REST HAVEN MANOR
Facility I.D. Number: 0013052
Date of Survey: 12/05/02
The facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of the resident, in accordance with each resident's comprehensive assessment and plan of care. Adequate and properly supervised nursing care and personal care shall be provided to each resident to meet the total nursing and personal care needs of the resident.
An Owner, Licensee, Administrator, employee or agent of a facility shall not abuse or neglect a resident.
A facility employee or agent who becomes aware of abuse or neglect of a resident shall immediately report the matter to the facility Administrator.
A facility Administrator, employee , or agent who becomes aware of abuse or neglect of a resident shall also report the matter to the Department.
Employee as perpetrator of abuse. When an investigation of a report of suspected abuse of a resident indicates, based upon credible evidence, that an employee of a long-term care facility is the perpetrator of the abuse, that employee shall immediately be barred from any further contact with residents of the facility, pending the outcome of any further investigation, prosecution or disciplinary action against the employee.
These requirements are not met as evidenced by:
I. Based on record review, staff interviews, and resident interviews, it was determined that the facility failed to assure that residents had an environment that was free from physical and verbal abuse. The facility staff had knowledge of physical abuse to R2, R11, R6, and one unidentified resident. The facility staff had knowledge of verbal abuse to R1, R12, R14, and R3. The facility staff had not reported all witnessed abuse, had not conducted investigations and had not implemented preventive measures to protect the 35 in-house residents from actual and potential physical and verbal abuse. There were 2 incidents of physical abuse with 2 identified residents, 1 from the sample (R2 - reddened area to left shin and 3 - 1 inch purple marks to left foot) and 1 off the sample (R11- a bruise to the right forearm). There were 7 incidents of mental abuse with 4 residents (R1, R2, R3, and R6) from the sample, 2 residents (R12 and R14) off the sample and 1 unidentified resident.
The findings include:
On the first day of the survey, E1, Administrator, was asked if the facility had any investigations of abuse. E1 stated that they had not investigated any allegations of abuse in the last year. During the survey, the facility staff were questioned on abuse and it was found that facility staff witnessed abuse and failed to report it and that there were incidents of abuse allegations that the facility administrative staff knew about and failed to investigate appropriately according to regulatory requirements.
1. E9 (Certified Nursing Assistant), was interviewed on 11/20/02 at 11:45a.m. and on 11/22/02 at 3:20p.m. per phone, pertaining to an alleged resident abuse involving a staff member E3 (CNA) which occurred on 10/23/02 to R2.
According to record review and staff interviews, R2 is a total care, confused resident that is combative with care often hitting and pinching staff; three assistants are often required to care for R2. Per interview with E9 on 10/23/02 at approximately 1:15 p.m., E9, E3 and E16 (CNAs) were grooming R2. R2 was sitting in his easy chair in resident room 21, E3 was standing to the right of R2 shaving him, E16 was standing behind R2 holding his shoulders and E9 was on R2's left side holding his hands. R2 had his legs crossed left over the right. R2 was combative attempting to hit staff. According to E9, "(E3) lifted up her right foot and stomped her foot down (R2's) left shin and top of the left foot leaving a 6 to 8 inch red mark on the front of his leg and a 4 inch red mark on the top of his left foot". When E9 was questioned if E3's action was intentional, E9 stated "yes, it was done on purpose". E9 stated that E3 left the "imprint of her shoe on his foot." According to E9, R2 responded by hollering and cursing stating "you son of a b**** !" R2 was then taken to the shower room by E3. E9 stated she reported this to E15, RN and E8,RN. Approximately 45 minutes later E9 stated she reported this incident to E1, Administrator and E2, Director of Nurses. Per interview with E16 on 11/20/02 at 1:25p.m., she was present but denied seeing this intentional action on 10/23/02 by E3 because of her position holding R2. E16 did state during this interview that she had observed E3 stomping R2's foot at other times when providing care.
