able to get the feces off of R8's buttocks. E7 confirmed she did "support" R8 against the wall while showering her. E7 denied seeing R8 bang her head on the wall. E7 gave a written statement dated 7/30/02. E7's statement documents that on Sunday 7/28/02 she was working alone on the north wing of Angel Guardian cottage when R8 had a bowel movement. E7 documented she cleaned R8 with a long handled bath brush and soap. E7 documented she did hold R8 against the wall to rinse her off. E7 identified 2 other staff as working with her at the time of the incident, with 1 of the 2 staff on break at the time of the incident. E1's investigation of E7 abusing R8 does not identify any other staff that were working 7/28/02 in R8's living area. E1 was interviewed 9/18/02. E1 stated E7's statement of 2 other staff present at the time of the abuse was not accurate, however this was not included in the investigation. E1 stated E12 (Hab Aide) was working 7/28/02, however this is not included in E7's statement or E1's investigation. E1's investigation does not identify any other employees or clients that may have observed or have knowledge of E7 abusing R8. The investigation does not identify when the abuse occurred (date and time). The investigation documents that the incident may not fit the DPH (Department of Public Health) definition of abuse, but it is an incident of gross disregard for the dignity of the resident. On 9/20/02 at 1:15P.M., E1 provided a written statement confirming E7 was terminated 8/1/02. 2. R16, per her Admission/Discharge Sheet, is a 63 year old female whose diagnoses includes Profound MR Blindness, Dysphagia, and Recurrent Aspiration Pneumonia. R16, per her 9/02 Physician's Order Sheet (POS), is on a puree diet with pudding-thick liquids and needs assistance with feeding. Per review of a 7/28/02 abuse investigation (involving E7 and R8), an Employee Warning Form was noted. The form, dated 5/30/02, documented E7 received a written disciplinary warning regarding a 5/25/02 abuse incident involving R16. E7 received a written warning due to being "verbally offensive" to R16 and pinching her nostrils to get her to eat. On 9/17/02 E1 (Administrator) was asked for any information regarding the 5/25/02 abuse incident involving E7 and R16. On 9/18/02 E1 stated the 5/25/02 incident was not investigated. E1 stated the incident was overlooked - it should have been handled as abuse. However the incident was looked at for disciplinary purposes with E7. There was no investigation of the 5/25/02 incident of abuse involving E7 and R16. 3. R17, per her Admission/Discharge Sheet, is a 59 year old female whose diagnoses includes Profound MR and Blindness. Per review of a 7/28/02 abuse investigation (involving E7 and R8), an Employee Warning Form was noted. The form, dated 5/3/02, documented E7 received a verbal disciplinary warning regarding a 5/2/02 incident involving R17. E7 received a verbal warning due to, "Failure to treat residents with dignity/respect. Was verbally offensive and loud to resident on 5/2/02. Co-worker complained to supervisor, as she witnessed the incident." The Employee Warning Form does not identify the resident to which E7 was verbally offensive. E1 (Administrator) was interviewed 9/18/02. E1 identified R17 as the client. E7 was "verbally offensive" and loud to R17 on 5/2/02. On 9/17/02 E1 was asked for any information regarding the 5/2/02 abuse incident involving E7 and R17. On 9/18/02 E1 stated the incident was overlooked - it should have been handled as an abuse. However the incident was looked at for disciplinary purposes with E7. There was no investigation of the 5/2/02 incident of abuse involving E7 and R17. 