Statement of Violation

ORCHARD COURT

Facility I.D. Number: 0040970

1430 State Route 127 South
Jonesboro, Illinois 62952

Date of Survey: 05/06/2003

Incident Report Investigation of April 27, 2003

"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 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.

Orientation and In-Service Training

All new employees, including student interns, shall complete an orientation program covering, at a minimum, the following: general facility and resident orientation; job orientation, emphasizing allowable duties of the new employee; resident safety, including fire and disaster, emergency care and basic resident safety; and, understanding and communicating with the type of residents being cared for in the facility. In addition, all new direct care staff, including student interns, shall complete an orientation program covering the facility’s policies and procedures for resident care services before being assigned to provide direct care to residents. This orientation program shall include information on the prevention and treatment of decubitus ulcers and the importance of nutrition in general health care.

Each of the facility’s developmental disabilities aides shall comply with one of the following conditions no later than 45 days after the date of initial employment.

Enroll in a Department approved developmental disabilities aides training program (see 77 Ill. Adm. Code 395). The program shall be successfully completed no later than 120 days after the date of initial employment. Programs approved in accordance with 77 Ill. Adm. Code 395.150(a)(2) may last longer than 120 days. However, a developmental disabilities aide may be employed no more than 120 days prior to successful completion of the program.

There shall be available sufficient, appropriately qualified nursing staff and habilitation personnel, and necessary supporting staff, to carry out the training and habilitation program. Supervision of delivery of training and habilitation services shall be the responsibility of a person who is a Qualified Mental Retardation Professional.

Appropriately qualified staff shall be provided in sufficient numbers to meet the training and habilitation needs of the residents. At a minimum, staffing shall be provided as described in Section 350.810(b) of this Part.

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 neglected to follow its own policy and procedures by its failure to ensure that admission information included "special procedures for health and safety of the resident, activities and a plan of continued care and discharge" for one client in the sample (R1) who was transferred to the facility on 03/14/03, with the need to "maintain eyesight monitoring" due to history of elopement. After his transfer/admission, R1 made attempts to leave out of the facility, and the facility neglected to institute a system of monitoring to address R1's behavior of attempting to leave the facility. As a result of the facility's failure to provide R1 with necessary supervision to prevent elopement, R1 eloped from the facility on 04/27/03, without staff's knowledge.

Additionally, based on interview and file review, the facility has neglected to follow its own policy and procedures by its failure to ensure that each employee of the facility has completed a training program that enables the employee to provide needed supervision and monitoring to protect the health and safety of three of three clients in the sample (R1, R2, R3) with history of elopement behaviors, having the potential to impact all clients of the facility.

The facility failed to prevent neglect by its failure to provide supervision of cognitively impaired individuals with known elopement risk by competent trained staff. As a result, staff failed to provide R1 with necessary supervision and monitoring to prevent him from eloping from the facility on 04/27/03, without staff's knowledge. Additionally the facility failed to provide staff with initial and ongoing training to assist staff in providing the needed monitoring and supervision to R1, R2, and R3 who have known history of elopement.

Findings include:

Per review of the Incident Report dated 04/27/03, R1 eloped from the facility on 04/27/03, after last being seen by staff at approximately 11:30 A.M. R1 was found by facility staff at approximately

1:00 P.M. in a wooded area, near a creek behind in the woods.

Per review of the Admission Record, R1 is a 21-year-old male who functions at a profound level of mental retardation.

R1 was observed at the facility on 04/29/03, from 3:30 to 4:45 P.M. R1 was observed to ambulate without assistance of staff and was observed to be non-verbal. At 4:30 P.M., R1 was observed outside in the back yard of the facility. E14 (Direct Care Staff-Certified) was present in the area. E14 stated that he had worked at the facility since November of 2002, and generally works second shift. E14 stated that he was aware that R1 was to be on "constant visual" prior to his elopement on 04/27/03. E14 stated, "I was told to really watch him when he was outside. Inside he can go where he wants to. You can't stop him from going to his room." When E14 was asked by the surveyor how he could maintain constant visual of R1 when he was in his bedroom, E14 stated, "Well I guess you can't. You would have to check on him every now and then."