According to R2's record review, nurse's notes on 10/23/02 at 2:00p.m., "CNA reported possible injury to resident's left foot and shin during transfer, res has reddened strip on left shin (skin intact) 3 x 1" purple marks on left metatarsal area of foot. No swelling, skin intact both areas."Per interview with E1 on 11/20/02 at 3:00p.m., the injury was reported to her as an unknown cause and pictures were obtained. The picture revealed 3 purple 1 inch vertical marks on the top of R2's left foot and a red area on the left lateral side of the shin.
According to interview with E1 on 11/20/02 at 3:00p.m. in the Administrators office, she was aware of this allegation and interpreted it as an "employee to employee dispute" and the three employees were questioned (E3, E9, and E16). The conclusion drawn by E1 was E9 was trying to get E3 fired. No written investigation or incident report for the injury was completed, this was confirmed by interview with E1. This incident was not treated as a resident abuse allegation so no investigation was done and this was not reported to the Illinois Department of Public Health.
On 11/21/02, E1 was asked again about this incident and also asked if there were photographs. E1 immediately pulled two photos of R2's shin and foot out of her desk.
2. E4 stated on 11/20/02 that she had witnessed E3 abusing R2 more than once. E4 stated that she has seen E3 take her knee and grind it into R2's "crotch area" when changing him or shaving him. E4 demonstrated to surveyor how E3 would put her knee in R2's groin area and move her knee from side to side briskly while R2 was in his recliner being held by two staff. E4 explained that usually the two staff are not facing E3 as they place their arm under R2's arm with their back facing E3. E4 stated that this was witnessed by her 3 or 4 months ago. E4 explained that R2 is very difficult to care for because he swings his hands and arms, but that one can deal with R2's behaviors. E4 then stated that E3 can be rough. E4 stated that she did not report this incident "because frankly it doesn't do any good." E9 and E17 both verified that they had witnessed E3 kneeing R2 in the groin.
3. On 11/20/02 at 12:30 p.m., E5, CNA, stated that two weeks ago R2 was swinging his arms and hands when staff were attempting to shave him. E5 stated that she was holding R2 when out of the corner of her eye she saw E3 shove her knee into R2's groin with force. E5 stated that R2 immediately stated, "you son of a B****". E5 stated that E3 is cruel, and that R2 makes E3 mad. E5 stated that she did not report this because it doesn't do any good, and because prior to this E9 reported E3 for stomping on R2's foot and E9 got in trouble not E3.
4. On 11/20/02 at 1:22p.m., R11 was interviewed and was found to be an alert and oriented resident. The record of R11 showed a current assessment that confirmed that she had no long term or short term memory deficit. R11 stated that on the Friday after being admitted to the facility (approximately 2 months ago) E3 threw her on the toilet twice. R11 stated that E3 did not pick her up and put her on the toilet. R11 described E3 as pushing her off from the wheelchair and on to the toilet. She stated she had never been treated that way before and when she reported the incident to the Charge Nurse she exploded. R11 stated that it "hurt" when E3 did this to her. She stated that she could still feel that traumatic feeling because E3 did it twice to her in the same day. R11 stated after she exploded to the staff about this, R11 told her spouse that she was "kind of afraid" of what E3 would do if E3 found out that she was the one that complained. R11 further stated that she just wished that E3 wouldn't be so angry.
R11 stated that she has a condition that causes her skin to be very thin and frail. A review of her diagnoses confirms her statement. R11 stated that the first part of this current week, E3 transferred her out of the bed by grabbing her by the arms only. She stated that within two to three minutes after the transfer she noted bruising to the right arm where E3 had grabbed her. R11 explained that due to the diagnosis she is frequently very weak and can't help with getting herself up out of the bed. R11's right arm was observed to have a reddish bruise to the upper forearm on 11/21/02. R11 stated on 11/20/02 that the bruise had gotten better in appearance than it was earlier in the week. R11 stated that she reported this to a Certified Nurses Aide on the same day that it occurred. E1 and E2 indicated during an interview on 11/20/02 that they were not aware of this incident.
