ROYAL HEIGHTS NURSING & REHABILITATION CENTER
Facility I.D. Number0041228
Date of Survey: 6/19/02
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 residents 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.
General nursing care shall include at a minimum the following and shall be practiced on a 24- hour, seven-day-a-week basis:
All necessary precautions shall be taken to assure that the residents environment remains as free of accident hazards as possible. All nursing personnel shall evaluate residents to see that each resident receives adequate supervision and assistance to prevent accidents.
All exterior doors shall be equipped with a signal that will alert the staff if a resident leaves the building. Any exterior door that is supervised during certain periods may have a disconnect device for part-time use. If there is constant 24-hour-a-day supervision of the door, a signal is not required.
Based on record reviews and resident and staff interviews, the facility failed to properly supervise residents in a manner which provides them with necessary supervision to prevent them from leaving the facility without staff's knowledge. The facility was unaware of seven incidents of residents leaving the facility unaccompanied by staff or family (R6, R13, R17 on two occasions, R3, R4, and R12).
Nursing notes on 5-21-02 at 7:00 P.M. written by R12 state, "resident is pacing back and forth in room, Ativan 2 mg. and Haldol mg. given Intramuscular stat and Zyprexa 30 mg, given per mouth." On 5-24-02 an incomplete accounting of the incident was given to the surveyor by the Administrator, E1.
Nursing notes at that time included a late entry of the account. There are inconsistencies of the account in the nursing notes, the Administrators report and with interviews of security staff. Several staff, wishing not to be identified, have stated that their jobs are being threatened if they speak to the Department surveyors or if they tell what events are happening in the facility. The Department was not notified of the incident as required by the regulations.
3. On 6-3-02 at 4:42 P.M. a second Police Report was made on R17. R17 had again left the facility without staff knowledge (taken from Belleville Police report, 6-3-02). Review of facility incident report on 6-6-02 indicates that R17 left the facility on 6-3-02 at 5:20 P.M. R17 "ran out of B-hall exit door setting off alarm, staff ran after resident and yelled to charge nurse to overhead security." E24, nurse's aide in care of R17 at time of incident, reports to surveyor on 6-6-02 at 3:30 P.M., she saw R17 a short time before he exited the building on 6-3-02. He was walking down A hall on the second floor and E24 was working on B hall. E24 stated she was the only CNA on the second floor with care of over 88 residents at the time of the incident. The only other CNA assigned to the second floor had left the building to go with the security guard to pick up a dialysis resident off the facility grounds. The security guard usually on this floor had gone downstairs to take the place of the security guard who had left. Two nurses were on the 2nd floor passing out medications at that time. E24 heard the door alarm sound, but by the time she got to the door she could not see who had exited or where they had gone. A resident (R12) watching out the window reported to her that he had seen R17 go out and go between the apartment buildings. According to E24, staff were unable to find R17. On 6-6-02, E25, the new Medical Records assistant was interviewed concerning R17's elopement. E25 stated that on 6-3-02 at about 5:10 P.M. she got on the city bus about ½ block from the facility. She thought that a passenger already on the bus looked like someone from the facility. E25 called the facility from her car phone and described the resident. It was determined to be R17. E25 stated that she stayed on the bus for a few blocks then got off the bus to get on the Metro link train. R17 did the same thing. She (E25) tried to keep the facility informed, however, she and the resident soon separated. (R17) has not been seen since that time. The Power of Attorney for R17, Z12 was notified and "believes" that R17 has found a friend in St. Louis, Mo. The Department was not notified of this elopement. This incident was reported to surveyors by staff on 6-6-02 while surveyors were investigating another incident of elopement. R17 is a 55 year old male, admitted to the facility on 5-17-02 with diagnosis of Paranoid Schizophrenia. No Care Plan was completed for this resident to address elopement concerns or staff approaches to prevent elopements despite. On April 7, 1999 R17 was adjudicated incapacitated and disabled by the circuit court of St. Louis County, Missouri per record review.
4. On 6-6-02 the Administrator gave surveyors a newly revised Policy on elopements. This policy referred to elopements as "flights" when alert residents left the facility without staff knowledge. This policy states: "Elopement does not occur when a resident who is cognizant of date, time and full surroundings, leaves the facility against medical advice with or without signing out. Resident "flight" may include, but is not limited to:
E1 stated that this policy was made at the advice and with the assistance of the facility legal department. (The majority of the 177 residents residing in this facility have diagnosis of mental illness with drug and alcohol involvement. This information was taken from staff interviews and record reviews during this and previous surveys.)
5. On 4/20/02, sometime after 6:00 p.m., R4 eloped from the building and walked to Z12's (R4's mother) home, per record review. Z12's house is approximately one and one-half mile away from the facility. At approximately 7:35 p.m., Z12 telephoned the facility and said that R4 was at her home. Two male security personnel retrieved R4. The facility staff were unaware that R4 was gone from the facility. On 5/23/02, R4's medical record was reviewed. R4's physician's order sheet, dated May 2002, indicated the following diagnoses: Polydipsia Hemorrhoids/ Rectal Bleeding, Constipation and Seizure Disorder. On 5/23/02, the incident reports from January 2002 through May 2002 were reviewed. There was no incident report regarding R4 attempting elopement from the facility. On 5/23/02, a Discharge/Transfer Summary sheet from R4's previous residence indicated the following: "He also has an extensive history of elopement from community placement provider and -------Mental Health Center". This discharge summary was dated 9/24/01. On 5/23/02, R4's nurse's notes were reviewed. R4's nurse's note, dated 4/16/02, indicated R4 had a seizure on this date (four days prior to his elopement). There was no documentation in the nurses' notes regarding R4 eloping from the facility on 4/20/02. On 5/23/02, R4's Wander Risk Assessment was reviewed. This assessment indicated the following : "Any 'YES' response is considered to be a warning that resident is at risk for wandering that may result in elopement." There was no date on the assessment. The assessment indicated R4 was "NOT AT RISK". On 5/23/02, R4's assessment, dated 4/2/02, noted that R4 had wandering behavior daily. His care plan, dated 4/17/02, did not address any problems related to elopement or wandering. On 5/24/02, at 9:50 a.m., E30, E31 and E32 (Mental Health Professions contracted by the facility) were interviewed. They noted that R4 attended their mental health program. They were not aware that R4 had eloped from the building to see his mother. On 5/30/02, an interview was conducted with Z12, R4's mother. She said that about one month prior, R4 had come to her house during the evening hours. She said that R4 visited for awhile.
Z12 said she contacted the facility to notify the facility staff that R4 was at her home and two security guards from the facility picked him up at her home. Z12 lives approximately one and one-half mile from the facility. She said that it was dark when the facility staff picked R4 up from her home and the temperature was warm. On 6/4/02, at 10:25 a.m., E1, the administrator was interviewed. She said that she was aware that R4 had left the facility and gone to his mother's home. She said that he was returned to the facility by the facility security.
She said that R4 eloped from the facility by tying sheets together and climbing out of his room window. On 6/4/02, at 12:00 p.m., the surveyor observed R4's room window was on the second floor and was approximately 20 feet from the ground. On 6/4/02, at 2:10 p.m., E15 (the security manager) and E16 (the assistant security manger) were interviewed. Both of these employees said that they were aware of the incident although this was only through rumors. E15 said that she was not aware of any report regarding R4 leaving the building. Both noted that E21 may have information regarding this incident. On 6/4/02, at 2:30 p.m., an interview was conducted with E21, a security guard. He said that he recalled R4 getting out of the building on 4/20 or 4/21. He said that he was working on the 1st floor when he was told to pick up R4 at his mother's home. It was approximately 7:30 or 7:35 p.m. when he retrieved R4 from Z12's home. He said that he did report this incident to the security personnel on the next shift. He said that he did write a report and this report should have been given to E15, the security manager.
On 6/4/02, at 2:50 p.m., an interview was conducted with E13, a Registered Nurse. She said that she received a telephone call from Z12 on 4/20/02. Z12 told E13 that R4 was at her home. This was between 7:00 p.m. and 8:00 p.m. and it was dark outside. She said that the last time that she saw R4 was during the smoke break which was approximately between 6:00 p.m. and 6:15 p.m. She said "There was no reason to think he was missing because she last saw him at smoke break." E13 said at no time did the door alarms sound. She said that when R4 was returned to the facility she began to assess his physical condition. She said that he hid in the downstairs 1st floor bathroom. As she was discussing the incident with R4 in his room, she noticed that his window was opened and there was a pile of sheets on the ground below his window. She said that she thought she wrote an incident report. On 6/4/02 at 3:15 p.m., E1 provided the surveyor with an incident/accident report regarding R4. The report indicated the following "tide (tied) sheets together climb out of window went over Mothers during search for resident called mother stated he was their (there) security went to pick him up." R4 continues to reside in the facility. His care plan has not been updated to address his elopement potential. This incident was not reported to the Department.