Nursing Notes identified that R1 was transferred to the facility on 03/14/03, from a sister facility. Review of the Nursing Notes identified that R1 had two documented incidents of elopement/attempts from his prior sister facility. On 07/15/02, R1 attempted to leave the facility twice. On 05/06/02, R1 left the facility walking to the other sister facility. Review of the Incident Reports provided by the facility for R1 identified that on 05/06/02, R1 was placed on "maintain eyesight monitoring" due to his elopement attempts. Additional staff assignment sheets were provided to surveyor that identified that R1 had been on "maintain eyesight monitoring" until his transfer to the facility on 03/14/03. Review of R1's Nursing Notes and per review of his individual program plan did not identify that R1's need for "maintain eyesight monitoring" was continued as a special procedure needed for R1's safety to prevent elopement.

Interview with E3 (Resident Services Director/RSD) on 04/29/03, at 3:50 P.M., E3 stated that R1 had been on "maintain eyesight monitoring" when he transferred to the facility on 03/14/03. E3 stated that she thought that the need for eyesight monitoring had been continued at R1's present facility. E3 stated that the QMRP (Qualified Mental Retardation Professional) would have been responsible to ensure that this monitoring need was continued.

Per interview with E6 (Present QMRP) on 04/30/03 at 9:10 A.M., E6 stated that she was not aware that R1 was to be on "maintain eyesight monitoring". E6 stated that she had been at the facility since 03/24/03, and that E4 was the QMRP at the time R1 was transferred to the facility.

Per telephone interview with E4 (Former QMRP) on 04/29/03 at 9:30 A.M., E4 stated that she did not remember if she was told that R1 was to be on "maintain eyesight monitoring" at the time of his transfer.

Per telephone interview with E5 (Direct Care Staff) on 04/30/03 at 9:10 A.M., E5 stated, "No one told me that he (R1) needed to be watched. I thought it was strange because at (stated name of prior facility), R1 was on visual supervision. I said something to E6 (present QMRP) about R1 going outside when staff are in the parking lot. R1 had been trying to go out to be with staff while they're smoking outside and when staff were coming to work or going home."

Per interview with E6 (QMRP) on 04/30/03 at 9:10 A.M., E6 stated that she did not remember any staff member telling her that R1 was attempting to leave the facility. However, per telephone interview with E4 (Former QMRP) on 04/29/03 at 9:30 A.M., E4 stated, "I remember staff saying that they thought R1 might try to leave and go back to (stated name of prior facility). I told them to watch him." E4 stated that she did not recall if she had documented this information but would check some of her papers that she had.

Per review of R1's Nursing Notes and QMRP Reports, no documentation was noted of R1's attempts to leave the building and/or the level of supervision staff were to provide R1 to prevent him from elopement. Additionally, review of the Inservice records did not identify that staff of the facility had received any type of training and or inservicing about R1's program needs prior to and/or after his transfer to the facility.

Forty-four days after his transfer to the facility, R1 eloped from the facility on 04/27/03, without staff's knowledge. Review of the facility's investigation identified that R1 was last seen by staff at approximately 11:30 A.M. in his bedroom. At approximately 12:00 P.M., staff discovered that R1 was not in his bedroom, nor in the facility. Staff began a search of the facility's ground and areas surrounding the facility. R1 was found in a wooded area, west of the facility playing in a creek at about 1:00 P.M..

Review of the Incident Report completed by the facility upon R1's return to the facility identified that R1 received a superficial scratch to the right side near his waist and a 1 centimeter open area to his inner left elbow. R1 was sent to the Emergency Room at 1:45 P.M. for further assessment. Review of the Emergency Room report identified that R1 had "abrasions, side of abdomen and back."

On 04/29/03 at 1:30 P.M., E2 (Assistant Administrator), E7 (Direct Care Staff that found R1 on 04/27/03), E6 (QMRP) and E8 (Licensed Practical Nurse/LPN) and the surveyor walked to the area where E7 found R1. During this observation, the surveyor noted that R1 went through an area where an abandoned house was located. "No Trespassing" signs were observed to be posted around the area near the house. Debris of broken glass, rotten wood, and rusted barb wire were noted on the ground. The area behind the house and down the hill leading to the woods was also littered with the same debris. Upon entering the wooded area, the hill was was noted to slope at a steep downward angle requiring the surveyor to hold onto the trees to maintain footing and to keep from being propelled forward. E7 showed the surveyor where R1 was found. E7 was standing on the edge of the hill that dropped off 3-4 feet to the bank of the creek. E2 stated that they thought R1 had slid down the embankment to get to the creek. E7 (Direct Care Staff) stated that he could not get R1 up the embankment by himself and yelled for help. E7 stated that he had checked by the creek before and had not seen R1, but had checked again and had spotted R1's white shirt. E7 stated, "R1 was playing with a stick in the creek when I found him."

