Facility I.d. Number: 0040428 50
Date of Survey: 01/10/2003
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)
The facility shall provide a Resident Services Director who is assigned responsibility for the coordination and monitoring of the resident=s overall plan of care. The Director of Nurses or an individual on the professional staff of the facility may fill this assignment to assure that resident=s plans of care are individualized, written in terms of short and long range goals, understandable and utilized; their needs are met through appropriate staff interventions and community resources; and residents are involved, whenever possible, in the preparation of their plan of care.
The facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial 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.
Based on observation, record review, and interview the facility neglected to:
The example includes:
A review of R2's resident admission face sheet indicates that R2 was admitted to the facility on 08/09/01, with diagnoses including schizo affective disorder, brain atrophy, and history of lung cancer. The face sheet also indicates that the reason that R2 was admitted to the facility was for supervision and structure. R2's current physician's orders (January, 2003) has documentation that R2 also has diagnoses of dementia, Alzheimer's type, bipolar disorder, and agitation. Review of R2's quarterly MDS dated 05/05/02, and significant change MDS dated 10/14/02 indicates that R2 has short-term memory loss (long-term memory loss not assessed) and severely impaired decision-making skills.
Review of psychosocial progress notes forR2dated02/14/02, and 07/30/02 has documentation that R2 is becoming more and more confused and that R2's only interaction with others is when it regards a cigarette. The psychosocial history for R2 dated 08/09/02 has documentation that R2 is unable to hold a conversation, has poor memory, demonstrates poor judgement, and is hard to redirect.
On 12/04/02, while the surveyor was at the facility, R2 was observed wandering on the second floor of the facility. The surveyor attempted to interview R2 on 12/04/02, at 11:20 A.M. in the facility's second floor dining room. R2 was observed to be very confused, rocking back and forth in a chair and thrusting her tongue in and out of her mouth. R2 only stated, "Yes I want a cigarette. What time is it? Is it one o'clock? I get a cigarette at one o'clock" R2 then refused the interview and walked away.
During an interview with E3 (psychosocial director) on 12/04/02, E3 stated that R2 did offer a sex act (oral sex) to another resident approximately two weeks ago.
During interview with R1 on 12/04/02, at 11:30 A.M., R1 told surveyor ALast month R2 offered me oral sex probably for a cigarette. She did start the oral sex on me but she didn=t finish. That was the first time she did it to me.@ Review of the RAP (resident assessment protocol) summary for behavior for R1 dated 09/10/02 shows documentation that R1 is inappropriate with female staff and co-residents by making lewd sexual remarks. Nursing note documentation of team meeting dated 09/11/02 has documentation that, "R1 still making sexually inappropriate remarks to staff and female residents."
During interview with R3 on 12/04/02, at 12:20 P.M. in the second floor break room R3 stated that R2 once told him that she would give him oral sex for a pack of cigarettes. R3 also stated that one time R2 came up to him and started rubbing him on his chest trying to get his cigarette.
In review of a letter from Z1 (former administrator) regarding the sex act between R1 and R2, Z1 indicated that R2 was caught (by the facility staff) in the act of performing a sex act (oral sex) on R1 on 11/03/02. The letter also shows documentation that R2 was actively soliciting sexual favors to R1 in exchange for cigarettes and that there were multiple witnesses who overheard R2 soliciting R1.
Review of nursing note documentation shows that R2 had a history of physically aggressive behavior and inappropriate sexual behavior. The nursing note documentation reveals the following:
During interview with R3 on 12/04/02, at 12:20 P.M. in the second floor break room, R3 stated, AI once asked R2 what would you do for me for a pack of cigarettes?@ R3 said that R2 replied, AI=ll give you oral sex.@ R3 also stated, AOne time R2 came up to me and started rubbing me on my chest. I had my eyes closed and was smoking a cigarette and she came up to me and started rubbing me on my chest trying to get my cigarette.@
08/16/02 - Increasingly agitative to others. Asking for cigarettes. Harder to redirect. Often just walking up to others and taken cigarettes right out of their hands creating many disturbances.
08/18/02 - offered to give other resident her ring for a cigarette.
09/13 and 09/15/02 - Slapping other residents on upper arm and demanding they give her a cigarette.
10/22/02 - Negotiating to perform oral sex (on R1) for a cigarette.
11/10/02 - Constantly redirected and refocuses but still continues to beg for cigarettes from others.
11/13/02 - Involved with altercation. Taking cigarettes from other residents.
11/14/02 - Continually asking anyone " Give me a cigarette. Give you a quarter or I will give you a kiss."
11/16/02 - Going into other room following others.
11/18/02 - Found by staff to be in another male's room with three other male residents.
11/20/02 - Continues to wander about facility asking anyone for cigarettes. Refocused and redirected but has little effect.
11/24/02 - R2 going up to various men residents offering to kiss them for cigarettes. Counseled but continues 2-3 times.
There was no documentation in the nurses= notes for 11/03/02, regarding R2 performing a sexual act on R1.
Review of the facility incident reports for R2 showed the following:
11/04/02 - Red welt, size of a hand on left top of arm.
11/09/02 - R2 grabbed cigarette out of another resident's hand. Other resident scratched R2. Two to three long red scratches noted to inside of R2's right arm. R2 not redirectable and has no time comprehension.
11/13/02 - R2 in process of taking another resident's cigarette out of his hand. Other resident started hitting and punching R2.
During interviews with E5 and E8 (facility staff nurses) on 12/04/02, at 11:00 A.M. and 11:40 A.M. in the facility's second floor nurses station and second floor dining room, both stated that they do try to keep R2 busy but R2 is not assigned to any specific person for monitoring of her behaviors during the day.
E5 stated during her interview that she did hear approximately two-to-three weeks ago that R2 did perform a sex act on another resident.
Review of R2's comprehensive program plan, presented to the surveyor on 12/04/02 had no documentation addressing R2's aggressive behavior or R2's safety. This was approximately five months after nursing documentation that R2 was exhibiting aggressive behavior. This resulted in R2 sustaining physical injury from other residents. The comprehensive program plan also did not address R2's inappropriate sexual behavior until 11/03/02, even though R2 had solicited R1 (resident with known history of inappropriate sexual behavior with females) for a sex act on 10/22/02 was overheard by many witnesses soliciting R1 for sexual favors on 11/03/02 (per Z1' a letter), and was caught in the act of performing a sexual act on R1 on 11/03/02. Intervention/approaches on the care plan are as follows:
AResident will be monitored and counseled daily for inappropriate behavior and redirect when needed.@ The program plan did not address who should monitor R2, how often during the day R2 should be monitored, nor who should counsel R2. The program plan did not address the safety of R2 until 11/03/02, which was approximately four months after R2 was exhibiting aggressive behavior and one month after R2 sustained injuries from her aggressive behavior.
While surveyor was at the facility on 12/04/02, the surveyor noted R2 wandering on the second floor of the facility with no specific staff member assigned to monitor her whereabouts or behaviors.
After the facility addressed the R2's inappropriate sexual behavior on the plan of care it was noted that the intervention for offering sexual favors showed documentation that "Resident will be monitored and counseled daily for inappropriate behavior and redirect when needed". The program plan did not address who should monitor R2, how often during the day that R2 should be monitored, nor who should counsel R2.