5. E4 stated on 11/20/02, E3 tells residents if "you don't stand up I'm going to drop your ass on the floor." E4 stated that she had been present when E3 told this to R1 and R12. R1 and R12 are non-interviewable residents. E4 stated , " E3 usually does the abusing to residents who are confused or are questionably confused". E4 stated that she did not report this because the administration does nothing.
6. A telephone interview with Z2 (Ombudsman) on 11/20/02 at 1:22 p.m., indicated that on 5/28/02 he received an anonymous complaint from a female. The complainant alleged that a CNA reported to the complainant that E3 had forced a resident down onto the toilet. Z2 stated that the particular resident was not named and that when he interviewed E1 on 5/31/02, E1 indicated that she had knowledge of an incident involving E3. E1 would not identify the resident. Z2 stated that upon entry to E1's office he identified that he was visiting due to a complaint of physical abuse. E1 informed Z2 that the incident that she had knowledge of involved E3 losing grip of a resident. Z2 then left the building without any further investigation.
During an interview with E1 on 11/20/02, she indicated that Z2 comes in monthly and she did not remember if the discussion in May of 2002 included a discussion on an allegation of abuse.
No written abuse investigation was done by the facility nor was this reported to the Department.
7. According to a resident interview with R14 on 11/20/02 at 1:20p.m., the resident complained that E3 was
"bossy" with her and often did not assist her as needed. When incontinent of urine and assisted to the commode
by E3, E3 will throw an incontinent brief at this resident and state "to change it". R14 stated it was difficult for
her to dress herself due to a stroke in the past. R14 stated eventually "I get the brief changed but it takes awhile. The other aides always help me." This resident also stated E3 will not assist R14 out of the bathroom and expects her to get back in the room by herself. When questioned if this resident has reported this to staff, R14 stated "you know I have to live here". According to an interview with E9, CNA, on 11/20/02 at 11:45a.m., she was aware of this residents complaints and stated the resident was afraid E3 would hurt her. This was not reported to the Charge Nurse, Director of Nurses or Administrator by the resident or E9.
On the most recent Minimum Data Set dated 09/11/02, R14 was documented as requiring extensive assistance of 2 or more persons for transfers, toilet use, and dressing and also has one sided weakness. R14 has no long or short term memory loss and is independent for making daily decisions.
8. R3 is an 85 year old resident with diagnoses that include Chronic Constipation, Degenerative Disc Disease, Osteoarthritis, and Severe Rotoscoliosis. Due to R3's degenerative disease, she is currently dependent on staff for transfers, including assistance with using the bathroom. R3 was described on the initial tour of the facility as an interviewable resident.
During the group interview on 11/20/02 at 1:30 p.m., when residents were asked whether staff treated them with respect and dignity, two residents indicated that "There's one lady who's overbearing." They also indicated that it was a problem for the staff and for residents. The residents were invited to speak with the surveyor privately after the meeting if they had something that they wanted to share and felt uncomfortable doing so in a group. R3 indicated that she would like to talk privately.
In an interview with R3 on 11/21/02, R3 stated, "We have this one girl who works here." and indicated E3. "She don't care who she hollers at. She hollers at me with no excuse. She hollers at anyone." R3 further indicated that, "She makes me nervous." and, "She'll say 'You know you were supposed to have done this, or done this...'" R3 used pointing gestures (within the scope of her ability) to indicate that E3 would scold her for not doing something. She indicated that these would be things that she had never said she would do.
When asked if she could describe a specific date and incident, R3 indicated that she could not recall a date, but could describe an incident within the past week. R3 stated that E3 opened the bathroom door while she was on the stool and directed her to "Get up." She stated that she was not finished, but that E3 tried to make her hold onto something to get herself up anyway. She stated, "The other girls wait (until you're finished) and take time to help you."