6. On 4/24/02, between 8:00 p.m. and 8:45 p.m., R3 eloped from the facility. R3 walked to the Mobil station which is approximately 0.1 mile down the street from the facility. This street is a two lane street and is heavily traveled. After walking to the Mobil station, R3 bought some alcohol and returned to the facility. The facility staff were not aware that R3 had left the facility. R3 is alert and oriented with no physical mobility limitation; however, R3 is deaf. On 5/23/02, at 2:40 p.m., an interview was conducted with E33, a security personnel. He said that R3 went out an exit door on the 1st floor and jumped the facility fence and walked to the Mobil Station down the street from the facility. He said that the 1st floor exit door is unlocked because during smoking time the door is not alarmed and not locked to allow residents to come in and out to smoke.
He said that he did not write a report because he thought E13, the charge nurse, would write a report. He said that E21, a security personnel, retrieved R3 from the Mobil station. He could not recall a specific date as to when the incident occurred.
On 5/23/02 at 3:40 p.m., E1 (Administrator) was interviewed. She said that she was not aware of any incident regarding R3 eloping from the facility, walking to the Mobil station and buying alcohol. On 5/23/02, R3's medical record was reviewed. His physician's order sheet dated April 2002, noted that R3 had the following diagnoses: Major Depression with Psychotic Features, Alcohol Abuse and Deafness. There was a written order, dated 4/24/02, indicating that R3 was to be directly admitted to the hospital. On 5/23/02, his nurse's notes were reviewed. His nurse's note, dated 4/15/02, indicated the following "Resident informed of facility policy R/HT (related to) + (positive) urine drug screen and restriction of visitors and no out pass for 30 days once out pass reinstated resident may receive drug screen upon return from pass." His nurses' note, dated 4/24/02 (9:15 p.m.), indicated that R3 was displaying suspicious behavior. His room was searched and alcohol was found. He was transferred to the hospital per physician's order. There was no documentation regarding his elopement from the facility or how he obtained the alcohol. E13 wrote this nurse's note. On 6/4/02, at 1:50 p.m., E15 (the security manager) and E16 (the assistant security manager) were interviewed. They noted that if a resident would elope from the facility, the security personnel on duty should write a report regarding the elopement. Both said they were unaware of R3 eloping from the facility.
On 6/6/02, at 10:20 a.m., an interview was conducted with E13. She said that around 9:00 p.m. on 4/24/02, R3 entered through the 1st floor smoking door. She said that she thought this was strange because the 2nd floor residents smoke at 8:00 p.m. She said that he had mud on his feet and was acting suspicious. She said that he went up to the 2nd floor via the elevator even though she attempted to stop him. She said that no alarm sounded when R3 entered the 1st floor smoking door because it had been shut off while the residents smoked.
She said that she and two security personnel (E21 and E33) confronted R3 and told him that they needed to search his room. They found beer and Mad Dog 20/20 in a drawer in R3's room. She said that when the security personnel found the liquor R3 began to curse at her. E13 said R3 smelled of alcohol. E13 indicated that R3 told her that he jumped from his 2nd floor window to get out of the facility and he would do it again.
Prior to this incident, E13 said she last saw R3 at 8:00 p.m. during the 2nd floor smoking break. She said after this incident, she notified R3's physician and R3 was sent to the hospital. After the interview, E13 provided the surveyor with an Incident/Accident Report form, dated 4/24/02. It indicated the following: "4/24/02 Approx. 8:45 p.m. noted Res on first floor B hall coming thru exit door. Acting very suspicious behavior excorted (escorted) (up) to 2nd floor". On 6/6/02 at 11:35 a.m., E21, a security personnel, was interviewed. He said that on 4/24/02, he was working on the 1st floor of the facility. He said that around 9:00 p.m.-10:00 p.m., he was called to the 1st floor nurse's station. He said that R3 was on the elevator and E13, the charge nurse, was trying to stop him. He said that he and E33 (a security personnel) went to the 2nd floor and assisted E13 with searching R3's room. They found a 24 ounce can of beer and a pint of Mad Dog 20/20 in a drawer in R3's room. E21 said that he walked down to the Mobil station to confirm that R3 had purchased the alcohol at that station. E21 said the station attendant confirmed that R3 had been in the station and purchased the alcohol. He said that the last time he saw R3 prior to the incident was dinner time, approximately 5:00 p.m. This incident was not reported to the Department.
7. On 5/26/02 at approximately 12:00 p.m., E16 saw R12 in the lot to the north of the facility. R12 had turned off the alarm on the 2nd floor B-hall exit and had eloped from the facility. The facility staff were not aware that R12 had left the facility and were not aware what time he eloped from the facility. On 6/4/02, R12's medical record was reviewed. His physician's order sheet dated May 2002, indicated the following diagnoses: Schizophrenia and Polysubstance Abuse. He was admitted to the facility on 5/17/02. On 6/4/02, the "Behavior Report" regarding the above incident was reviewed. The report dated 5/26/02 at 12:30 p.m., indicated the following: "Resident turn alarm off and exit the doors". There was no further information provided regarding when R12 was last seen in the facility. On 6/4/02, R12's nurse's notes were reviewed. His nurse's notes dated 5/26/02 at 1:00 p.m., indicated that R12 left A.M.A. (Against Medical Advice). There was no documentation regarding his elopement attempt. On 6/4/02 at 1:40 p.m., E16, the assistant security manager, was interviewed. She said that on 5/26/02, at approximately 12:00 p.m., she was in the lobby of the facility. She said that she was looking out the window and saw R12 in the grassy area next to the facility. She said that she brought R12 back into the building at which time he left "Against Medical Advice". She said that R12 told her that he had turned off the alarm at the 2nd floor B-hall exit. She said that no one saw R12 exit the building and she was not sure when he exited the building. She said that after the incident occurred, she did confirm that the 2nd floor B-hall exit door alarm was turned off. She said that the next day a new door alarm was put on this door which required a key to turn it off. This incident was not reported to the Department.
8. On 6/6/02 at 2:00 p.m., the exit door alarms were tested by E21, a security personnel. Two of three personal monitoring door alarms did not sound when a resident with a personal monitoring device was placed directly in front of the doors.
In addition, four doors which opened from the stairwells to the outside of the facility were not alarmed. E15, the security manager, indicated that the alarms were ordered and would be placed on the doors.
Date of Survey: 8/12/02
Annual Licensure Survey, Incident Investigation of 7/10/02; Incident Investigation of 6/17/02 and Complaint Investigation
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 residents 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.
All necessary precautions shall be taken to assure that the residents environment remains as free of accident hazards as possible. All nursing personnel shall evaluate residents to see that each resident receives adequate supervision and assistance to prevent accidents.
NO RESIDENT SHALL BE DEPRIVED OF ANY RIGHTS, BENEFITS, OR PRIVILEGES GUARANTEED BY LAW BASED ON THEIR STATUS AS A RESIDENT OF A FACILITY.
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 EMPLOYEE OR AGENT WHO BECOMES AWARE OF ABUSE OR NEGLECT OF A RESIDENT SHALL IMMEDIATELY REPORT THE MATTER TO THE DEPARTMENT.
RESIDENT AS PERPETRATOR OF ABUSE. WHEN AN INVESTIGATION OF A REPORT OF SUSPECTED ABUSE OF A RESIDENT INDICATES, BASED UPON CREDIBLE EVIDENCE, THAT ANOTHER RESIDENT OF THE LONG-TERM CARE FACILITY IS THE PERPETRATOR OF THE ABUSE, THAT RESIDENTS CONDITION SHALL BE IMMEDIATELY EVALUATED TO DETERMINE THE MOST SUITABLE THERAPY AND PLACEMENT FOR THE RESIDENT, CONSIDERING THE SAFETY OF THAT RESIDENT AS WELL AS THE SAFETY OF OTHER RESIDENTS AND EMPLOYEES OF THE FACILITY. (Section 3-612 of the Act)
These regulations are not met as evidenced by:
I. Based on observation, staff and resident interviews and record review, the facility failed to keep 8 residents (R20, R49, R44, R14, R12, R31, R9, R51), free from mistreatment, abuse and neglect. The facility failed to identify residents at risk for abuse and for abusing other residents, develop intervention strategies to prevent occurrences, provide sufficient staff and train staff to identify abuse, monitor for abusive behavior or re-assess on a regular basis to prevent abuse or further abuse from occurring and investigate when abuse has occurred. The Facility further failed to follow their own policies concerning resident admission policy; abuse prohibition; sexual health, activity and behavior; and program for behavior interventions.