1:10 P.M., E10 does not function in a direct care capacity, nor did Z1 supervise direct care staff on 04/27/03. E1 also stated that E3 (Resident Services Director) was on duty 04/27/03, for both facilities but was not at the facility at the time R1 was discovered missing.

Per review of the facility's investigation and as confirmed per interview with E5, E7 and E9, two of the three direct care staff (E7 and E9) had performed housekeeping duties during the morning of 04/27/03, rather than directly providing care and supervision to the clients of the facility. At the times that E7 and E9 were performing housekeeping duties, E5 was the only staff to monitor and supervise the eleven clients of the facility.

Per telephone interview with E5 (Direct Care Staff) on 04/30/03 at 9:10 A.M., E5 stated that he had been working at the facility since January 30, 2003, and had not finished his habilitation training program. E5 stated that he had been watching residents in the front room prior to lunch on 04/27/03, and that R1 had not been in the front room at that time. E5 stated that prior to lunch on 04/27/03, he had taken clients to the bathroom. E5 stated that when he took clients to the bathroom, R2 and R3 (clients with known history of elopement) were present in the living room, unsupervised, with other clients of the facility.

Interview with E7 (Direct Care Staff) on 04/29/03 at 2:15 P.M., E7 stated that he had just finished his habilitation training program as of 04/29/03. E7 stated that he had started working at the facility in June of 2002, left employment and returned in August or September of 2002. E7 stated that he worked the midnight shift on 04/27/03, and had stayed on duty due to a call-off. E7 stated that he had been helping E9 (Direct Care Staff) do laundry and had been watching the clients in the front prior to lunch. E7 stated that he had seen R1 watching a movie in his room about 11:30 A.M. During the interview with E7, E7 stated,"I did not hear the door alarm go off, but the alarms were fully functioning."

Per telephone interview with E9 (Direct Care Staff) on 04/30/03, E9 stated that she had been working at the facility since December 21, 2002. E9 stated that she had not finished her habilitation training program. E9 stated that she had been doing laundry prior to the time R1 was discovered missing on 04/27/03. E9 stated that she had never been told that R1 was to be monitored for elopement.

Per review of E9's written statement the following was noted, "About 11:15 A.M. - 11:20 A.M. is when the fire drill and severe weather drills was over with. Me and E7 went to the north end of the building and made the resident's beds for the next 5-10 mins. (minutes). About 11:25 A.M. I seen R1 playing in his room with blocks. (And he had a movie playing.) I then started laundry right after I had seen him in his room. I asked E7 to help put a basket of laundry away and then I started cleaning the bathrooms. Cleaning the bathrooms took about 20 to 30 mins. And when I was done, I did not see R1 in his room any more. So the last time I seen him was around 11:25 A.M. in his bedroom."

Per review of personnel records for E5, E7, and E9, no documentation was found that identified that these staff had completed any type of habilitation training program to assist them in the completion of their duties. Per interview with E2 (Assistant Administrator) on 04/29/03 at 12:50 P.M., E2 confirmed that neither E5, E7 or E9 had completed their habilitation training programs. During this interview with E2 regarding R1's elopement from the facility on 04/27/03, E2 stated that an assignment schedule was to have been completed by staff to identify which staff was responsible for which resident of the facility. During this interview, E2 confirmed that no assignment schedule had been completed by E5, E7 and/or E9 on 04/27/03, when R1 eloped from the facility.

During the Daily Status meeting on 04/30/03 at 1:10 P.M., E1 (Administrator) and E2 (Assistant Administrator) confirmed that no competent, trained habilitation staff had worked with E5, E7, and E9 on 04/27/03, to assist them in providing needed supervision and monitoring to protect the health and safety of R1, R2, and R3 who have history of elopement and for the eight other clients of the facility who all function at a severe to profound level of mental retardation.

