Facility I.D. Number: 0042465
Date of Survey: 1/9/2003
Incident Report Investigation of 12/27/02
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.
There shall be available sufficient, appropriately qualified training 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.
The facility shall provide all services necessary to maintain each resident in good physical health. These services include, but are not limited to, the following:
AN OWNER, LICENSEE, ADMINISTRATOR, EMPLOYEE OR AGENT OF FACILITY SHALL NOT ABUSE OR NEGLECT A RESIDENT. (Section 2-107 of the Act)
These regulations were not met as evidenced by the following:
R1 is a 37 year old female with diagnoses of severe mental retardation and Seizure Disorder.
Per facility incident report, dated 12/27/02, R1 was found in the bathtub alone by facility staff at approximately 8:05 a.m. with her face in the water. R1 was unresponsive and transported by ambulance to the hospital for emergency treatment. According to the hospital report, dated 12/27/02, R1 died that evening in the hospital.
Review of the facility and day training seizure records, R1 experienced seizure activity monthly, sometimes resulting in loss of consciousness and falls. Per physician orders, R1 had been prescribed Carbamazepine and Neurontin for seizures.
According to R1's individual program plan (IPP), dated 2/12/02, R1 "wears a protective helmet during all waking hours to prevent injury caused by a seizure". According to the physician orders of 12/02, R1 is to "wear seizure helmet during waking hours - will allow to remove during bathing" and R1 is to be "under direct supervision the entire time helmet is off". Also per R1's IPP, "staff must provide supervision when she is not wearing protective helmet (ie. Getting in and out of bathtub, dressing and undressing without helmet)".
Interview with E2, Direct Support Person (DSP), on 1/2/03 at 1:10 p.m. confirmed that R1 had awakened early on 12/27/02 and had been incontinent. Per E2, he asked R1 if she was ready to take her bath and R1 responded yes. Per E2's written statement, R1 "got up and I asked her to pick out what she wanted to wear. While she was doing that I was running her bath water. She got her pants and shirt and went to the bathroom - I went back to get her underwear and care kit. Removed her helmet and changed her bed while the water was running ".
Per interview and written statement, E2 confirmed that he had removed R1's helmet prior to collecting her bathing supplies and making R1's bed. E2 stated that when he left R1's bathroom, she was standing by the toilet, next to the sink.
E2 stated that during this time, he was also helping R3 who was in the other bathroom on the women's wing taking her bath. (Per R3's IPP dated 8/13/02, R3 requires assistance with bathing and also with getting in and out of the tub). Per E2, when he was going down the hall to get gloves to assist R1, R3 called out for help, saying she was ready to get out of the tub. E2 confirmed that he left R1 in the bathroom by herself, still standing and in her disposable incontinent briefs while he assisted R3 out of the tub.
E2 stated that he took R3 to her room to dress her and left R3's bedroom door open so he could see R1 in the bathroom. According to E2's written statement and verbal interview, he could still see R1 standing in the bathroom with her incontinent briefs partially off. E2 stated that after dressing R3 (who is in wheelchair), E2 pushed R3 to the dining room for breakfast. E2 confirmed that he left R1 alone in the bathroom, with her helmet off and with water in the bathtub while he took R3 to the dining room.
According to E2, when he returned to R1's bathroom approximately 37 seconds to 1 1/2 minute later, he found her face down in the tub in approximately 5 - 6 inches of water. Per interview and written statement, E2 called for assistance and E2 and E3 removed R1 from the tub and began CPR while the remaining staff (E4) called 911.
An interview with E3, DSP, on 1/2/03 at 1:30 p.m. confirmed that he could not detect a pulse during the CPR compressions, but after telling E2 to stop compressions, E3 placed his ear to R1's chest and detected a heartbeat. Per E3, E2 and E3 continued CPR until the ambulance arrived. According to E3's written statement, R1 was taken to the hospital at approximately 8:50 - 9:00 a.m.
Per hospital history and physical, dated 12/27/02, R1 was brought to the hospital that morning "in cardiac arrest". Per report, R1 was "intubated in the Emergency Room with warm water submersion", then transferred to Intensive Care Unit. The report further confirms that R1 "seems to be definitely septic" and the "blood pressure is extremely low. At this time, the patient's prognosis is extremely poor considering neurological status does not seem to correspond with presentation. It appears as though the patient has suffered a diffuse anoxic ischemic insult to the brain, and is in a coma with severe hypotension ....and severe anemia". Hospital records indicate that R1 expired at 8:21 p.m. on 12/27/02.
