Royal Heights Nursing & Rehab Center Date of Survey:04/15/03 Notice of Violation:6/11/03 Incident Report Investigation of 04/08/03 "A" VIOLATION(S): A FACILITY EMPLOYEE OR AGENT WHO BECOMES AWARE OF ABUSE OR NEGLECT OF A RESIDENT SHALL IMMEDIATELY REPORT THE MATTER TO THE FACILITY ADMINISTRATOR. FACILITY ADMINISTRATOR WHO BECOMES AWARE OF ABUSE OR NEGLECT OF A RESIDENT SHALL IMMEDIATELY REPORT THE MATTER BY TELEPHONE AND IN WRITING TO THE RESIDENTS REPRESENTATIVE. These regulations are not met as evidenced by: Based on record reviews and interviews, the facility failed to ensure that observations of abuse are reported immediately by staff. Based on record review and interviews, the facility failed to ensure R1's Health Care Power of Attorney (HCPOA) was notified immediately of R1 being struck by an employee and of the investigation of abuse being initiated. Record review of R1 reflects an entry dated 4/8/03 at 9:00 p.m. when E6 (LPN) entered the bedroom to administer medications to R1 and found R1 in bed with his right eye purple and swollen around the diameter of the eye. Interview with E6 4/14/03 in the administrator’s office at 4:06 p.m. indicates when entering R1's room, the lights were off, but E6 could distinguish the discoloration from the doorway. E6 further related summoning another nurse to witness the area. E6 phoned E2 (Assistance Director of Operations) to come to the floor and observe R1's eye. Interview with E2 in the office 4/14/03 confirmed receiving the call from E6 and observing the area and after an initial investigation, E2 received another report from E6 indicating E7 (CNA) had witnessed E8 (CNA) striking R1 with her hand earlier in the shift and of E8's comment that she hoped she hadn’t broke his (R1's) jaw. E7 and E8 were not available to interview, but signed statements were obtained by the facility from E7 and E8 and reviewed during the survey which included E7's observations of R1 being struck by E8 on the right cheek area as retaliation for R1 striking E8 during PM care. The investigation statement by E2 further listed E7 did not report the observation of physical abuse to the nurse until questioned about the injury for fear of staff retaliation and of the chain of events occurring between 7 PM and 8 PM. Review of the Belleville Police Offense report taken by Z2 (Officer) on 4/8/03 reflects E7's, E6's and E2's account of the event. E8's time card indicates a clock out time of 8:15 p.m. 4/8/03 which is earlier than the shift ending time of 10:45 p.m. An addendum to Z2's report for 4/9/03 reflects E8's arrest and charge of Aggravated Battery. Observations made on 4/14/03 of R1 reflect a confused, elderly man with bruising still present, but dissipating of the right eye area and right cheek. R1 was alert, but unable to respond to questions appropriately. Interview with R2 (roommate) 4/14/03, indicates R2 is alert, but could not remember chain of events of 4/8/03. Record review of R1's record, indicates a Face Sheet on Admission listing Z3 as R1's HCPOA. Nursing note entries reflect attempted notification of the Physician at 9:10 p.m, attempt of notifying another facility’s staff member at 9:20 p.m., calling an ambulance at 9:40 p.m, calling St. Mary’s Hospital and giving report of R1's condition at 10:45 p.m., and notifying the HCPOA at 11:40 p.m. Interview with E6 on 4/14/03 reflects uncertainty of the HCPOA on the face sheet as a separate note is taped to the adjoining copy of the face sheet with another facility listed on it as observed by surveyor. E6 further related Z3 was notified that an investigation was being done into R1's injury, as if it was unknown, and of R1's transfer to the hospital for evaluation. The interview further related that E6 had knowledge to believe the injury was in fact a result of R1 being struck by staff as witnessed by E7 at the time of the notification, but did not relate the information in it’s entirety to Z3. Interview with E4 (Social Services Director), 4/15/03 confirmed the taped information to the face sheet was in fact a caseworker at the McFarland Mental Health Center where R1 used to reside prior to admission to this facility on 10/01/01. E4 further related (as the facility’s designated Abuse Investigative Coordinator), that as of this date, the HCPOA has not been notified by phone or in writing of the abuse investigation. Date of Survey:02/03/03 Notice of Violation:03/7/03 COMPLAINT INVESTIGATIONS “A" VIOLATION(S): General nursing care shall include at a minimum the following and shall be practiced on a 24- hour, 7-day-a-week basis: 3) Objective observations of changes in a resident's condition, including mental and emotional changes, as a means for analyzing and determining care required and the need for further medical evaluation and treatment shall be made by nursing staff and recorded in the resident's medical record. 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 RESIDENT’S 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. Based on record reviews and interviews, the facility failed to monitor R1 after being shoved backwards to the floor and R1's decline in condition which was not subsequently reported to the physician timely. Based on interviews and record reviews, the facility failed to investigate R2's assaultive behaviors as abuse, failed to immediately evaluate R2 for therapy or placement, and failed to consider the safety of the residents and employees of the facility. (R1, R8, E1, E17, E4, and E13) Findings include:
Date of Survey:2/03/03 Notice of Violation:3/7/03 COMPLAINT INVESTIGATIONS "A" VIOLATION(S): 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 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. These regulations are not met as evidenced by: Based on staff interview and clinical record review, the facility does not always ensure that residents are adequately supervised so that a resident may leave the building without the knowledge of the staff, for one of one resident on the sample (R3). Based on staff interview and record review, the facility exterior door located in the laundry room was not alarmed nor supervised, which allowed one resident (R3), to leave the facility without the knowledge of the staff. Findings include: The facility form entitled "Review of Elopement" states that on 01/11/2003, R3, a confused resident who is alert, wandered away from the Facility and was found by the local ambulance company approximately 6/10ths of a mile from the facility. R3 was last seen in the facility at 5:50P.M. and was found at 6:10P.M.. The report further states and E1 confirms that R3 always wears a coat and hat indoors and was wearing both when found on 01/11/2003. On 01/23/2003, while the surveyor was checking the door alarms in the facility accompanied by E3, Maintenance Director, the surveyor noted R3 sitting in an easy chair in the day room wearing a lightweight coat and a green baseball cap. Z1, the representative from the ambulance company who took R3 to the hospital gave the following information on the Patient Report Form : "Patient Complaint: I don't know what's wrong with me. Aps to find 79 yr male pt sitting back of police car. P.D. advised they received calls for an elderly man flagging down traffic, they advised pt to bpd then he just came from the hospital. UDA pt A&O to self pt confused and disoriented. Pt. act/said something was wrong with him and he was trying to get to hospital. Initially pt stated he had CP but later denied having CP. Pt stated he was having trouble breathing. pt denied N/V or dizziness. Pt advised he had a cough for approximately one week. Last meal was earlier today. Pt A&O to self, confused to place and time". The Facility's Administrator's Report, dated 01/11/2003, for the same incident recounts the following: "All facility alarms were tested and were found to be in working order. The alarms were re-tested again and once again were in working order. Staff reported hearing only a resident personal safety alarm go off at approximately 5:50P.M. to 6:00P.M.. Two staff attended to the resident with the personal alarm.” When the Administrator and the Building Engineer arrived at the facility, staff statements were taken. Review of statements allowed re-creation of the incident. The laundry aide was exiting and entering the laundry room door, in her duties of passing laundry on the first floor. The laundry room door was not locked. The laundry door was not alarmed. It was determined that the resident exited the restricted service hall and exited through the laundry door that was not alarmed. Facility camera tapes were reviewed and no residents were present on the tapes exiting the front door of the facility. One security guard was at the front reception desk. Another security guard was on the second floor. All employee's whereabouts were accounted for as staff on the first and second floors were assisting residents back to their rooms and addressing personal care needs. Review of R3 's most recent assessment, dated 12/12/2002 shows that he has short and long term memory problems, is moderately impaired in cognitive skills for daily decision making and is independent in ambulation. The Cognitive Loss/Dementia Resident Assessment Protocol also dated 12/12/2002, ..."Resident is pleasantly confused - has been cooperative with care. Resident has periods of forgetfulness - requires prompting". During an interview with Z2, R3 's physician, on 01/21/2003, at 11:36A.M., Z2 stated that R3 would not be aware of safety factors in his environment while he was out of the building. R3 was found approximately 6/10ths of a mile to the north/northeast of the facility walking along State Highway 161. State Highway 161 is a 4-lane highway which transects business and residential areas. It is constructed of asphalt. The speed limit in the area where R3 was located is 45 miles per hour and the traffic pattern is very busy. Royal Heights Road is located to the west of where R3 was located and 17th Street is to the east of where R3 was located. These two roads run horizontal to and intersect State Highway 161. Royal Heights Road is also a busy residential/business road which serves an area hospital. 17th Street is also a busy residential/business road. The weather conditions from the National Weather Bureau for the date of 01/11/2003 are listed as a maximum of 27 degrees Fahrenheit, a minimum of 10 degrees Fahrenheit with an average of 19 degrees Fahrenheit. There was trace amount of snowfall. R3 was taken to the hospital by the ambulance company which was called to the location by the local police. R3 was admitted to the hospital with diagnoses of pneumonia and confusion. Laboratory studies performed by the hospital on R3 on 01/12/2003 found that R3 's glucose was 189 MG/DL (normal is 70-110 MG/DL), his BUN was 32 MG/DL (normal is 7-18 MG/DL) and his Creatinine was 1.9 MG/DL (normal is 0.6-1.3 MG/DL). The surveyor interviewed E1 and E3 concerning the exterior door in the laundry room. The surveyor noted that the door is equipped with an alarm that sounds when opened however, it is not audible if there is no one present in the laundry room or on the service hallway. On 01/11/2003, when the problem was originally noted, the facility immediately corrected the problem. When staff leave the laundry room at any time the doors which open into and out of the laundry room are now kept locked. All staff were in-serviced concerning locking the laundry room doors on 01/11/2003. |