II. Based on observation, record review and staff and resident interviews, it was determined that the facility failed to provide adequate supervision on the second floor of the nursing home to prevent: 1. access to knives by residents, (R33, R50, R46); 2. injuries or potential injuries to residents due to violent behavior by residents, (R46, R30, R12, R74, R37, R46); 3. Unalarmed doors and residents leaving the facility; 4. illegal drug use by residents in the facility, (R49, R35, R34, R12, R14); 5. open access to the medication room by residents, (R32).
III. Based on observation, staff, resident and other interviews and record review, the facility failed to provide specialized rehabilitative services for residents with mental illness and/or mental retardation diagnosis as indicated by the Pre-Admission Screening and Annual resident Review (PASARR) and as required in the residents comprehensive plan of care for 7 residents on the sample (R12, 13, 15, 21, 14, 11, 20) and 10 residents off the sample (R33, 34, 35, 48, 36, 44, 45, 49, 42, and 28). The facility failed to provide a structured environment, manage inappropriate behaviors, encourage daily living skills, develop appropriate personal support networks, provide a formal behavior modification program, and coordinate services with outside programs which complements the implementation of facility program to meet residents needs.
I. 1. R20 is a thin woman who appears much younger than her age of 41. A History and Physical dated 7/18/01 states that R20 has diagnoses, in part, of Moderate Mental Retardation and Schizophrenia. The cumulative diagnoses sheet in the clinical record also lists a diagnosis of Cerebral Palsy. R20 was originally admitted to the facility on 8/16/99. She is below her ideal body weight of 120 pounds, with a weight of 108 pounds in June and 111 pounds in July. An Annual Psychiatric Evaluation dated 8/16/01 states "This 40 year old very thin, confused female, easily and often agitated, poor anger management, impulsive, lacks insight, poor judgement......Social judgement is poor". R20's most recent assessment, dated 5/21/02, shows that she is moderately impaired -decisions poor; cues;/supervision required. During confidential resident interviews, several residents stated that they were concerned about R20 as the staff allow R42 to enter R20's room at night and "sodomize" or have sexual relations with her. Confidential resident interviews further reveal that staff knows that R42 has an extremely strong sexual appetite and is continually approaching residents and staff for sex. E38, psych-social coordinator for the second floor, stated that R42's physician is considering ordering Depo Provera in order to attempt to curb his strong sexual appetite. R42 is 52 years of age with a diagnosis of Schizophrenia. The surveyor asked E38, if R20 was having sexual relations. E38 stated that yes, it's their policy to not interfere in resident rights. E38 stated that R20 may seem very child like however, she's capable of understanding a lot more than you initially think. E38 further stated that they have care planned for R20 to have "appropriate" sexual relationships as she was having sex in exchange for junk food and soda. A 7/25/02 psych social progress note states "Spoke with resident along with CP nurse about resident's behavior of trading sexual favors for food.
Resident understands what was being said. It was explained to resident how inappropriate and dangerous her behavior is. Res was informed of her order to attend a day program. She then stated, "I don't want to go - it's boring". Res was informed that staff would monitor her and use what ever reasonable methods available to deter behavior. Administrator was notified. She instructed nurse, through PSC to arrange an OB/GYN appt for res immediately.....". The surveyor asked E1 for an assessment concerning R20's ability to understand sexual relationships. The Facility was unable to produce any type of assessment. The surveyor asked E1 if there was an assessment or evaluation that identified R20's IQ or functional level. E1 stated that there has never been an IQ test or other evaluation conducted to ascertain R20's functional level.
E1 contacted Z11, R20's psychiatrist, and asked him how R20's diagnosis of Moderate Mental Retardation was determined. Z11 stated that it was strictly from his interaction with her. E1 also asked Z11 if R20 would be able to understand the implications of a sexual relationship. Z11 stated "that's not my place to decide-that's up to a Judge". On 7/29/02 AT 3:30 PM, the surveyor asked R20 if she knows what sex is. R20 answered "yes". The surveyor then asked R20 if she had sex. R20 stated "I have sex and I want to - they give me money". The facility has not contacted R20's Health Care Power of Attorney regarding R20's sexual activity. The American Association of Mental Retardation (AAMR), defines Moderate Mental Retardation as having a mental age range of 6-8 years and an academic advancement to about 2nd grade.
E13, nurse aide, stated in an interview on 7/31/02 that R20 had to be monitored for sexual interactions. E46, CNA, stated that they had to watch R20 for sexual interactions because she was "borderline". E13 stated that she had not seen any sexual favors for sodas.
2. Interview with R49 on 7/29/02 identified that R49 is R20's roommate. R49 was asked if any men came into her room at night and bother R20 and she shook her head yes. When asked what they do R49 stated "F--- her". When asked who did this R49 identified R42. R49 was asked how often this happens and R49 stated "every night". R49 stated she hears them and one night caught them. R49 stated she told R42 to get out. R49 was asked if R20 knew what was going on and she replied no that she thought R20 was asleep. R49 was asked how that made her feel and she stated she was scared. R49 stated that her medication makes her sleep soundly and she was afraid he might come in and do that to her when she was asleep. The facility indicated that R49 is reliably interview able.
3. R9 was involved in several altercations. R9 has diagnoses, in part, of schizophrenia and bi-polar disorder. The most current assessment dated 2/12/02 identifies R9 as moderately cognitively impaired but independent with activities of daily living. The following are examples of incidents involving R9.
a. On 7/7/02 R9 was in the main dining room at 8:25 AM and R11 cursed at R9 causing R9 to curse back at him. R11 twisted R9 around by the arm and threw her to the floor. During the altercation R11 "pricked" R9 with a fork according to the incident report. On 7/8/02 R9 approached the surveyor and showed the surveyor a wound on R9's lower left arm on 7/8/02 that was approximately two inches long. R9 stated she had been stabbed with a fork by R11. R9 7/29/02 that R11 was on top of R9 when he jumped R9 in the dining room. The investigation of incident report went on to say that when R11 pushed R9 to the floor another resident, R70, began an altercation with R11. R59 then joined in the fray and struck R70 several times. R9 further stated that R11 is having a relationship with her roommate and spends the night in their room. R9 told the surveyor that she was afraid to get undressed or go to sleep as R11 was always there and would get angry at her if she came into her own room. R9 also stated that R11 often spent the night in her room with her roommate. The surveyor asked R9 if the facility had moved her to a different room or had prohibited R11 from entering her room since the altercation occurred. R9 stated "No, he's still coming in and I'm afraid".
R11 was transferred to the facility on 2/1/02 from a sister facility due to violent behavior at the sister facility. The history and physical dated 1/28/02 stated the facility could not handle R11 after he was involved in physical altercation. R11 has diagnoses, in part, of schizophrenia, major depression and Huntington. R11 was assessed as modified independence for cognition and independent with activities of daily living.
b. On 7/24/02 at 12:45 PM, R9 was observed with fingerprint bruises on her right upper arm by the surveyor. There were three finger sized, dark purple marks on top of her arm and one thumb print size mark on the under side of her arm. R9 was asked what happened to her arm and she stated "Grabbed her from behind". R9 was very lethargic and only stated "lots of earrings" when asked who grabbed her. R9 walked away. There was no incident report on the finger marks as confirmed by E2, Director of Nursing At 1:30 PM R9 was observed walking very unsteady down the hall to her room. R9 had to sit down in a chair by the telephone area to rest. R9 then went to her room and went into the bathroom.
When she came out she flopped down on her bed. R9 was very lethargic and her speech was very slurred. When asked what happened to her arm she stated R22 "beat her" and made knots on her head. R9 stated she hasn't felt good since then. R9 stated R32 made the bruises on her arm. Surveyor then went to tell E21, LPN, that R9 had requested a nurse. R9 stated they had checked her twice that morning. E21 stated R9 had been complaining all morning and that was her behavior. Surveyor stated R9 was acting very lethargic. E21 asked a CNA to check her blood pressure which was 80/50. E21 went to recheck and the blood pressure was 90/50.