4. R13 is a 68 year old female with diagnoses of Severe Mental Retardation. R13 is verbal, utilizes a wheelchair, and needs assist with ambulation and transfers at all times. (Per Physician's Order Sheet of 8/29/02.) Per review of the facility's incident reports, the Accident, Illness, Seizure and Documentation Report form of 4/08/02 indicated, "On 4/08/02 it was reported to me that resident had 2 small bruises on her upper left arm. Upon speaking with resident, she reported that staff pinched her." E5, Housemother of Angel Guardian Cottage (who wrote the Accident Documentation Report), stated on 9/18/02 that she was unable to recall who reported the incident to her. "I spoke to R13 who told me E7, direct care staff, pinched her and showed me the finger-size purple bruises." Review of photographs dated 4/08/02 at 5:25P.M. indicated R13's left inner arm with 2 circular finger-sized bruises. E5 continued to state, "I spoke to R13 who told me E7 pinched her. E7 punished her. R13 showed me the finger-size purple bruises." E5 further stated, "We tracked it down through conversation with R13 and E7 that it occurred on 4/06/02 around 8:00A.M. when she was in her room at breakfast time." Review of Narrative Notes Statement of 4/06/02 regarding R13's behaviors at 7:35A.M. and 8:35A.M., written by E7, the alleged employee perpetrator, indicated R13 was crying, yelling and screaming in the day room and refusing to eat breakfast, therefore E7 escorted R13 back to R13's bedroom....."I helped her back to her chair asking her if she was going to behave herself and come back to the day room when she picked up her cereal bowl and was going to throw it at me. I took the dishes away and let her sit in her room like she wanted." Interviews with E1, Administrator, and E5, Housemother, on 9/18/02 indicate no one other than R13, the alleged abused individual, and E7, the alleged employee perpetrator, were interviewed. E1 stated, "During the interview with E7, we felt it was inappropriate holding, though E7 doesn't remember doing anything to cause bruising." Record verification of letter sent to Illinois Department of Public Health (IDPH) on 4/10/02 regarding follow-up investigation of E7's alleged pinching of R13 indicated: "During the follow- up investigation and interviews of staff in R13's cottage, it was determined that no one witnessed the alleged pinching of resident......We have not been able to substantiate R13's statement. After completion of interviews of staff, it has been determined that R13's statement is unfounded." Interview with E1, Administrator, and E5, Housemother on 9/18/02 indicate no one other than R13, the alleged abused individual and E7, the alleged employee perpetrator were interviewed. E1 stated, "We would have asked another person who worked with E7, but I don't remember. This on our part is a fault. As far as documentation, there is none; we only talked to R13 and E7." 5. R18 is a 30 year old female with diagnoses of Profound Mental Retardation and Grand Mal Epilepsy. R18 has a history of frequent falls and is to use a wheelchair as needed. (Per Physician's Order Sheet of 8/22/02.) Per review of facility's incident report, the Search Developmental Center Incident Observation Report Form of 6/03/02 indicated, "R18 came this morning with her left hand swollen." A fax transmittal to IDPH on 6/07/02 indicated, "R18 - Fracture 4th finger, left hand." The letter also indicated: 6/03/02 - "noted swelling at workshop (no falls)". 6/04/02 - "hand with redness...later in day unwitnessed fall on cottage, no injury". 6/05/02 - "hand remains puffy, some type bug bites...increased swelling. X-rays ordered indicating fracture." Letter continues, "I have submitted the information without a formal incident report as I cannot determine when or how fracture occurred." E3, Director of Nursing, (who wrote the IDPH letter of 6/07/02), stated on 9/17/02 that on 6/03/02 nursing determined the swelling to be bug bites. Review of nursing progress notes of 6/03/02 at 8:00P.M. indicated " Left hand appears swollen, monitor...Workshop noted her hand swollen when she arrived there in A.M.. Etiology unknown." E3 stated, "Besides the bus driver, no interviews were done." Nursing notes of 6/04/02 at 5:30P.M. indicated, "unwitnessed fall in cottage, left hand swollen." No incident report or investigation of injury of unknown origin was noted. E3 on 6/17/02 stated, "I guess I didn't interview on this incident (unwitnessed fall)." Review of x-ray report of 6/05/02 indicated: Left hand, acute comminuted fracture of mid 4th metacarpal with some dorsal soft tissue swelling. 