Based on interview and file review, the facility has neglected to ensure that each employee of the facility received training and orientation at the time of hire and on an ongoing basis by competent trained staff that enables the employee to provide needed supervision and monitoring to protect the health and safety of three of three clients in the sample (R1, R2, R3) with history of elopement behaviors, having the potential to impact all clients of the facility.

Findings include:

1) Untrained staff failed to provide R1 with necessary supervision and monitoring to prevent elopement on 04/27/03.

Review of the Admission Record identified that R1 is a 21-year-old male who functions at a profound level of mental retardation.

Nursing Notes identified that R1 was transferred to the facility on 03/14/03 from a sister facility. Review of the Nursing Notes identified that R1 had two documented incidents of elopement/attempts from his prior sister facility. On 07/15/02, R1 attempted to leave the facility twice. On 05/06/02, R1 left the facility walking to the other sister facility. Review of the Incident Reports provided by the facility for R1 identified that on 05/06/02, R1 was placed on "maintain eyesight monitoring " due to his elopement attempts. Additional staff assignment sheets were provided to surveyor that identified that R1 had been on "maintain eyesight monitoring" until his transfer to the facility on 03/14/03. Review of R1's file did not identify that R1's need for "maintain eyesight monitoring" was continued as a special procedure needed for R1's safety to prevent elopement.

Forty-four days after his transfer to the facility, R1 eloped from the facility on 04/27/03, without staff's knowledge. Review of the facility's investigation identified that R1 was last seen by staff at approximately 11:30 A.M. in his bedroom. At approximately 12:00 P.M., staff discovered that R1 was not in his bedroom nor in the facility. Staff began a search of the facility's ground and areas surrounding the facility. R1 was found in a wooded area, west of the facility playing in a creek at about 1:00 P.M..

Review of the facility staffing schedule for 04/27/03 identified that E5, E7, E9 (Direct Care Staff), E10 (Food Service Supervisor), and Z1 (Temporary Fill-In Nurse) were on duty for the first shift on the morning that R1 eloped from the facility. Per interview with E1 (Administrator) on 04/30/03, at 1:10 P.M., E10 does not function in a direct care capacity, nor did Z1 supervise direct care staff on 04/27/03. E1 also stated that E3 (Resident Services Director) was on duty 04/27/03, for both facilities but was not at the facility at the time R1 was discovered missing.

Per interview with E2 (Assistant Administrator) on 04/29/03, at 12:50 P.M. regarding R1's elopement from the facility on 04/27/03, E2 stated that an assignment schedule was to have been completed by staff to identify which staff was responsible for which resident of the facility. During this interview, E2 confirmed that no assignment schedule had been completed by E5, E7 and/or E9 on 04/27/03, when R1 eloped from the facility.

Per telephone interview with E9 (Direct Care Staff) on 04/30/03 at 9:11 A.M., E9 stated that she had been working at the facility since December 21, 2002. E9 stated that she had not finished the habilitation training program. E9 stated that she had never been told that R1 was to be monitored for elopement. E9 also stated that she had "never done any assignment sheet" nor had she been told to do any assignment sheet since she had started working at the facility in December of 2002.

Per review of personnel records for E5, E7, and E9, no documentation was found that identified that these staff had completed any type of orientation and/or habilitation training to assist them in the completion of their duties. Per interview with E2 (Assistant Administrator) on 04/29/03 at 12:50 P.M., E2 confirmed that neither E5, E7, or E9 had completed their habilitation training programs.

Review of personnel records for E7 identified that he had been hired by the sister facility on 06/28/02. E7 transferred and began working at the facility in September of 2002, on third shift. Review of the facility's staffing schedule and as confirmed per interview with E15 (Training Coordinator) on 05/01/03 at 10:20 A.M., E7 works the midnight shift with E16 (Direct Care Staff). E15 stated that E16 was hired on 06/15/02, and has not completed the habilitation training program. E15 confirmed that on Thursdays, Fridays, and Saturdays, E7 and E16 have worked together on midnights since September 26, 2002, to present without the assistance and direction of competent, trained habilitation staff.

