Facility I.D. Number:0040970
Jonesboro, Illinois 62952
Date of Survey: 05/27/2003
Incident Report Investigation of May 9, 2003
The facilitys 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 have written policies and procedures governing all services provided by the facility which shall be formulated with the involvement of the administrator. The policies shall be available to the staff, residents and the public. These written policies shall be followed in operating the facility and shall be reviewed at least annually.
All personnel shall have either training or experience, or both, in the job assigned to them.
There shall be evidence of training and habilitation services activities designed to meet the training and habilitation objectives set for every resident.
Physicians shall write a diet order, in the medical record, for each resident indicating whether the resident is to have a general or a therapeutic diet. The diet shall be served as ordered.
AN OWNER, LICENSEE, ADMINISTRATOR, EMPLOYEE OR AGENT OF A FACILITY SHALL NOT ABUSE OR NEGLECT A RESIDENT. (Section 2-107 of the Act)
These Regulations are not met as evidenced by:
Based on observation, interview, and file review, the facility has failed to implement their own policies and procedures to prevent neglect of the client by their failure to provide necessary supervision to protect clients with known special needs from harm as evidenced by:
On 05/09/03, R1 had a choking incident after he took a piece of meat that had not been mechanically altered by staff at the 5 P.M. meal. The facility inserviced staff; but as observed on 05/21/03, staff failed to monitor R1 prior to and during the P.M. meal and failed to provide all foods at a mechanical soft consistency to prevent re-occurrence of further choking incidents.
Per review of R1's Physician Order Sheet dated April 16 to May 15, 2003, R1 is a 40-year-old male who functions at a profound level of mental retardation. R1's Physician Order Sheet identified orders for an "1800 calorie, mechanical soft low fat, low calorie snacks".
Per review of the Preliminary Reporting Form and the Incident Report dated 05/09/03, R1 was eating his supper when he began to choke. R1 put two of his fingers down his throat and started to vomit. Staff noted pieces of corn and pieces of a chicken nugget were expelled while R1 was in the bathroom. Staff also documented that "R1 vomited a lot of mucous with blood streaks in it."
Per review of R1's Progress Notes, the following late entry was noted as written by E3 (Qualified Mental Retardation Professional/QMRP): "I was entering the dining room to assist with supper when I noticed that whole chicken nuggets were being served to R1's table. Before I could grab the bowl, I noticed that R1 was holding his throat. He got up quickly from the table and walked to the bathroom. I followed him and DSP (Direct Support Person) E5 followed him. He put his fingers down his throat and a sm. (small) piece of chicken nugget came out in the toilet. I contacted the nurse on duty and checked on R1. He seemed OK and came back to the table. I spoke with the cook and E1 (Administrator). We decided to let her (E20 Food Service Staff) go. She (E20) ground up some chicken nuggets and all staff began cutting up the nuggets in very sm. pieces for the residents as well. The nurse (E4) checked R1 and I stayed until 7 P.M.. The following day, I (E3) made diet cards with the nurse's assistance to help the DSP's with the residents' diets and to ensure that they followed the diets correctly while assisting residents with meals."
On 05/21/03 during the Entrance Communication at 12:30 P.M., E3 (QMRP) provided the surveyor with a copy of the diets that were identified on the diet cards that she had made for the facility staff. E3 also provided the surveyor with an Inservice Report dated 05/12/03, that identified that staff had been inserviced on mealtime responsibilities and diets. E3 also stated that E20 (Food Service Staff) had been terminated since this was the second incident of a client choking. E3 stated that E20 had been counseled prior to 05/09/03, by E2 (Assistant Administrator) due to an incident when R6 had choked.
Per interview with E2 on 05/22/03 at 9:50 A.M., E2 stated that nothing formal in the way of counseling had been done for E20 (Food Service Staff) regarding the incident when R6 had choked.
Review of R6's Nurse's Notes identified that on 03/08/03 at 5:15 P.M., "During supper, R6 attempted to big a bite of meat and became choked. Staff encouraged R6 to cough et (and) he coughed it out. Meat was cut in smaller pieces et he had no further problems..." Review of R6's Physician Order Sheet identified that R6 is to have a "mechanical soft diet with ground meat fork tender."
Per interview with E19 (A.M. Food Service Staff) on 05/21/03 at 1:10 P.M., E19 provided the surveyor with a copy of the menu for 05/09/03. E19 stated that R1 did not receive his proper diet on 05/09/03, and called the surveyor's attention to the fact that R1 is on a calorie-controlled diet in addition to mechanical soft diet. E19 stated that R1 should not have received chicken nuggets but rather baked chicken since he was on a calorie-controlled diet. E19 stated that she was told that no baked chicken was fixed on 05/09/03, for the clients on calorie-controlled diets.
On 05/21/03 at 5 P.M., R1 was observed in the dining room of the facility. R1 was observed to be ambulatory and was not observed to verbalize with staff and or peers of the facility. Staff were heard to prompt R1 to leave the area, but staff were not observed to physically assist R1 from the dining room. Food Service Staff (E21) was observed placing food and bowls of food on the table. R1 continued standing at his table in the dining room, and no staff were observed to assist him away from the table. E21 was observed to set a plate down at R1's table to his left. The plate was observed to have pieces of cut-up chicken on the plate. R1 had the opportunity to grab any of the food items off of the table during this observation due to the lack of staff supervision. When R1 was served his meal 5:17 P.M., R1 was served ground chicken, broccoli, potatoes and a whole slice of bread. E5 (staff) was present at the table and was observed to assist the other clients in the meal time set up. At 5:20 P.M., R1 picked up his whole slice of bread and tore the bread in half. R1 stuck half of the bread into his mouth without intervention. R1 then tore the remainder of the bread from the crust and stuck the bread into his mouth. R1 then ate the crust of the remaining bread in one bite without intervention. R1 completed his meal with no intervention and/or prompting from staff (E5) who was present at the table. No diet cards were observed to be used by staff (E5) during the 5 P.M. meal to ensure that staff follow the diets correctly while assisting residents with meals.
Review of the diet order cards that were provided to the surveyor on 05/21/03, identified that all of R1's foods are to be cut. Record review identified that R1 has an eating program that was not observed to be implemented at the 5 P.M. meal on 05/21/03. R1 has an eating objective that states: "with two verbal prompts, R1 will be prompted by staff to slow meal pace by putting down his utensil in between bites."
Interview with E19 (A.M. Food Service Staff) on 05/22/03 at 1:55 P.M., E19 stated "No" when asked by the surveyor if mechanical-soft diets receive whole slices of bread. E19 stated that she either tears or cuts up the foods and breads for clients on mechanical-soft diets. E19 stated that Day-Training had called her and said that R1 was sent a whole sandwich for lunch. E19 stated, "He got the wrong sandwich because I cut my sandwiches up into eights for the mechanical soft diets."