6. Per review of the allegation investigation dated 2/14/02, R14 reported to E11 (Behavior Specialist) on (Wednesday) 2/13/02 that on Sunday night (2/10/02), E8 (Housemother on St. Mary's cottage) had choked her. Per record verification of the Admission and Discharge Record and the Physician's Order Sheet, R14 is a 47 year old verbal, ambulatory female who has a diagnosis which includes Mild Mental Retardation and Down Syndrome. Review of the investigation showed E9 (Director of Psychology) gave a statement on 2/14/02 which reported that R14 said E8 was upset because R14's closet was messy, and that E8 had choked her and had hurt her throat. Review of the facility's investigation showed that R14 (the victim), E8 (the alleged perpetrator), and Z2 (Medical Director) were interviewed. Although the investigation had included a statement made by E9 (who had also spoken to R14 about the allegation on 2/14/02), there was no documentary evidence to show that E11 (Behavior Specialist and the staff who R14 first spoke to regarding the allegation) and E9 (Director of Psychology and the staff who R14 talked to regarding the allegation) had been interviewed about their discussion with R14, and about any additional information regarding the allegation. In addition, there was no documentary evidence to show that interviews had been conducted with any other staff working on the evening of 2/10/02 (the evening the alleged choking incident was said to have occurred), or with any of the verbal clients who might have been witness to the incident. Per interview on 9/18/02, E1 (Administrator) said that she had not interviewed any of the other staff or any of the clients to determine if they had witnessed the incident. E1 said that her investigation included only interviews with R14, Z2, and E8, but that E11 and E9 had not been interviewed for the investigation. 7. Per review of the allegation investigation dated 4/16/02, R15 reported to E17 (a staff driving R15 to a doctor appointment) that E10 (habilitation aide on St. Joseph's cottage) had hit her. Per record verification of the Admission and Discharge Record and the Physician's Order Sheet, R15 is 34 year old verbal, ambulatory female who has a diagnosis which includes Moderate Mental Retardation. Review of the facility's investigation showed that only R15 and E10 had been interviewed. Per interview on 9/18/02, E1 said that she had not interviewed E17 (the driver and who R15 spoke to about the allegation), E18 (the staff who reported the allegation to the administrator), other staff working on the day the incident was said to have occurred, or any of the verbal clients who might have been witness to the incident. Based on interview, record verification, and review of photographs, the facility failed to ensure that further potential abuse was prevented while the investigations of alleged and/or abuse of residents (R13, 14, 15, 16, 17) were in progress. While the investigations were being conducted and while results of the investigation were not yet determined, the alleged employees involved (E7, E8, E10) were allowed to continue working, giving direct care to the residents involved. Findings include: 1. R13 is a 68 year old female with diagnoses of Severe Mental Retardation. R13 is verbal, utilizes a wheelchair, and needs assist with ambulation and transfers at all times. (Per Physician's Order Sheet of 8/29/02.) Per review of the facility's incident reports, the Accident, Illness, Seizure and Documentation Report form of 4/08/02 indicated, "On 4/08/02 it was reported to me that resident had 2 small bruises on her upper left arm. Upon speaking with resident, she reported that staff pinched her." E5, Housemother of Angel Guardian Cottage (who wrote the Accident Documentation Report), stated on 9/18/02 that she was unable to recall who reported the incident to her. "I spoke to R13 who told me E7, direct care staff, pinched her and showed me the finger-size purple bruises." Review of photographs dated 4/08/02 at 5:25P.M. indicated R13's left inner arm with 2 circular finger-sized bruises. E5 continued to state, "I spoke to R13 who told me E7 pinched her. E7 punished her. R13 showed me the finger-size purple bruises." E5 further stated, "We tracked it down through conversation with R13 and E7 that it occurred on 4/06/02 around 8:00A.M. when she was in her room at breakfast time." Review