Review of personnel records for E9 identified that she had been hired by the facility on January 30, 2003. Review of the facility's staffing schedule and as confirmed per interview with E15 (Training Coordinator) on 05/01/03 at 10:20 A.M., E9 has worked 8 A.M. to 6 P.M. on the weekends since 01/05/03, and has not worked with trained staff on the first shift. Additionally E5 (Direct Care Staff) was hired on 01/30/03, and started working weekends on the 7-3 shift. Review of the staffing schedule for February of 2003, the present and as confirmed per interview with E15 (Training Coordinator) E5, E7, as well as E17 have not completed their habilitation training program and work the morning shift on weekends without the assistance and direction of competent, trained habilitation staff.

During the Daily Status meeting on 04/30/03 at 1:10 P.M., E1 (Administrator) and E2 (Assistant Administrator) confirmed that no competent, trained habilitation staff had worked with E5, E7, and E9 on 04/27/03, nor consistently during nights and weekends to assist these staff in providing needed supervision and monitoring to protect the health and safety of the eleven clients of the facility who all function at a severe to profound level of mental retardation.

2) Direct Care Staff have failed to receive initial orientation and ongoing training to meet the needs of R2 and R3, who have history of elopement behaviors.

Per telephone interview with E5 (Direct Care Staff) on 04/30/03, at 9:10 A.M. E5 stated that prior to lunch on 04/27/03, he had taken clients to the bathroom. E5 stated that when he took clients to the bathroom, R2 and R3 were present in the living room unsupervised. E5 stated that he was unsure if R2 and R3 were to be on constant visual observation. E5 stated he did not think they needed to be constantly monitored by staff because their electronic monitoring devices would go off if R2 or R3 tried to go out the door. E5 stated that he has been employed at the facility since January 30, 2003.

During the survey interviews were also completed on 05/01/03, with second shift Direct Care Staff (E11, E12 and E13) that have been employed with the facility but are in the process of completing their habilitation training programs. All three of the staff interviewed stated that they had received no formal orientation to the facility and/or the residents of the facility.

Interview with E13 at 2:55 P.M., E13 stated that she had been working at the facility since July of 2002, and had just finished her training program as of 04/30/03. When asked by the surveyor as to what type of orientation she received from the facility when she was hired, E13 stated "None." E13 stated, "I keep an eye on them (R2 and R3) all the time even though they have a (stated name of the electronic ankle device). I was here when R2 eloped before, and I don't want to go through that again!"

Interview with E11 on 05/01/03 at 2:40 P.M., E11 stated that she had started working at the facility during the last week of April of 2002. E11 stated that facility staff had "introduced me to the clients" and "told me where to find the program books". E11 stated, "I knew R2 and R3 had ankle bracelets, but they didn't tell me how to watch them or the type of supervision R2 and R3 needed."

Interview with E12 on 05/01/03 at 2:50 P.M., E12 stated "E14 (Direct Care Staff-Certified) walked me through what I was to do and showed me where the books were." E12 stated that he was told that R2 and R3 were the "two elopers" and that we had to make sure they don't run off. E12 stated, "That's it, that was my orientation." E12 stated that he was not told what level of supervision was need for R2 and R3 to prevent them from eloping from the facility. Per review of R2's Behavior Treatment Program, R2 is a 44-year-old male who functions at a profound level and has a behavioral program in place to reduce wandering and elopement behaviors. Review of the program's methodology identified that R2 is to be "Supervised continuously by staff during waking hours and 1:1 between the hours of 3 P.M. and 7 P.M. every day."

Per review of R3's Behavior Treatment Program, R3 is a 56-year-old male who functions at a profound level of mental retardation. R3 has a behavior program in place to reduce elopement and wandering behaviors. Review of the program's methodology identified that "R3 will be within eyesight of staff during waking hours at all times."

During the Daily Status meeting on 04/30/03 at 1:10 P.M., E6 (QMRP) stated that R3's behavioral program had just been reviewed and revised on 03/19/03. E6 did not respond when asked by the surveyor if staff had been trained on the program's revisions. E1 (Administrator) and E2 (Assistant Administrator) confirmed that additional staff training was needed to assist staff in providing the clients with necessary supervision as identified per the behavioral programs to prevent elopement.