9. On 11/20/02 at 10:50a.m., E4 stated that some time last spring, after the noon meal, she walked into R6's room and through the opened bathroom door saw E3 slam R6 on to the toilet. E4 told surveyor that when E3 did this to R6, the porcelain rattled. R6 immediately told E3, "Oh, you hurt me, don't be so damn rough." E4 stated that E3 did not know that E4 was standing at the doorway at the time of the incident. E4 also stated that E3 was not using a gaitbelt to assist in transferring R6 to the toilet. E4 stated that she reported this incident to the Charge Nurse on duty on the date of the occurrence.
E15, Registered Nurse, stated during an interview on 11/20/02 that she reported this occurrence to E2. E2 stated she interviewed E4 and could not substantiate this allegation and no further investigation was done. E1 stated during an interview on 11/21/02 at 3 p.m. that she did not know about this occurrence.
10. According to E8, E3 was abusive as long as 2 or 3 years ago. On 11/20/02 at 10:00a.m., E8 (Registered Nurse) stated that she wrote up a Certified Nurses Aide (CNA) for slapping a resident. E8 explained that a couple of years ago she wrote up E3 for slapping R7. E8 stated that E3 ended up with a three day suspension for slapping R7. E8 stated that she got in trouble because she was not supposed to write the staff up. She was supposed to go to the office to report the problem. E8 stated that after she wrote up E3 she was questioned by the Administrator as to how many people knew about the slapping. E8 stated that ever since then she is not to take reports of abuse. The Certified Nurses Aides and the families have been told to not report abuse to E8 when she's working, but to report it to the office. E8 stated that if someone reports abuse she can not discipline the CNA, and would have to allow the CNA to continue to work and closely monitor so that the accused wasn't with the resident by herself. E8 stated that families have called her at home to voice concerns about E3 and she tells them to report it to the office.
11. E3's employee file was reviewed on 11/21/02. No documentation about this incident or a three day suspension was found in the file. E3's file did contain a warning dated 11/29/99 addressing E3's tone of speaking to residents. The recommended action was to have another worker with E3 when tending to confused residents. The 2000 and 2001 evaluations for E2 contains written statements that E3 "need to slow down and talk with residents rather than talk at them."
II. Based on staff interviews, facility data review, and Marion Regional Office Long Term Care Incident Report review, the facility failed to investigate 5 incidents of alleged abuse against R6, R11, R2, R3, and an unknown resident. Failed to protect residents after allegations of abuse were made by staff and residents, resulting in resident injury, fear and nervousness. Staff failed to report per the facility policy incidents of alleged abuse against R-1, R-2, R-3, R-12, R-13 resulting in continued mistreatment. And the facility failed to report to the Illinois Department of Public Health, Marion Regional Office Long Term Care Division all alleged allegations of abuse when the facility became aware of such allegations.
The findings include:
A. The facility was aware of the following alleged allegations of abuse and did not do an investigation nor did they exclude E3, CNA, the alleged abuser from contact with residents while an investigation would have been under way.
E17 stated R3 reported to her approximately 3 months ago that E3 sat R3 down on the commode really hard and hurt her. E17 was working on the 3-11 shift and this occurred on the 7-3 shift, E17 stated she did not know who to report this incident to so she waited until the next day to reported it to E8. E17 stated nothing is ever done when incidents are reported. This incident was confirmed with a resident interview with R3 on 11/21/02 at 9:55 a.m.
There was no investigation of this incident.
B. Facility staff failed to report abuse as required. The facility Administrator, E1, was unaware of the following alleged allegations of abuse.
C. During the first day of the annual survey on 11/19/02, E3 was observed to be working as a Certified Nurses Aide in the facility and was found to be on the current CNA work schedule. During an interview with E1 and E2, it was confirmed that E3 was working in the facility as a CNA and had not been suspended for any reason. E3 did not work on 11/20/02 as this was her regular scheduled day off. E3 was reassigned on 11/20/02 to the laundry which is located in a separate building until the conclusion of the investigation.
D. A review of the Departments Incident Report file on 10/31/02 verified that there were no incidents of alleged abuse for this facility in the last year. After the facility was made aware of the allegations of abuse on 11/20/02, a fax was sent to the Department indicating an investigation was underway concerning E3.