of Narrative Notes Statement of 4/06/02 regarding R13's behaviors at 7:35A.M. and 8:35A.M., written by E7, the alleged employee perpetrator, indicated R13 was crying, yelling and screaming in the day room and refusing to eat breakfast, therefore, E7 escorted R13 back to R13's bedroom....."I helped her back to her chair asking her if she was going to behave herself and come back to the day room when she picked up her cereal bowl and was going to throw it at me. I took the dishes away and let her sit in her room like she wanted." E1, Administrator, on 9/18/02 stated, "I was made aware of the pinching allegation on 4/08/02. E7, employee involved, was off on 4/08/02 and 4/09/02. On 4/10/02 she (E7) came back to work and went directly to Angel Guardian Cottage, then later I talked to (interviewed) her." E1 stated, "During the interview with E7, we felt it was inappropriate holding, though E7 doesn't remember doing anything to cause bruising; so we let her back to work, in-servicing her in use of gait belt, transferring and lifting on 4/17/02 (7 days later)." 2. R16, per her Admission/Discharge Sheet, is a 63 year old female whose diagnoses includes Profound MR, Blindness, Dysphagia, and Recurrent Aspiration Pneumonia. R16, per her 9/02 Physician's Order Sheet (POS), is on a puree diet with pudding-thick liquids and needs assistance with feeding. Per review of a 7/28/02 abuse investigation (involving E7 and R8), an Employee Warning Form was noted. The form, dated 5/30/02, documented E7 (former Hab Aide) received a written disciplinary warning regarding a 5/25/02 abuse incident involving R16. E7 received a written warning due to being "verbally offensive" to R16 and pinching her nostrils to get her to eat. The 5/25/02 abuse incident occurred at approximately 8A.M., per E13's (volunteer) written statement. E13 documented, "As I was walking down the hallway towards the North Side I heard 'open your mouth! open your mouth!' The voice was loud and sounded quite frustrated and angry..." "As I turned the corner I witnessed E7 take hold of R16's nose, by pinching her nostrils together, and then pushing her head back (by use of R16's pinched nose) and then forcefully shove a spoonful of thickened milk into R16's mouth." E13 documented that she told E7 that R16 was finished eating. E13 then repositioned R16 in her chair as "... (one leg hanging off chair, blanket on floor, body leaning to one side)..." Then E7 "... yelled from the kitchen, 'She needs to go to bed now.'" E13 responded by telling E7 that "R16 needs to sit-up for at least one hour to digest her food ... do not lay her down." Per review of payroll and E7's time card, E7 worked 5/25/02 from 5:57A.M. until 2:35P.M.. E1 (Administrator) was interviewed 9/18/02. E1 verified this incident of abuse was not investigated. The facility failed to prevent further potential abuse as they did not investigate this incident, and E7 continued her duties as a Hab Aide. E1 stated this incident (5/25/02) was overlooked and should have been looked at as abuse. E7 continued her duties as a Hab Aide until 8/1/02 at which time she was terminated. E7 was terminated due to an abuse incident that occurred 7/28/02 (involving E7 and R8). 3. R17, per her Admission/Discharge Sheet, is a 59 year old female whose diagnoses includes Profound MR and Blindness. Per review of a 7/28/02 abuse investigation (involving E7 and R8), an Employee Warning Form was noted. The form dated, 5/3/02, documented E7 (former Hab Aide) received a verbal disciplinary warning regarding a 5/2/02 incident involving R17. E7 received the verbal warning due to, "Failure to treat residents with dignity/respect. Was verbally offensive and loud to resident on 5/2/02. Co-worker complained to supervisor, as she witnessed the incident." E1 (Administrator) was interviewed 9/18/02 and identified R17 as the client E7 abused. Per review of payroll and E7's time card, E7 worked 5/2/02 from 5:59A.M. until 2:32P.M.. The facility failed to prevent further potential abuse as they allowed E7 to continue her duties as a Hab Aide. Per review of Incident Reports E7 was involved in another incident of abuse (involving R16) on 5/25/02. E7 continued her duties as a Hab Aide until 8/1/02 at which time she was terminated. E7 was terminated due to an abuse incident that occurred 7/28/02 (involving E7 and R8). 