Facility I.D. Number: 0040970
1430 State Route 127 South
Date of Survey: 05/27/2003
Incident Report Investigation of May 15, 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.
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 05/15/03, R2 was found on a locked bus after being left on the bus from 9:30 A.M. until he was discovered at approximately 2 P.M. while at the facility's day-training site. His whereabouts were unknown to the facility's day-training staff. R2 has a history of elopement and is to have constant staff supervision to ensure staff know where he is at all times. After the incident, the facility's day-training staff initiated new transportation policy and procedures and inserviced staff as of 05/16/03. As of 05/21/03, the facility's day-training staff were not implementing the new transportation policy and procedures, nor had all staff been inserviced on the policy to assist in the prevention of re-occurring incidents of leaving clients on the bus. Additionally, during observations on 05/21/03 at the facility, R2 was not provided with constant supervision as identified per his behavioral intervention plan to assist in the reduction of elopement behaviors.
Per review of R2's Physician Order Sheet for April 16 to May 15, 2003, R2 is a 44-year-old male who functions at a profound level of mental retardation. R2 has additional diagnoses of Psychosis, Autism, and Impulse Control Disorder. Further review of R2's Physician Order Sheet identified that R2 is to be 1:1 staff supervision due to his history of elopement.
Review of the Incident Report dated 05/15/03 identified that R2 was discovered on the facility's day-training bus at 2:15 P.M. where he had been since 9:30 A.M. that morning. Under the description of the incident, the following was noted: "E13 (facility's day-training bus driver) went to start R--- 2 (name of bus and number) for afternoon transportation. Upon entering the bus, he discovered R2 sitting in the driver's seat. Initial investigation discovered no way to enter or exit the bus without turning the key. V--P staff (R2's vocational program) had not seen him all day-he was absent yesterday, staff thought he was absent again. R--- 2 rider (E10) had left the bus earlier than usual due to maladaptive behaviors occurring outside of the bus."
Under the section to identify what steps the facility's day-training staff had taken to ensure the immediate health and safety of the alleged victim(s), the following was noted: Check off list of consumers exiting the bus was to be implemented (check off of consumers loading is already in practice). Bus driver will now be required to complete a physical walk through of the bus."
Per interview with E9 (facility's day-training Coordinator of Rehabilitation Services/CORS) on 05/21/03 at 1:33 P.M., E9 stated that she was investigating the Incident of 05/15/03 involving R2. E9 stated that during her investigation, she discovered that E12 (facility's day-training staff) had notified E18 (former Program Coordinator) that R2 was absent and had asked E18 to call his home. E9 stated that the facility's day-training had an "unwritten policy" for the Program Coordinator to call the person's home to check on the client. E9 confirmed during this interview that E18 had failed to call R2's home and that if she had, she would have known that R2 had been on the bus that morning. E9 stated that E10 (facility's day-training staff) had been the rider and E17 (facility's day-training Director of Operations) had been the driver on the bus for R2 on 05/15/03. E9 stated that on the morning of 05/15/03, that R8 who also rides the bus with R2 was having behaviors and had been pushing clients while trying to run off the bus. E9 stated that E10 (rider) had to get off of the bus due to R8's behavior. E9 stated that E17 (driver) had parked the bus and had not checked the bus on that date. E9 stated that once the bus is locked, there is no way in or out without a key. E9 stated that when R2 was found at 2:15 P.M., the bus was locked and no windows were open on the bus.
Telephone interview with a weather representative from the Southern Illinois Airport Weather Service identified that the high temperature for 05/15/03 was 78 degrees Fahrenheit.
Per interview with E10 (facility's day-training bus rider) on 05/21/03 at 2:50 P.M., E10 stated that R8 had had behaviors on 05/15/03 which required her to get off of the bus and to remove R8 with her. E10 stated that she had remained by the bus while the clients were unloading and thought everyone had gotten off of the bus. E10 confirmed that R2 had gotten on the bus from home, and that she had checked him on the check-list as getting on the bus. E10 stated that she had worked all day in the senior program room on 05/15/03 and that no one had come and asked her if R2 had rode the bus that morning. E10 stated that she did not know that R2 was not in his program room until he was found four and half hours later on the bus.
Interview with E13 (facility's day-training bus driver) on 05/21/03 at 2:15 P.M., E13 confirmed that he had found R2 sitting in the front seat of the bus. E13 stated that the doors to the bus were locked, and the windows on the bus were up. E13 stated that he did not see any one else on the bus with R2. E13 stated that when he found R2, the front of R2's shirt was wet from sweat and there was some white foam coming down from the sides of his mouth. E13 stated he got assistance and took R2 into the building.