An incident report dated 7/16/02 noted that R9 was banging on other residents doors and her right wrist was blue and swollen. An x-ray was negative. An incident report on 7/17/02 noted that R32 had come up behind R9 and grabbed her by both upper arms and threw her to the floor. The report stated there were no apparent injuries.
Another incident report dated 7/17/02 noted R9 was struck in the face by R10 which resulted in a small abrasion to her inner lip area. Neither the incident reports nor the investigation identified the fingermark bruises and how they occurred.
On 7/16/02 Z16, ombudsman, was at the facility and R9 approached her and stated Z17, Adapt staff, grabbed her by the arm that morning. R9 also stated R22 hit her on the head several causing knots on her head. The incident involved cigarettes. E43, Social Service Director, was present when R9 made the statements. On 7/24/02 at 3:35 PM, E43 did not recall any incidents or fights for R9. On 7/30/02 at 10:27 E43 did recall R9 stating she and R22 had got into it but never heard her say anything about being hit in the head.
Interview with Z17, day program staff, on 7/29/02 stated R9 was on her caseload. Z17 was unaware of the fingermarks on R9 or any bruising. Z17 stated she had been on vacation last week and this was her first day back to work. Z17 stated about two weeks ago Z17 did "grab R9 to come upstairs when she tried to jump the fence. R9 was outside in the smoking area. Z17 stated she took R9 by the arm to guide her back upstairs. Z17 stated it was not hard and did not feel it was hard enough to bruise her. There is no investigation into the fingermarks on R9 and how they occurred. There are no nurses or social service documentation regarding the fingermarks or R22 hitting R9.
c. On 7/28/02 at 9:15 PM in the dining room R9 was very upset and yelling at staff, Z4, day program staff, "Shut the f--- up, I'll kill you." R9 was very agitated and trying to use the phone. There was 1 nurse aide, E44, and 1 day program staff, Z4, in the dining room and 38 residents. At 9:20 PM R9 got in R71's face and began screaming and making obscene gestures. R71 began screaming and R9 screamed at him "Shut the f--- up". Another resident yelled at R9 to shut up or he'd knock her teeth out. R71 jumped up from the table and ran from the dining room screaming "I can't take it no more, I'm going to kill someone." Z4 went out with him. R9 then went to the telephone and threw it down. R9 yelled across the ding room at R72 "F--- you N----". R9 then turned and pulled up her dress and bent over and "mooned" the entire dining room. R72 screamed at R9 and R9 made an obscene gesture to R72. R9 then ran down the exit door and set off the alarm. E44 followed her and this left only 2 diet aides in the dining room.
4. R44 has a diagnosis of Paranoid Schizophrenia. He is a young man, 22 years of age, with weight and height proportionate. He was originally admitted to the facility on 2/11/02. A Facility Psych/Social Monthly Response Note dated 6/11/02 states "Res is doing well with attending groups or activities, but he needs improvement with interacting with peers. He will not refuse any interaction attempts and he responds well. Res lacks skills needed in approaching peers. He believes that if he stays away from people, there will be no conflicts. He is very comfortable talking with staff". R44's most recent assessment dated 5/30/02, shows that he is independent for cognition and has no mood or behavior problems. During the second floor resident group interview, R44 stated that he is extremely uncomfortable with the actions of some of the female residents. R44 stated that they walk around the Facility undressed, leave the doors to their rooms open exposing themselves and come up and rub all over the men. R44 and other residents stated that staff do not intervene when the women inappropriately touch the male residents. On 7/28/02, the surveyor observed R51, a female resident, approach various men sitting in the dining room waiting for their lunch. R51 came up behind one of the men placing her breasts against the back of his head and arms around his shoulders, rubbing back and forth and "hugging" the male resident to her chest. The male resident sat in is chair and did not encourage or discourage R51's actions. Staff present in the dining room did not intervene. R51 then approached another male resident and began stroking his head and cheek. The male resident did not encourage nor discourage R51's petting. Staff present in the dining room did not intervene.
5. During an interview with R12, on 7/28 and 7/29/02, he stated that he was disgusted with what was going on in the facility. R12 stated that he voluntarily admitted himself to the facility on 7/22/02 as he was told that it was a Drug Rehabilitation Center. R12 told the surveyor he wished to leave as the behavior he was seeing by the staff and residents was "putting him over the edge". R12 stated that he has observed sex acts between residents and prostitution by residents for as little as a dollar. R12 stated "I've seen a woman suck on a man for as little as a soft drink - but, that's nothing". R12 further stated that staff doesn't seem to care and staff even watch the residents engaged in sex acts on occasion.
6. Review of R14's assessment dated 6/20/02, indicates that he has no problems with short or long term memory and that he has modified independence in cognition- with some difficulty in new situations only. During an interview with R14 on 7/29/02, he stated that he was really worried about R20 as R42 was going into R20's room at night and sodomizing her. The surveyor asked R14 how he became aware of this happening. R14 stated "everyone knows it, the staff joke about how well endowed (R42) is". R14 stated that he didn't know how R20 could be a willing partner because "just look at her". R14 further stated that R20 isn't the only woman that R42 has tried to sexually abuse. R14 stated that R42 was found on top of R31 recently. R14 stated that R42 entered R31's room while she was asleep in bed and attempted to penetrate her. R31 is a 26 year old female, originally admitted to the facility on 4/21/00. R31 has diagnoses, in part, of Borderline Intelligence, Severe Chronic Mental Illness and Early Infantile Autism. R42's Facility behavior tracking for the month of July states "7/21/02, Went into a residents room (R31) while she was asleep and pulled his penis out but we caught him before he could do anything to resident". There was no notation in R31's chart concerning the incident nor did the facility investigate the incident. The surveyor attempted to interview R31 however she only gave one word responses to questions, such as "yes" and "no" or would shrug her shoulders. R31's responses were not appropriate to the questions which were asked by the surveyor.
7. There are two residents with police records, R55 and R57. R55 had a record for child molestation and R57 had a record for sexual assault, according to Z36. In an interview with E47 (Admissions Coordinator), on 7/31/01, at 1:26 P.M., she stated it was the facility's policy to not admit Pedophiles and abusers of the elderly. According to the Discharge/Transfer Summary from a state mental health facility, found in the facility's records, R57 has a history of being Unfit to Stand Trial on charge of, "attempted heinous battery". He poured gasoline on a person, with the intention of igniting it. In the facility clinical record, it's stated that R55, who is a resident on the 1st floor, was moved to the 2nd floor, for conducting himself inappropriately with a female peer.
There are at least three residents on the second floor with a diagnosis of Hepatitis C and one resident with a diagnosis of Human Immunodeficiency Virus. Interview with E11, care plan nurse, on 7/31/02 identified that if a resident was assessed as sexually active she would care plan for it. E11 provided the care plans of 5 residents known to be sexually active. E11 stated the only way they would know if a resident was sexually active was if they told staff or staff observed the interaction. E11 stated the residents would be counseled on safe sex, sexually transmitted disease, pregnancy and relationships. Condoms are available on the unit from Social Service. Interview with E11, LPN, E13, CNA, and E46, CNA could not positively identify sexually active individuals.
The Facility has a policy entitled "Policy of Resident Sexual Behavior" which states: "This policy has been developed to insure that all residents retain the right to have sexual expression while residing at (facility), furthermore, this policy is to insure that the rights and safety of all residents are protected. Resident Rights: 1. (facility) recognizes that all resident retain the right to sexual expression as accepted by the norms, values, and laws of our society. 2. All residents retain the right of privacy for intimate relations........ Resident Responsibilities: 1. all residents will be subject to the same laws and responsibilities, and societal norms related to sexual conduct as in the community. 2. Residents will not be knowingly allowed to violate the sexual rights of others. 3. In cases where a resident has violated the law or sexual rights of others the following will occur: a) All criminal acts will be reported to the proper authorities. b) Resident will be provided with structured counseling on unacceptable sexual behavior. c) If a resident persists with such behaviors, and he/she is deemed a danger to self or others-he/she will be discharged from the facility.......5. All and any alleged sexual abuse will be investigated per the OBRA Abuse Prohibition Act. Measures according to this act will be implemented as indicated". The facility failed to: hold residents to societal laws, norms and values; prohibit residents from violating the sexual rights of other residents; report violations to the proper authorities; investigate alleged sexual abuse.
