PRAIRIE MANOR HEALTH CARE CENTER Facility I.D. Number: 0039750 Date of Survey: 07/16/2002 Complaint Investigation “A" VIOLATION(S): AN OWNER, LICENSEE, ADMINISTRATOR, EMPLOYEE OR AGENT OF A FACILITY SHALL NOT ABUSE OR NEGLECT A RESIDENT. (Section 2-107 of the Act) This REQUIREMENT is not met as evidenced by: Based on staff interviews of E2 (ADON), E1 (DON), E16 (Administrator), E3 (RN), E4 (CNA), E6 (CNA), E9 (CNA) and E11 (Abuse Coordinator) and R1 interview and Z1 (R1's MD) interview, facility nursing staff failed to report and investigate an allegation of abuse and failed to protect residents from harm during the investigation, by not suspending the staff involved in the allegation pending the results of the abuse investigation, effecting two of three units in the facility. R1 and E2 (ADON), during interviews told surveyor, that on 5/29/2002, R1 notified E2 (ADON), that on 5/28/2002 on the 2P.M.-10P.M. shift, 3 staff members entered R1's room, 2 of them physically held R1 down in bed while the 3rd person performed a body check on R1 against her will. R1 also showed E2 (ADON) bruises on R1's arms stating that the bruises resulted from the staff holding her down. R1 was visibly upset crying and stated she was scared to stay at the facility as a result of the above. R1 whom was admitted 5/28/2002 6P.M. to facility for rehab, after being hospitalized, signed out of facility Against Medical Advise (AMA), on 5/29/2002 7A.M.. E2 (ADON), told surveyor and E1 (DON), during 6/5/2002 10:15A.M. interview that E2 did not feel the bruises were the result of being grabbed so she did not initiate an investigation or interview any of the 2P.M.-10P.M. staff from 5/28/2002 and did not report this allegation to E1 (DON) or E16 (Administrator). E1 (DON) notified surveyor that she would initiated the Abuse Investigation on 6/5/2002. E16 (Administrator), told surveyor on 6/7/2002, that the staff involved in this allegation: E3 (2nd floor RN), E4 (2nd floor CNA) and E6 (3rd floor CNA), were not suspended as a result of this allegation, E3 continues to work as of 6/7/2002, E4 worked up to a 5/31/2002 suspension, resulting from an allegation of neglect toward another resident and E6 continued to work up to the occurrence of an anxiety attack on 6/5/2002. R1 is alert and oriented x 3, per Z1 6/5/2002 interview and chart record review and R1 was continent of bowel and bladder and uses the toilet. R1 told surveyor that E3 (RN) told her not to report this, because it won't matter, they do it all the time. E2 (ADON), E3 (RN), E4 (CNA), E6 (CNA), E5 (RN), E7 (CNA) and E8 (CNA) told surveyor during interviews 6/05/2002 and 6/07/2002 that on 5/28/2002, R1 was admitted on the 2P.M.-10P.M. shift and was very anxious and continuously refused the nursing staff to do a body check on her. E5 (RN) stated that E3 (RN) and E4 (CNA) were the staff that performed R1's body check on 5/28/2002 at about 9P.M.. E4 (CNA), told surveyor that E4 (CNA) and E6 (CNA) held R1 down in bed so that E3 (RN) could perform the body check. E3 (RN) told surveyor that R1 was "very obstinate and anxious" about not allowing us to do a body check on her. E16 (Administrator) told surveyor on 6/7/2002 that E3 (RN) did do a body check on R1 on 5/28/2002. R1's chart has a completed Nursing Admission Assessment including the body check dated 5/28/2002. E9 (CNA), told surveyor that on 5/28/2002 at 10P.M., R1 was noted sitting up in bed with bilateral side rails up, crying, and complaining of trouble breathing even while using the oxygen and asking to go home. E5 (RN) told surveyor 6/7/2002, that she did not go in and see R1 again on 5/28/2002 after E3 (RN) did the body check . In addition R1's clinical record has no documentation of R1 refusing assessments or being anxious, crying complaining of trouble breathing or of any behaviors or concerns from 6:50P.M. admit up to 5/29/2002 6:40A.M. note that R1 was unhappy and was requesting to go home. R1 signed out AMA on 5/29/2002. |