| Sharon Health Care Elms Facility I.D. Number: 0032789 Date of Survey: 03/19/03 Complaint Investigation "A" VIOLATION(S): The facility shall have written policies and procedures, governing all services provided by the facility which shall be formulated by a resident Care Policy Committee consisting of at least the administrator, the advisory physician or the medical advisory committee and representatives of nursing and other services in the facility. These policies shall be in compliance with the Act and all rules promulgated thereunder. These written policies shall be followed in operating the facility and shall be reviewed at least annually by this committee, as evidenced by written, signed and dated minutes of such a meeting. The facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of the resident, in accordance with each resident’s comprehensive assessment and plan of care. Adequate and properly supervised nursing care and personal care shall be provided to each resident to meet the total nursing and personal care needs of the resident. RESIDENT AS PERPETRATOR OF ABUSE. WHEN AN INVESTIGATION OF 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. These regulations are not met as evidenced by: Based on observation, record review, and interviews, the facility failed to provide total supervision and structure to prevent 1 of 1 aggressive residents ( R6) from physically attacking other residents. The facility failed to incorporate historical transfer and admission information into the interdisciplinary approach to address R1's aggressive behavior. The facility failed to ensure that all staff were provided with a comprehensive, consistent, and proactive approach to effectively monitor and prevent R6's aggressive episodes. R6 physically attacked 3 residents (R1, R7, and R8). R7 sustained a concussion with loss of consciousness, R1 was knocked from his wheelchair, and R8 received an abrasion on his cheek when R6 hit him with a closed fist. Findings include: R6, an 83 year old resident was admitted to the facility on 12/12/02. Current physician order sheet identifies R6's diagnoses as senile dementia, rule out Alzheimer's Disease type, Chronic Urinary Tract Infections, and Diabetes Mellitus. Assessment dated 12/24/02, lists R6's height as 5 foot 7 inches, with body weight listed as 164 pounds. This same assessment notes that R6 ambulates independently and has full range of motion of all extremities. Pre admission psychiatric social history dated 9/07/02 describes R6 as having a history of 3 previous psychiatric admissions for "increased aggression". R6 is described as being previously employed as a minister and having been a boxer. The social history also notes that R6 is "volatile, aggressive, and combative". Interview with E10, psych-social counselor, on 3/6/03 and again on 3/11/03 verified that the warning signals described in the transfer papers from the hospital dated 9/7/02 "to watch for changes in facial expressions, urinary tract infections and discomfort and increased pacing" were not addressed in the current plan provided by the psych-social department nor ever mentioned in the interdisciplinary care plan. Social Service assessment notes of 12/24/02 states: “Resident wanders in facility with no purpose. Resident has displayed incidence of physical aggression–striking out at others without a rational reason/provocation; Not easily redirected." During interview with E8, Social Service Director, on 3/11/03 at 4:30 p.m., E8 verified that he "had very little contact with (R6)." E8 stated that his involvement with R6 had been limited to attempts to verify R6's cognitive status, obtain information regarding R6's background and to obtain consent information data from the family. During interview on 3/11/03 at 3 p.m. with E7, psych-social coordinator, E7 verified that the initial psych-social assessment/plan dated 12/30/02 was to address areas triggered by the assessment dated 12/24/02. The concerns noted on this assessment were "wandering, physically abusive, and resists care". According to the psychosocial assessment of 12/30/02, R6's behavior was describe as "disruptive to the therapeutic milieu of the facility. Increased anxiety in others". Behavior tracking data gathered from 12/12/02 through 12/26/02 documents that R6 was physically abusive 8 times in this time period. The goal for the "Episodic Program" was " Will have less than 16 episodes of physical abuse per month" signed by the Qualified Mental Health Professional, E12 on 1/17/03. Subsequent notation of E12 on 01/31/03 refers to the number of "physical abusive episodes" (of over 10/month) without revision to the behavior program. Interviews with R5 on 03/11/03 at 3:00 p.m. stated that R6 "is violent and likes to attack people who cannot defend themselves. He does these things without any warning. I am afraid of him." R4 on 3/11/03 at 2:45 p.m. stated that R6 "needs to be somewhere where he won't hurt anyone. I've seen him hurt other people, I am afraid of him. I tell him I love him so he leaves me alone." The facility continued to track the labile behaviors of R6 without providing an ongoing analysis to interpret the data into a meaningful individualized summation by the interdisciplinary team. The fractionalized approaches from separate departments were not compiled to make a comprehensive evaluation of the effectiveness of the approaches holistically. For example:
This lack of communication and coordination between departments was verified by the psychosocial coordinator, E7 on 03/11/03 at 3:30 p.m. and 03/06/03 at 3:00 p.m. and with E9, Occupational Rehabilitation Aide on 03/06/03 at 2:10 p.m. On January 18, 2003, a psychiatric evaluation completed by Z5, a Master Social worker, and Z6, a Psychiatrist, provided the following recommendations: "This gentleman needs supervision in all areas of his life. He obviously could not function without total supervision and structure". R6 continued to display verbal and physical abusive acts towards staff, visitors and other residents as follows: The QMHP/ Careplan Coordinator notes of 12/27/02 stated R6 "has been assaultive to others unprovoked 8 times and resists care 10 times," and for 01/31/03 stated R6 "had 10 episodes of being physically abusive. He wanders daily throughout the day." Review of the nursing notes and behavior tracking from January, 2003 through March 7, 2003 documents at least 31 separate occasions where R6 was disruptive in the facility. Examples are in the nursing notes of:
There were no care plan modifications developed by the facility to instruct their staff in providing "total supervision and structure" as recommended in the January 18, 2003 psychiatric evaluation. On January 19, 2003 at 2:30 a.m. R6 was found "standing over (R7) and stated I hit him". R7 remained "unresponsive with labored respirations" for approximately 10 minutes. R7 was transferred to a local hospital emergency room and found to have "a concussion with moderate loss of consciousness". Recommendations on the emergency room transfer form when R7 came back from the hospital 6 hours later included "watch for new or worse symptoms or concerns. Move patient so he is not the roommate of someone who assaults him." R7 expired on 01/21/03. Interviews on 03/11/03 at 9:00 a.m. and 03/19/03 at 9:30 a.m. with the County Coroner, Z3, stated R7's original death certificate of 01/22/03 was amended to include "recent head injury with a subarachnoid hemorrhage" as a part II contributing factor to the death of R7. Local police were called after the incident. Nursing noted dated 1/19/03 at 3 a.m. state that according to the police "resident had to be incarcerated because he was a danger to self and others". However, the resident was returned to the nursing facility 5 minutes after he left with the police. There were no changes to the approaches in the care plan after this incident, other than the use of recliner chair with a lap tray which was to be used "during acute periods and remove tray when calm". No individualized approaches were developed to guide direct care staff in how to use this intervention. Interview with direct care staff E13 and E14, Certified Nurse Aides and E15, Licensed Practical Nurse on 03/11/03 at 3:50 p.m. verified that they had not been in-serviced directly concerning the care to be provided to R6 to prevent R6's aggression. Resident interviews with R1, R4, and R5 on 3/06/03 between 1:30 p.m. and 2:30 p.m. confirm that on 2/23/03 they witnessed R6 knock R1 from his wheelchair unprovoked. This attack occurred in the smoking area of the facility. Z1, relative of R1, and Z2, Ombudsman, verified in interview on 03/06/03 at 9:00 a.m. and on 03/11/03 at 10:00 a.m. that R1 had related the incident to them. Z1 verified on 03/06/03 at 9:00 a.m. interview of reporting the incident to the Director of Nursing (E1) on 2/27/03. During interview with E1 on 3/5/03 at 2:00 p.m. and 3/6/03 at 10:30 a.m., E1 continued to discount the allegations made by R1 since R1 had initially told E1 that it did not happen. E1 verified that the incident was not thoroughly investigated, following all steps of the facility's abuse protocol in these interviews. According to incident report dated 3/7/03, R6 punched R8 in the face with his closed fist, while the 2 residents were in the smoking area at 9:20 a.m. Again, this physical aggression was without any provocation. R8 sustained an abrasion to his right cheek. R6 was sent to the local hospital for a psychiatric evaluation, but returned to the facility without having had any psychiatric evaluation or treatment. No changes were made to the R6's Episodic Behavior Program to address any new proactive interventions. As of 3/11/03, the facility had made no other attempts to provide R6 with a follow-up psychiatric evaluation. |