The Facility Abuse Prevention Program and Facility Procedures states "This facility is committed to protecting our residents from abuse by anyone including, but not limited to, facility staff, other residents, consultants, volunteers, staff from other agencies........". The policy further states that "Residents who allegedly mistreated another resident will be removed from contact with that resident during the course of the investigation. The accused resident's condition shall be immediately evaluated to determine the most suitable therapy, care approaches, and placement, considering his or her safety, as well as the safety of other residents and employees of the facility".
II. The second floor of the nursing home houses 100 residents that have been assessed to need specialized psychiatric rehabilitation. The second floor unit can only be left when staff unlock the elevator or unalarm the exit doors. An Adapt program office is located on the floor with 26 residents identified as Adapt clients. Adapt provides services to residents from state psychiatric hospitals. Other residents have other day programs such as Z21, Z22, Z20, Z33, and Z23 they can attend outside the facility. There are four wings with male and female residents on each hall. Ages of the residents range from 19 years old to 75 years old with the majority of the residents under 55 years of age. At least 10 of the residents are identified as having poly-substance or alcohol abuse. Currently there is one resident involved in Z33, substance abuse program. Recreational activities observed during the survey included smoking at two hour intervals, watching television, listening to the radio, meals, snacks, reading the paper, and sleeping. There were no structured activities such as bingo, crafts, dances, shopping or outings observed during the hours of the survey as described as available in the facility "Specialized Psychiatric Services Program."
1. The following are examples of residents with knives in their possession on the 200 floor:
A. R33 is a 42 year male with a diagnosis, in part, of Paranoid Schizophrenia, Paranoid Personality, history of substance abuse and mental retardation. On 7/31/02, at 8:45 A.M., during an interview with ADAPT staff, Z4, a statement was made that R33 had an incident at the day treatment program and his physician, Z6, wanted R33 to be held back from the program. In a review of physician Progress Notes dated 7/12/02, it was written that R33 had been found with a butcher knife in his room.
Nurse's Notes were reviewed and a note dated 7/11/02, at 0250 stated, "Certified Nurse Aid (CNA) entered room to find resident peeling an apple with an unauthorized 10-12 inch blade knife; resident refused to surrender knife to CNA or Security. Z5, Z19 staff, was notified of possession of knife and refusal to surrender the knife".
According to a second entry in the Nurse's Notes, at 0330, Z5 arrived, spoke with R33 and obtained the chef knife R33 had in his possession; also obtained a meat carving knife and a steak knife from R33's duffle bag.
A Nurse's Note at 0355 stated new orders were received from the physician, Ativan 1 mg IM given in right deltoid-tolerated well and was very cooperative. In an interview with Z19 Program Director, (Z9), she confirmed the knife was the incident at the day program that Z4 was referring to. She stated that at the day program they work in the kitchen, without a lot of supervision, the day program kitchen had knives missing, but Z19 did not conduct an investigation and she didn't know if the facility had investigated the incident, but they think this is where R33 got the knives.
The Facility Incident Tracking Log was reviewed and the incident was not on the Log. Facility Administrator (E1) was interviewed and she stated that this incident was on a Security Incident Report, not a Facility Incident Report.
In a review of the Security Incident Report, dated 7/10/02 at 2:40 A.M., it was noted that R33 was found in his room with a large knife more than 6 inches long. Security (E35) was informed of the knife, went to R33's room and R33 refused to hand over the knife and told Security to get out E35 left the room and Z5 from Adapt was called at 2:45 A.M.. Z5 arrived at the facility at 3:20 A.M. Z5 and E35 found the knife but not the one R33 had earlier. They had a CNA (E36) take R33 out to smoke and R33's room was checked and the big knife and another knife were found. All together they found 3 knives in R33's room.
In another interview with E1, she stated the facility did an investigation. This investigation was obtained from the Director of Nurses (E2). The investigation was dated 7/10/02 and signed by E2. The investigation stated, "Received behavior report from security re: R33 having possession of knives in his room. Knives were removed from his room and given to me this A.M. I, in turn, turned them over to E37, Security Supervisor. I then informed resident that it was against policy to have knives in his possession both for his safety and the safety of others. He stated, "OK, I'm sorry I didn't mean to cause trouble".
In a review of R33's Medication Administration Record, it showed that R33 had an injection of Ativan 1MG stat on 7/11/02. The new Physician Orders were, 1)Ativan 1 mg IM Stat; 2)Ativan 1 mg PO or IM q 4-6hrs, 3) If unable to calm res with Rx, may send to hospital for psych eval. Also on 7/11/02 new Physician Orders were: 1)dc Seroquel 2) increase Zyprexa 30mg at bedtime 3)Haldol 2mg twice a day 4) Cogentin 1 mg at 8A and 4P. On 7/12/02 another Physician Order reads, "increase Haldol 2 mg twice a day and 2mg at bedtime". The information provided by the facility, (the investigation and accounts of the knife incident) did not show any record of R33's behaviors escalating in a manner that would make R33 need the sedative drug, Ativan stat, or a change of antipsychotic medication.
Review of R33's Adapt Individualized Treatment Plan, Objective #3 with start date 7/30/02 states, "(R33) will have zero incidents of verbal aggression or homicidal threats for three consecutive months". These behaviors were not addressed in R33's clinical record dating from 9/26/01 to current.
In a review of R33's Care Plan, it showed the approaches to be used, regarding the knives in R33's room, are 1) Explain to res what type of utensils are appropriate 2) Explain to res family about utensils and not to bring any in 3) Periodic room checks with res permission for contraband. The responsible discipline is Nursing.
On 8/1/02 Z9 stated she was not for sure that R33 got the knives at the day program, they didn't do an investigation to determine where they actually came from.
B. R50 has diagnosis of schizoaffective disorder. On 4/27/02 a social service progress note states that R50 was counseled for having a knife in her possession. The note states that R50 was "cooperative and stated that she would not have used it for anything. R50 agreed not to have such weapons in her possession. R50 was assessed a moderately cognitively impaired on the 7/2/02 Minimum Data Set. On 7/17/02 R50 was sent to the emergency room due to agitation, refusing medications and being upset with another resident and in a psychotic state according to the hospital history and physical. R50 was asked why she was at the hospital and stated in the history and physical "a little gang warfare at Royal Heights. Every time I get something good going, people burn my bridges down."
C. R46 was able to grab a knife off the dining room table and wave it at staff on 7/28/02 during the noon meal. R46 had exhibited aggressive behavior prior to the incident. R46 threw the knife at a group of residents with no injury incurred. R46 was sent to Z32, hospital.
2. The following are examples of violent behaviors or the potential for violent behavior by residents to residents and resident behavior which resulted in injury or the potential for injury to residents.
A. R46 has a diagnosis of schizophrenia. The Minimum Data Set dated 7/8/02 assessed R46 as moderately cognitively impaired. At 11:00 AM on 7/28/02 R46 was involved in an altercation with another resident where a visitor was pushed down.
Throughout the morning of 7/28/02, surveyors heard R46 hollering and screaming as she proceeded down the hallways. She made the following statements: "I'm gonna cut your f---ing head off! I'm gonna cut your f--- ing throat!" Surveyors noted R46 getting in other residents faces and screaming at them. R46 walked up to one of the surveyors as R46 was waiting with a group by the elevator, put her face close to the surveyors face and began yelling.
On 7/28/02 at 12:55 PM R46 was observed walking down the hall toward the dining room, yelling loudly. Z4, day program staff, was following her. As R46 entered the dining room she grabbed a knife off of the table from another resident. R46 then ran to the north side of the dining room behind a table. R46 was screaming "Don't follow me b----". R46 was holding the knife out in front of her and waving it. Z4 was standing in front of R46 on the other side of the table and softly talking to her. R46 then threw the knife toward a group of residents sitting in the dining room and hit R68 on the arm. R46 then pushed the table over and screamed "Leave me the f--- alone". E30, LPN, then entered the dining room and R46 followed her out of the dining room. At 1:50 PM, R46 was observed walking up the stairway from the smoke area with the local police. Between the time of 12:55 and 1:50 PM, when the police arrived at the Facility, R46 continued to wander about the Facility, hollering and cursing. R46 was not accompanied or supervised by staff during this time. R46 continued to loudly curse as she and the police went down the elevator. E25 stated R46 was being sent to the hospital and the police were there to see if she would leave with them. The ambulance from the hospital was waiting at the facility.