During the interview with E9 on 05/21/03, E9 stated that she had questioned all of the facility's day-training staff and had prevention measures in place. E9 stated that the transportation policy and procedures had been changed since the incident, and that the facility's day-training staff had implemented a check on and check off list. E9 stated that staff had been added to assist in loading and unloading the clients off the bus. E9 also stated that visual checks would be completed by the riders and the drivers after everyone had exited the bus. E9 stated that this procedure was implemented on 05/16/03 and that staff had been trained to implement the new transportation policy.
On 05/21/03, the surveyor reviewed the new check on/check off list that was initiated on 05/16/03. Review of the check list identified that the facility's day-training staff were still using the old check list. The facility's day-training staff had used the new check list on 05/16/03 and resumed using the old check on list as of 05/19/03. The surveyor also reviewed the inservice training that had been completed by the facility's day-training. The training roster that was provided to the surveyor was dated for 05/16/03. The inservice roster identified that only five of the facility's day-training staff had been inserviced as of 05/16/03. Interview with E9 confirmed that E10 (rider on the bus on 05/15/03) had not been inserviced on the new transportation policy and procedures. E9 also confirmed that all staff had not been inserviced on the new transportation policy and procedures to assist in the prevention of re-occurring incidents of leaving clients on the bus.
Review of the facility's day-training Incident Report and per review of R2's Nurse's Notes, R2 was not provided with necessary monitoring as ordered by his physician (Z1). Review of the Incident Report dated 05/15/03 identified that R2 was examined by the facility's day-training Licensed Practical Nurse (E15) at approximately 2:35 P.M. after being on the locked bus approximately four and a half hours. Per interview with E15 on 05/21/03 at 1:50 P.M., E15 confirmed that she had assessed R2 on 05/15/03. E15 stated that R2
showed no apparent injury but was noted to have reddening of the sclera of both eyes. E15 stated that R2's temperature with 98.4 degrees axillary, pulse was 88, and his respirations were 20. E15 stated that she had observed R2 drinking fluids well, and that he also had been taken to the restroom and had voided. E15 stated that she had called the facility and had talked with the nurse (E4) at the facility.
Per interview with E4 (Licensed Practical Nurse/LPN) on 05/22/03 at 10:15 A.M., E4 stated that she had assessed R2 at 6 P.M. Per review of R2's Nurse's Notes and as confirmed per interview with E4, E4 notified the Facility's Medical Director (Z1) about the incident occurring with R2. Review of the Nurse's Notes for R2 identified that on 05/15/03, E4 notified Z1 at of the incident at 3:10 P.M. with NNO's (No New Orders).
Per telephone interview with Z1 (Facility's Medical Director) on 05/22/03 at 10:40 A.M., Z1 stated that he had been concerned about R2 being left on the bus and had told E4 (LPN) to force fluids and to monitor R2.
Per review of R2's Nurse's Notes, and as confirmed per interview with E4 on 05/22/03 at 10:56 A.M., no further documentation was completed after R2 was assessed at 6 P.M. even though Z1 had ordered R2 to be monitored. E4 stated that nursing staff should have documented and assessed R2 for at least another
Per record review, R2 has a behavior intervention program in place to assist in the reduction of elopement and wandering behaviors. Review of the program's behavior interventions identified that R2 will be under constant supervision by staff during waking hours.
Observations at the facility on 05/21/03 did not identify that R2 was constantly supervised by staff to prevent him from wandering and/or eloping from the facility. R2 was observed in the dining room at approximately 5:15 P.M. R2 was observed to be ambulatory without assistance of staff and was not observed to verbalize with staff and or peers. At 5:25 P.M., R2 finished his meal within ten minutes and left the dining room area. R2 went into the activity room and was not visible from the dining room area. Four staff (E5, E6, E7, and E8) were observed sitting in the dining room at the dining tables. None of the four staff were observed to look to see where R2 went when he left the dining room. None of the four staff were observed to get up to determine where R2 had gone until brought to the attention of staff by the surveyor. Staff remained in the dining room until the surveyor asked staff as to R2's whereabouts. E5 stated that R2 was assigned to her and then she immediately got up from the table and went and returned R2 to the dining room. During this observation, E5 left the dining room and went to the kitchen to get her meal. E5 did not have full visual contact with the living room and/or the living room door while seated in the dining room, nor when in the kitchen.
Additional examples are available for 05/21/03, in regards to the facility's failure to provide clients with necessary monitoring and supervision as observed:
R3 was observed at approximately 6 P.M. to kick at a metal patio chair and attempt to pick the chair up and throw it at R4 without intervention until surveyor intervened. No staff were present outside on the patio. When brought to staff's (E6's) attention, E6 stated, "R4's been teasing him." An additional observation is available for R5 who was also outside on the patio and was observed to drink from a soda can that had been discarded by R3 on the patio without intervention.