4. Per review of the allegation investigation dated 2/14/02, R14 reported to E11 (Behavior Specialist) on (Wednesday) 2/13/02 that on Sunday night (2/10/02), E8 (Housemother on St. Mary's cottage) had choked her. Per record verification of the Admission and Discharge Record and the Physician's Order Sheet, R14 is a 47 year old verbal, ambulatory female who has a diagnosis which includes Mild Mental Retardation and Down Syndrome. Review of the investigation showed E9 (Director of Psychology) gave a statement on 2/14/02 which reported that R14 said E8 was upset because R14's closet was messy, and that E8 had choked her and had hurt her throat. Review of the facility's investigation showed that E8 (the alleged perpetrator) was interviewed on 2/16/02. Per interview on 9/18/02, E1 (Administrator) said that she was sure E8 continued to work with R14 and other clients in St. Mary's cottage on 2/14/02 (the day the allegation of abuse was made), on 2/15/02 and 2/16/02 (the day E8 was interviewed and the day the allegation was found to be unsubstantiated). Since the allegation of abuse was made on 2/14/02, and the investigation was incomplete until 2/16/02, the facility had no way to guarantee that E8 would not continue to abuse R14 and other clients. The facility put the safety of R14 and other clients at risk for further abuse because E8 was allowed to work with R14 and the other clients while the investigation of the allegation was being conducted. 4. Per review of the allegation investigation dated 2/14/02, R14 reported to E11 (Behavior Specialist) on (Wednesday) 2/13/02 that on Sunday night (2/10/02), E8 (Housemother on St. Mary's cottage) had choked her. Per record verification of the Admission and Discharge Record and the Physician's Order Sheet, R14 is a 47 year old verbal, ambulatory female who has a diagnosis which includes Mild Mental Retardation and Down Syndrome. Review of the investigation showed E9 (Director of Psychology) gave a statement on 2/14/02 which reported that R14 said E8 was upset because R14's closet was messy, and that E8 had choked her and had hurt her throat. Review of the facility's investigation showed that E8 (the alleged perpetrator) was interviewed on 2/16/02. Per interview on 9/18/02, E1 (Administrator) said that she was sure E8 continued to work with R14 and other clients in St. Mary's cottage on 2/14/02 (the day the allegation of abuse was made), on 2/15/02 and 2/16/02 (the day E8 was interviewed and the day the allegation was found to be unsubstantiated). Since the allegation of abuse was made on 2/14/02, and the investigation was incomplete until 2/16/02, the facility had no way to guarantee that E8 would not continue to abuse R14 and other clients. The facility put the safety of R14 and other clients at risk for further abuse because E8 was allowed to work with R14 and the other clients while the investigation of the allegation was being conducted. 5. Per review of the allegation investigation dated 4/16/02, R15 reported to E17 (a staff driving R15 to a doctor appointment) that E10 (habilitation aide on St. Joseph's cottage) had hit her. Per record verification of the Admission and Discharge Record and the Physician's Order Sheet, R15 is 34 year old verbal, ambulatory female who has a diagnosis which includes Moderate Mental Retardation. Review of the facility's investigation showed that E10 (the alleged perpetrator) was interviewed on 4/18/02. Per interview on 9/18/02, E1 said that E10 continued to work with R15 and other clients in St. Joseph's cottage on 4/16/02 (the day the allegation of abuse was made), on 4/17/02 and 4/18/02 (the day E10 was interviewed and the day the allegation was found to be unsubstantiated). Since the allegation of abuse was made on 4/16/02, and the investigation was incomplete until 4/18/02, the facility had no way to guarantee that E10 would not continue to abuse R15 and other clients. The facility put the safety of R15 and other clients at risk for further abuse because E10 was allowed to work with R15 and the other clients while the investigation of the allegation was being conducted. |