B. R30 is a 62 year old female who resides on the second floor of the facility. A 6/18/02 Facility Incident/Accident Report states the following: 9:30 AM, res states she threw a chair through window in room 217 et used glass to cut her L arm". The Investigation of Incident form further states "On 6/18/02, 9:30 AM resident threw chair at window stated "I wanted to hurt myself". Noted multiple superficial cuts to L forearm. "Stated I wanted to cut myself with the glass". Resident was counseled 1:1 with nurse and then with psychosocial coordinator. Maintenance placed plywood covering over window. Resident placed on q 15 minute face checks remaining calm and quiet through afternoon. MD's paged after incident and again in afternoon. No new orders from medical doctor. Psych MD ordered observation of resident and if any further s/sx of risks to self to send to E.R. 4:15 PM resident states "I shouldn't have broken my window and cut myself. I couldn't stop myself, I wish I hadn't done that". Resident has made several statements over past few weeks about harming self without making any attempt".
On 6/20/02, the Facility Incident/Accident Report states the following occurred concerning R30: "7:10, nurse heard glass break, other nurse and aid ran to res room. While this nurse called security other nurse brought res out, left arm bleeding. Gash to L forearm. Adipose tissue exposed". The Facility Investigation of Incident further states "Resident broke window with chair and cut forearm with glass. She made no verbalizations after last incident of breaking window (6/18/02), of suicidal ideations. Behavior prior to incident was calm, resident sent immediately to St. Mary's ER for eval and was admitted".
C. On 7/29/02, the surveyor was approached by R12 immediately after arriving on the second floor. R12 stated "I have to get out of here today - I can't take it here - these people are all crazy and no one does anything about it". R12 further stated that his roommate is volatile and last night he had walked into their room and kicked R12 "real hard" in the knee. R12 showed the surveyor his left knee which was slightly swollen and reddened in the meniscus area. R12 stated that he went to the nurse to report what had happened and the nurse stated that they were busy and not to bother them. R12 clinical record review shows that he has Arthritis and Peripheral Vascular Disease. The incident was not investigated by the facility.
D. R74 was admitted to the facility on 2/27/98 from Z32, hospital. R74 has diagnoses, in part, of schizophrenia, paranoid personality disorder and depression. R74 was released from Z32, hospital, to the facility with the agreement he would receive mental health services from Z11, day program, secondary to his probationary status.
On 4/20/92, R74 called 911 from his sisters home and stated he "may have killed my sister" according to the history and physical from Z32, hospital. When the officers arrived at the home "there was bloody footprints on the kitchen floor, and a large pool of blood on the dining room floor. The body of R74's sister was found in the dining room floor, already dead, with numerous high velocity blood spatters on the walls, floor, and furniture, in addition to several clumps of hair and scalp laying on the floor. The clumps of the hair and scalp had been chopped from her head by an axe, which was laying next to the body." R74 stated he had been arguing with his sister which culminated in the violence. R74 was admitted to Z32, hospital, on 1/27/93. R74 received a conditional release from Z32 and was admitted to the facility on 2/27/98.
R74 attends Z22, day program, all day on Friday which is a "clubhouse" model for psycho-social rehab. Residents attend group meetings and are taught activities of daily living. R74 was noted to attend services with Z11, 2 days a week on the June, 2002 summary. R74 is not care planned for any behaviors.
E. On 7/28/02 at 11:00 AM, R37 and R46 were involved in an altercation at the 200 floor nurses station. They were loudly arguing and pushing each other. E25 was passing medications in front of the nurses station in the immediate area where R37 and R46 were arguing. There was a lot of noise and chaos with residents swarming around the medication cart. R37 turned and shoved Z3, R69 's mother, as she was walking up the hallway. Z3 fell on her back onto the ground. The surveyor could hear a "thud" when Z3 hit the floor. R37 pushed Z3 with enough force that she went sliding down the hall on her back. Staff did not intervene between R37 and R46 nor did they assist Z3. Z3 laid on the floor for several moments before standing. When she did stand, Z3 was very upset and crying and her face was red. Z3 stated R69 had been here two and a half years and she wanted to take him home "away from here". Z3 stated she had enough and left the facility. At no time did staff assess Z3 for injuries or investigate the causative factors which led to the altercation nor counsel R37 and R46.
3. The following are examples of an elopement from the facility, unalarmed doors and residents leaving the facility:
A. R8 has a diagnosis of chronic schizophrenia and depression. On 7/15/02 at 5:45 AM the police returned R8 after being found on Fox Glen Road off Route 161 approximately 6 miles from the facility. It was determined through their investigation that R8 went out the first floor dining room window. The facilities investigation report indicated that R8 had been seen by E24, Licensed Practical Nurse, at 4:30 AM. Staff were not aware that he was missing until the police returned R8 to the facility. R8 was interviewed. R8 said his wife had been in the hospital and he was sad. He said he was aware that the windows in the first floor dining room opened and knew he could leave the building through the window prior to the incident. R8 stated that he "was down and out and just wanted to get away. Wanted to go to the woods and pray for his wife." The facility took R8 to see his wife in the hospital on 7/16/02. R8 said that the facility staff and his daughter kept him informed of his wife's condition. Through interview with R8 it appeared he could recognize dangers. Under cognitive status in R8's chart he was identified as modified independence.
B. During an exterior door alarm check on 7/29/02 it was observed that an alarm did not sound when the exterior door leading to the smoking area was opened and the exterior door near the entry door to the dietary department. Unauthorized persons could have entered or left the building without notifying staff in these two locations. After addressing the concern with staff alarms were placed on these doors.
C. Residents on the second floor go downstairs and outside to an enclosed patio to smoke every two hours. Staff unalarm the second floor door on the north hall, (B Hall), to allow residents to go down a stairwell to the first floor outside patio. The door on the first floor of the stairwell that exits into the first floor hall is not alarmed. The exit in the stairwell into the patio is propped open with a chair. The outside patio is enclosed with a privacy fence. Staff take the container with the cigarettes downstairs to the patio and sit at a table and pass out the cigarettes. Residents go up and down the stairwell unsupervised during the smoking period. In addition, the elevator that is usually locked in unlocked to allow second floor residents that are to use the elevator to go to the first floor to smoke. The elevator opens onto the first floor hall and the residents leave the elevator and must walk through the first floor to exit into the stairwell that leads outside to smoke.
Observations and/or incidents of residents using the elevator or the stairwell unsupervised include:
D. There were several incidents of residents leaving the facility as follows:
4. The following are examples of illegal drug use by residents.
A. On 4/15/02 a resident grievance was submitted by R49 to Z24, former social service director. R49 stated that she thought a staff on second floor was selling residents drugs such as pot and crack cocaine. R49 stated to Z24 that she had seen residents with drugs on the second floor. This information was forwarded to Illinois Department of Public Health but no date was on the form.
In a written statement by R39 dated 4/15/02 taken verbally by E1, Administrator, he confirmed that R35 was receiving drugs from the
outside from a visitor. R39 stated that R35 and R34 smoke "almost everyday". R39 also stated "They smoke it out of a soda can with a hole on the side of it. They also have a pipe in the vent in our room which they sometimes use." R39 stated "They use pine spray to cover up the odor from security and nursing so when the window is open you can't smell it". R34 and 35 tested positive for drugs, (THC). THC is marijuana.. No police were contacted. R34 and 35 were restricted afterwards by restricting them from leaving the building and no visitors except their guardian or power of attorney. R35 has a history of substance abuse, depression and suicidal ideation.
B. R12 told the surveyor that he voluntarily checked into the facility as he was told it was a drug rehabilitation center. On 7/29/02, he told the surveyor that someone had offered him marijuana the evening before. The surveyor asked "Who offered it to you - a resident or staff member?" R12 stated "just someone up here". The surveyor asked "who?" R12 stated "I don't want to say". However, R12 did state that he has seen facility staff selling marijuana.
C. R14 stated that one of the nurses gave him drugs. He stated that she would give him other residents drugs, those residents that didn't know any better, such as Ativan, and would sign it off as being given. R14 further stated that E16 would give him drugs that were prescribed to her by her private physician, such as Xanax. R14 has diagnoses of Major Depression and Recurrent Personality Disorder. R14's most current Minimum Data Set (MDS) shows a 0 for cognition, which means he has no cognitive impairments. He has a physicians order in his clinical record which states "7/9/02, DC resident from facility, health has significantly improved, facility can no longer meet residents needs". During an interview with E1, the surveyor was told that R14 was being discharged from the facility as he tried to obtain pain killers while on an approved leave from the facility. Reportedly, based on interview with R14 and E1, E16 took pharmacy scripts from R14 for Vicodin and Valium. R14 stated that E16 said that she would have them filled for him however, four days later E16 turned the scripts in to E1 stating that R14 was threatening her, stating he would make up lies, if she didn't get his prescriptions filled. There is no evidence that the facility performed a thorough investigation of R14 allegations concerning E16. The facilities corrective action is to involuntarily discharge R14.