Telephone interview with Z1, Coroner, on 1/6/03 at 11:40 a.m., verified that the preliminary findings determined that R1 died of "complications due to drowning episode" at residential facility. Z1 also confirmed that the coroner's preliminary findings also indicate that there is "no evidence of head injury, such as blunt force trauma, or stroke" that would have contributed to R1's death.
In addition, Z1 stated that R1 had probably been under the water for approximately 5 minutes. Z1 explained that clinical death occurs in about 4 minutes and biological death occurs between 4 - 6 minutes when a person drowns. Z1 further explained that since R1 had been found unresponsive and unable to be revived, he felt that R1 had been in the water well over the 38 seconds to 1 minute as staff had initially reported.
Interview with E1, Residential Services Director (RSD)/Owner on 12/31/02 at 2:45 p.m. confirmed that R1's IPP and physician orders both state that R1 needs supervision while her helmet is off. However, E1 also stated that when R1 goes to the bathroom "we release her". E1 said that staff would always remove R1's helmet, R1 would then toilet herself and then staff would assist R1 into the bathtub. E1 again confirmed that "staff are not there" while R1 was toileting. E1 explained that staff always leave the bathroom to give R1 her privacy while toileting.
Interview with E2 on 1/2/03 at 1:10 p.m. confirmed that he was the only one assisting with personal care needs at the time of the incident because E3 was passing medications and E4 was providing breakfast. E2 also stated that R1's helmet is always removed when she is in the bathroom and confirmed that he doesn't have clarification if taking R1's helmet off prior to her bath is part of 1:1 supervision or if just awareness of her having helmet off and being in the area is sufficient. E2 again confirmed that he had left R1 alone in the bathroom that morning, but tried to maintain visual contact with her while he was assisting R3.
After reviewing the investigative report, surveyor then asked E1 what the facility did after R1's death to assure that no other residents were in danger. E1 replied that no changes were made regarding staff supervision of clients while bathing and "saw no need" for re-training of staff.
Interview with E1 also verified that the facility does not have a policy to address the safety of residents with known special needs while bathing.
Per review of facility staffing, it was determined that 3 direct support persons (DSPs) were on duty when the incident occurred on 12/27/02 at approximately 8:05 a.m. Facility interviews, dated 12/27/02, indicated that E2 had "started laundry at the men's end - then proceeded to the women's end to check laundry needs there". While there, E2 began to get things ready for R1 to take her bath. E2 also stated that another resident (R3) was in the bathtub in the other bathroom on the women's wing.
Per Individual Program Plan (IPPs), R1 and R3 were both assessed as needing assistance while bathing. R1 is to have direct supervision whenever her helmet is off. R3 needs assistance with bathing herself and also with getting in and out of the tub. On 12/27/02, while R1 was standing in one bathroom with only her personal incontinence briefs on, R3 called out to say she was ready to get out of the tub. E2 stated that he went to help R3 get out of the tub, get dried off, then took her to her room to get her dressed. During the time E2 was in the bathroom with R3, E2 confirmed that R1 had been left unattended. E2 also confirmed that R1 was again left unattended when he took R3 to the dining room.
According to E2's written statement, E3 (DSP) "was passing medication" and E4 (DSP) "was providing breakfast" while E2 was assisting R1 and R3.
Interview with E1, Residential Service Director (RSD), on 12/31/02 at 2:45 p.m. confirmed that this was the usual staffing pattern in the mornings, when residents are home from day training. E1 also verified that the following 6 residents (R1 - R6) all have high personal care needs and require staff supervision:
Interview with E1, Residential Services Director (RS), on 12/31/02 a 2:45p.m. confirmed that, per IPP and physician orders, R1 requires supervision while her helmet is off.
Per interview, E1 confirmed that physician orders and IPP were not followed for R1.
6. R6 - IPP of 8/13/02 also confirms that R6 has been assessed as needing staff assistance during dining and "requires assistance in all aspects of bathing".
Interview with E1 also confirmed that after checking the above residents' IPPs, he determined that the residents' supervisory needs had been and continued to be met. In addition, E1 verified that he "saw no need" for training or re-training of staff after the incident with R1 on 12/27/02.