D. Interview with Z37, substance abuse counselor, on 7/30/02 identified that they had just started a group for drug and alcohol and he had been coming into the facility since July, 2002. The previous drug and alcohol group was discontinued a year ago due to lack of funding. R15 was admitted to the facility on 5/22/02 for alcohol rehab.
5. The following are examples of the Medication room on the 200 hall unlocked and unattended.
A. On 7/28/02 at 11:07 AM surveyor observed R32 go behind the nurses desk on 200 floor and enter the medication room. There was no staff in the med room. E25, LPN, was seated at the nurses station but did not notice R32 go into the room. R32 exited the med room before the surveyor could tell E25. E25 was not aware the med room door was open nor that R32 went into the room unattended when questioned by surveyor. R32 has diagnoses of schizophrenia and obsessive compulsive disorder. E25 locked the door. Surveyor tried the door again and the door was locked but the door opened. E30, LPN, walked up at that time and stated the door won't lock all the time and a work request was in to get it fixed because the lock was loose.
At 2:25 PM on 7/28/02 the surveyor tried the locked medication door again. The door opened when pulled. There was no staff at the nurses station. Medications were out in the medication room in bubble packs and in bottles. Some medications were in an unlocked cupboard. These medications out included: Remeron, Dilantin, Clozapine, Depakote, Trileptal, Hydrodiuril, Isosorbide, Prozac, Wellbutrin, liquid vitamins, Kaopectate, and Lactulose. At 2:35 PM E25 returned to the nurses station and was informed the medication room was not locked. E25 locked the door but at 2:40 PM E30 tried the door and it was unlocked. E30 relocked the door.
At 2:45 PM the surveyor tried the medication door again and the door opened. There were several residents wandering around the hall by the nurses station. At 2:50 PM E1, Administrator, tried the door and it opened even though the door was locked. Maintenance was immediately paged and E1 told nursing staff to monitor the door until it was fixed. At 3:03 PM E30 stated the lock had been broken since yesterday.
On entrance to the facility on 7/28/02 there were two licensed nursing staff, E25 and 30, and two direct care nursing staff, E13 and 44, on the second floor. E25 was a new employee to the facility and did not know the residents. There was one staff from the Z19, facility day program on the second floor, Z4. There was 100 residents on the second floor. Interview with staff, E13 and E44, confirmed this was the usual amount of staff during the day shift. Review of the daily schedule sheets identified that there were two direct care staff on the second floor for the 11:00 PM to 7:00 AM shift. There was usually one licensed staff for the entire building. Surveyors requested incident reports from E1, Administrator, on entrance 7/28/02. During an interview with E38, psycho-social director, on 7/31/02 at 1:25 PM regarding the note she wrote on R50 having a knife in her room it was discovered that the security department fills out separate "behavior reports" or "security incident reports". This was done for R50 who had a knife in her room. E38 stated she was aware of the knife incident because of the security report.
There was no incident report regarding the knife and R50 in the in the incident log provided by E1. At 3:40PM on 7/31/02 E37, security director, brought in the separate reports for review.
III. A description of the facility Outpatient Day Treatment Programs (Z21, 22, 23), the facility based mental health program which is not affiliated with the facility (Z19) and the facility psychosocial program is as follows:
Z19 is the facility based mental health program and has 2 to 4 staff in the facility during the 7 days a week. It was determined through an interview with the Program Director, Z9, on 7/31/02 at 10:30 A.M., that the Program consists of Group Rehabilitation Stabilization all day. In a review of the Schedule for Wednesday, July 31, 2002, Z9 gave the following descriptions of the groups: "Meal Time Skill Building", at 7:30 - 8:45 A.M., 12 Noon - 1:15 P.M., and 5 - 6 P.M., was mealtimes and Z19 staff sat in the dining room observing the Z19 Program residents; the "Community Integration" program which includes relaxation, is going outside for smoke breaks. The times are 9 A.M., 11 A.M., 1:15 P.M., with the last smoke break of the day being at 6:30 P.M., just before Z19 staff leaves the building; there are Groups listed for outings, but only if staff is available; Social Skills, during smoke break; and a variety of approximately one hour groups during the day.
There are 26 of 100 residents on the 2nd floor in Z19 Program. In an interview with Z4 on 7/31/02, 8 of the 26 residents on the list were not attending programs outside the facility. A list of residents on a list provided by Z9 on 8/1/02, did not have the same resident's on it. The Z19 Program staff could not provide any documentation showing dates and times that residents attended groups.
The Day Treatment Programs are:
a. In interviews with Director of Program Z21, (Z27), the facility residents are supposed to receive training, in part, on medications, hygiene, socialization and typing skills. No written report is sent to the facility.
b. The Director of Program Z22, (Z26), stated the residents are to receive psychiatric rehabilitation, peer support, vocational training and community resource development. No written report is sent to the facility.
c. The Director of Program Z20, (Z25), states the activities include, 1 hour of group therapy and then art therapy, life skills, pictionary for the rest of the day. The Program sends the facility a quarterly report on the resident's progress.
d. The Program Z23, is a 1 hour group therapy session with a psychiatrist (Z6). (From an interview with E45, the facility psychosocial staff.) No written report is sent to the facility.
The facility psychosocial program are programs 3 times a week for 30 to 45 minutes and include groups on anger, stress, health awareness.
The following residents were assessed on the "PAS/MH 1" as needing psychiatric rehabilitation services but are not receiving adequate services to meet their needs:
Review of R33's record showed 3 knives had been found in his room on 7/11/02. In a review of R33's Individualized Treatment Plan, it was noted that R33 has a history of verbal aggression and making homicidal threats. This information was confirmed by the Program Director for the Z19 Program, Z9. Z9 stated that R33 was being held back from his program until his psychiatrist, Z6 approved R33 leaving the facility for Day Program. Z9 stated R33 did participate in in-house Z19 programs.
In a review of residents in Day Treatment Programs submitted by the facility Program Director, Z9, he stated R33 was getting in-house programs from Z19. Both lists were checked and R33 was not on them as going to Day Program Z21. In a review of R33's Pre-Admission Screen, it was noted that the paperwork was not completed correctly. R33 has a diagnosis, in part, of Mental Retardation and Schizophrenia, but his Screen indicates Mental Health Services with his referral being to the facility. Observation of R33 on 7/28, 29 and 30, showed he was walking in the hall visiting with peers, plugged a "boom box" type music player into a wall outlet in the hall and was listening to music.
4. R28 has a history of attempted rapes. He was admitted to Z32, a State Mental facility when he was found to be unfit to stand trial for attempted rape and determined to be not guilty, by reason of insanity for attempted rape, according to the Discharge Summary from Z32. The Discharge Summary also states he has an extensive history of both verbal and physical aggression towards others. While he was at Z32, R28 attempted to rape a staff member and was transferred to a maximum security mental health facility. He was later transferred back to Z32 and then to the facility on 4/17/02. The PASARR identified R28 needs psychiatric rehabilitation services.
R28's release from Z32 stated he would attend the facility day program, Z19. In a review of R28's care plan, it stated that R28 had a history of extreme verbal/physical aggression and sexually inappropriate behavior. R28 has not attended any day programs due to low motivation. The first sheet given to surveyors from Z19 noted R28 was in the program. The sheet given to surveyors on 8/01/02 noted R28 was not in the program.
5. R11 has diagnoses of schizophrenia, major depression and Huntingtons disease. The screening for R11 was done 1/15/98 which was after the admission of 1/13/98 to the sister facility. There is no mention of Huntingtons' disease on the screen. This screen was faxed to the facility on 2/13/02. The 1/15/98 screen states that R11 did not have a severe mental illness diagnosis and no further assessment was done. The screening indicated the nursing facility services were appropriate by the Department of Rehabilitation Services.
R11 was transferred to the facility on 2/1/02 from a sister facility due to violent behavior at the sister facility. The history and physical dated 1/28/02 stated the facility could not handle R11 after he was involved in physical altercation. R11 has diagnoses, in part, of schizophrenia, major depression and Huntingtons. R11 was assessed on the MDS as modified independence for cognition and independent with activities of daily living.
R11 attends one program at the facility one day a week on relationships. R11 was involved with an incident of physical aggression with R9 on 7/6/02 where he knocked her to the floor, in the dining room, and stabbed her in the arm with a fork.
6. R12 was admitted to the facility on 7/22/02. Diagnoses listed in his clinical record are Organic Mood Disorders, Non-Insulin Dependent Diabetes Mellitus and Peripheral Vascular Disease. During an interview with R12 on 7/28 and 7/29/02, R12 told the surveyor that he had voluntarily admitted himself to the facility for drug rehabilitation. R12 stated that he had been told that the facility is a Drug Rehabilitation Center and he would receive intensive programming to help him "kick" his drug problems. R12 further stated that the drugs were now out of his system however, he had not been offered any counseling or programming since entering the facility. R12 stated that all he had done since entering the facility was sit around. He stated that he thought the facility is a negative environment for him as he had been offered Marijuana since being admitted. During an interview with E38 on 7/29/02, psych-social coordinator, the surveyor asked about programming for R12. E38 stated that they had not as yet evaluated or assessed R12 "we have 14 days to do an assessment". R12 asked the surveyor what services the facility was licensed to perform. The surveyor told R12 that the facility was a licensed Long Term Care facility. R12 stated "you mean a nursing home?" The surveyor stated "yes". On 7/30/02, R12 discharged himself from the facility and went to live with a family member. R12 told the surveyor that he would receive drug rehabilitation on an outpatient basis from a local organization. R12 was assessed on the PASARR screen as requiring psychiatric rehabilitation services.
7. R31 has diagnoses, in part, of early infantile autism, moderate mental retardation, and psychosis. A behavior tracking note in R31's clinical record stated that a male resident was found laying on top of R31 with his penis exposed. The PAS/MH 2 assessment determined that R31 does require psychiatric rehabilitation. R31 should have been referred to the DD PAS agent due to the fact she has a dual diagnosis. R31 attends a day program, Z20, Monday thru Thursday from 11:30 AM-1:30 PM. R31 was observed wandering up and down the halls of the facility numerous times during the survey. On 7/29/02 R31 was observed from 10:17 AM until 10:55 wandering up and down the halls. R31 appeared to have just awaken when she appeared in the hall at 10:17 AM. R31 appeared to have a blank or
pained expression on her face and would only answer yes or no to questions. R31 appeared disheveled in appearance. On 7/31/02 R31 was observed again wandering around the halls from 10:05 AM til 10:35 AM. The care plan dated 6/28/02 identified a problem of self isolating in her room.
8. R13 has diagnoses, in part, schizophrenia, polysubstance abuse and dependence. R13 has a history of assaultive behavior according to the annual psychiatric evaluation dated 5/17/01. R13 was admitted to the facility on 5/2/01 from another facility, Z34, who discharged him directly to the facility after he was determined to be a potential harm to others. R13 care plan dated 5/23/02 identifies R13 has a history of aggressive behavior at the last facility with the goal to have zero episodes of striking peers at the facility. The care plan also states that R13 makes threatening statements to peers about gangs and should have fewer that 3 threatening statements to peers thru the quarter. On 3/3/02 R13 was sent to the hospital after he was involved in a fight against another resident. The history and physical dated 3/3/02 states that R13 threatened to strike a nurse and another resident intervened and struck that resident. The history and physical states that R13 does "indeed have a problem with his temper and with his conduct, R13 was dismissed from a day program, Z20, on 10/22/01 due to stealing and similar behavior. The history and physical states that R13 "is on probation and I was told about three months ago that his probation office wanted to move him to Missouri, but so far nothing has happened. Because of the restrictions on probation, he cannot even go on a pass to his home. Besides, when he went on a pass about six months ago or so, it was reported that he did drink and/or use drugs". The history and physical also stated that R13 was "ready to become explosive at the slightest provocation." It stated that R13 had not been hearing voices for three to four months but before that "he had been constantly complaining about command hallucinations to kill himself or to kill other people." R13 was sent back to the facility.
The PASARR done 2/14/01 at another facility identified R13 did need psychiatric rehabilitation. R13 has not attended an outside day program since 10/22/01 due to stealing. R13 attends 4 groups in the facility and these include Coping with Mental Illness, Anger, Social Skills and Individual Living Skills.
9. R45 was admitted to the facility on 11/26/01 with diagnoses, in part, of schizophrenia, depression and alcohol abuse. The social service assessment dated 4/2/01 states "Res. cannot be assisted w/current program due to language barrier." The "Specific Level of Functioning Assessment" dated 3/30/01 states "Res. does not speak English and understands it at a minimum." On the "Short Portable Mental Status Questionnaire" dated 6/21/01 R45 "missed most questions, but his incorrect answers may be due to his lack of understanding English." R45 is Chinese. Interview with E1 on stated there was no residents in the facility that could not speak English. When asked about R45, E1 stated that he could understand some English and answer yes/no. R45 attends Z20, outside program, and two in-house programs on relationships and social skills.
Date of Survey: 8/30/02
Incident Investigation of 8/23/02
The licensee and the administrator shall be familiar with this Part. They shall be responsible for seeing that the applicable regulations are met in the facility and that employees are familiar with those regulations are met in the facility and that employees are familiar with those regulations according to the level of their responsibilities.
The facility shall develop and implement a policy concerning local law enforcement notification,
Ensuring the safety of residents in situations requiring local law enforcement notification;
Contacting police, fire, ambulance and rescue services in accordance with recommended procedures;
Seeking advice concerning preservation of a potential crime scene;
Facility investigation of the situation.
Facility staff shall be trained in implementing the policy developed pursuant to subsection (c).
The facility shall also comply with other reporting requirements of this Part.
These regulations are not met as evidenced by:
Based on record review and interviews the facility failed:
This failure placed all of the 157 residents in immediate danger.
E-1, Administrator, was interviewed on 08-27-02 at approximately 1:50pm, and E-1 stated she received a hand written note upon arriving at the facility at approximately 8:00am on 08-23-02. According to E-1 the note contained a threat of several bombs located within the facility. According to the note the devices were set to detonate at 7am, the morning of 08-23-02.
According to records received from the Local Police Department the first call reporting the threat was made at 10:50am. Police were dispatched at that time to the facility.
E-2, security supervisor, was interviewed on 08-28-02 at approximately 10:00am, and E-2 stated he had arrived at the facility at approximately 6:30am on 08-23-02. E-2 said he spoke to E-14, security officer, upon entering the facility, and that E-14 failed to mention anything to E-2 about finding the letter at 10:30pm, the previous evening.
E-2 confirmed the facility had a policy requiring all employees to report immediately to their supervisor any unusual occurrence or incident. Additionally, the policy requires that emergency 9-1-1 be called reporting any emergency situation.
E-4, receptionist, was interviewed on 08-28-02 at approximately 9:05am, and E-4 confirmed she had found the hand written note lying on the front reception desk when she arrived at work on 08-23-02 at approximately 8:00am. According to E-4, E-14 was present when she found the note, and E-14 told E-4 he had found the note the previous evening when he reported to work.
Z-1, Police Officer, was interviewed on 08-28-02 at approximately 3:50pm, and Z-1 indicated that E-1 had originally telephoned Z-1 sometime between 8:30am and 9:00am on 08-23-02, inquiring about a matter the parties had discussed several days previous. According to Z-1 it was after 3-4 minutes of conversation that E-1 "mentioned" receiving the bomb threat. E1 was advised to immediately report the treat through the proper channels (9-1-1).
During a second interview with E-1, on 08-27-02, at approximately 2:50pm, it was confirmed that E-1 had not contacted 9-1-1, according to the facility's existing policy for reporting bomb threats. Additionally, E-1 stated she never thought about evacuating the facility when she first became aware of the threat: According to E-1, she had "never evacuated patients when I was at 'a Local Hospital' and I do not intend to ever evacuate residents at this facility." According to E-1 the note indicated the bomb(s) where set to go off at 7:00am, and "it was already 8:30."
Review of the Local Police Report dated 8/28/02, and E-14's statement identified that he came to work at approximately 2230 hrs and saw the letter on the front desk, but did nothing about it. The report identified that E-16, housekeeping staff, was sitting at the front desk between 10:00pm and 10:15pm on 8/22/02, and he got bored, and wrote the ransom note indicating he would blow the building up.