Hitz Memorial Home

Penalty

Inspection fine: $75,965

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to conduct thorough investigations into multiple allegations of sexual abuse and to protect a cognitively impaired resident from potential further abuse during and after those investigations. The resident, admitted with diagnoses including hypertension with heart failure, dementia, narcolepsy, chronic respiratory failure, and osteoarthritis, was documented as severely cognitively impaired and unable to consent to sexual advances. Hospital records and family statements indicated the resident had always been mentally slow and did not like to be touched. Despite this vulnerability, the facility did not implement protective measures after repeated staff reports of concerning interactions between the resident and a family member. The first allegation occurred when a CNA reported feeling uncomfortable after entering the resident’s room and observing the family member quickly moving his hands away from the resident’s lap/stomach area on two occasions. The written investigation from the Administrator and Social Services Director concluded no abuse occurred, relying largely on the family member’s explanation that he was startled and holding a computer, and did not document any protective interventions or assessment of the resident’s vulnerability. Later interview with the CNA revealed additional details not included in the investigation, including that the resident’s shirt was lifted exposing her breast, that the resident would not have been able to expose herself, and that the family member intervened quickly when staff attempted to adjust the resident’s clothing. No additional staff statements or corroborating documentation were included in the investigation. A second documented allegation involved staff observations of the same family member positioned very close over the resident, with the resident’s wheelchair reclined and the family member reacting abruptly when staff entered, including jumping up and requesting privacy. A dietary aide’s written statement indicated she saw the family member’s hands under the resident’s blanket and that he jumped up quickly when she entered, causing a pillow to fall. In interviews, staff described not being able to see the family member’s hands, the resident appearing shocked and jumpy, and reports that the resident cried after the family member’s visits and seemed not to want to be touched. These details, including the aide’s observation of the arm under the blanket, were not reflected in the facility’s written investigation, which the Administrator and Business Office Manager confirmed as complete. Additional allegations arose in December when a CNA reported entering the room and seeing the family member with one leg on a chair and the resident’s shirt pushed up below her breasts, with the family member stating they were playing cards and telling the CNA to leave. The CNA stated he wrote a report and left it at the nurse’s desk, and another CNA confirmed being told of this incident but did not report it herself. The Administrator and Business Office Manager acknowledged being told about the leg-on-chair incident and viewing video footage from the family’s personal camera on the family member’s cell phone, but they did not initiate a formal investigation, did not verify the date or time of the footage, and relied on the video and the family member’s denial to decide not to investigate further. Another CNA later reported seeing the family member with his leg up on the resident’s wheelchair, wearing nylon shorts, jumping back and pulling his pant leg down when she entered, and appearing very anxious; she reported this to the Business Office Manager. Throughout these events, the facility did not initiate thorough investigations, did not consistently collect and reconcile staff statements, did not verify or preserve objective evidence, and did not implement care plan interventions or protective measures to keep the resident safe from further potential abuse. The facility’s abuse policy required immediate reporting of suspected abuse to the Administrator and mandated that the Administrator or designee report abuse to the state agency per state and federal requirements, and that employees report reasonable suspicion of a crime against a resident to law enforcement. Despite this, the Administrator stated she did not begin a sexual abuse investigation when informed by the surveyor because she did not know who it involved, and acknowledged that the investigations from the earlier dates were the complete investigations. The resident’s care plan, updated shortly before the survey, addressed self-care deficits but did not include any potential for abuse or interventions to keep the resident safe. Law enforcement later indicated that a staff member reported seeing the family member drop his pants and have his penis in the resident’s face and stated that the facility needed to take action and remove the family member and find a new POA. The surveyors determined that Immediate Jeopardy began with the first allegation and that the facility failed to protect the resident from further allegations of abuse and failed to conduct thorough investigations into four separate sexual abuse allegations involving the same family member.

Removal Plan

• Issued a visitor restriction notice to V17 by the Social Services Director to ensure R42’s safety.
• Abuse Coordinating Team called V39 to inform her the visitor restriction was moved to indefinite and explained the reasons.
• Mailed the visitor restriction letter and emailed it to V17 and V39.
• Obtained email acknowledgement of receipt of the restriction.
• Informed V17 the restriction is indefinite and related to safety concerns regarding incidents.
• Administrator ordered a camera system for public areas (hallways) to aid staff/resident safety and monitor visitors.
• Implemented nursing rounds at the end of every shift to verify the resident has remained free of abuse.
• Social Services Director initiated visits with the resident twice weekly to monitor for psychosocial changes.
• Interviewed all residents and documented they reported feeling safe and free of abuse/neglect.
• Administration to round on every shift to monitor activities.
• Initiated a sexual abuse care plan for R42.
• Updated the physician (Dr. [NAME]).
• Initiated an Abuse Checklist to ensure compliance and document all required steps with abuse reporting.
• Completed all-staff in-services on the Abuse Checklist.
• Implemented a team-based approach for all investigations to ensure accuracy and completeness for each allegation received.
• Implemented the Abuse Checklist for Abuse Coordinators to use with all received documentation (including statements) to conduct thorough investigations including resident assessments and interviews.
• Re-inserviced all staff on the facility Abuse and Neglect Policy.
• Abuse Coordinators conducted random competency checks.
• Added the new Abuse Checklist to new staff onboarding.
• QAPI members to hold a monthly QAPI meeting to discuss abuse investigations, staff compliance, and staff understanding of facility policy.

Penalty

Inspection fine: $75,965

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to follow its abuse policy in preventing, reporting, and investigating multiple allegations of possible sexual abuse involving one resident. The resident was admitted with diagnoses including hypertension with heart failure, dementia, narcolepsy, chronic respiratory failure, primary osteoarthritis, and was documented as severely cognitively impaired with a self-care deficit. Hospital records noted that a family member reported the resident had always been mentally slow and did not like to be touched. Despite this condition and vulnerability, the facility did not consistently treat staff reports of concerning interactions between the resident and a family member as abuse allegations requiring full investigation and reporting. In one prior incident, a CNA reported entering the resident’s room and observing the family member quickly moving his hands away from the resident’s lap/stomach area on two occasions, which made the CNA uncomfortable. This incident was reported to the Social Services Director and Administrator, who notified the Ombudsman, Medical Director, local police, and the resident’s POA. The facility’s investigation concluded that no abuse occurred, based on the CNA’s statement that she did not actually see inappropriate touching. In a separate incident, two CNAs reported that when they entered the resident’s room to obtain vitals, the family member jumped, grabbed an electronic device, told them to come back later because they were busy, and was again observed standing over the resident with his hands down by her wheelchair, jumping when they entered. Police, Adult Protective Services, the Medical Director, POA, and Ombudsman were notified, and both external agencies stated there was no evidence of abuse; the facility deemed the allegation unfounded. Later, additional staff reports in December described further concerning observations that were not handled in accordance with the facility’s abuse policy. One CNA stated she entered the room to get a mechanical lift and saw the family member standing next to the bed with one leg on a chair and the resident’s shirt pushed up below her breasts; the family member was rude, said they were playing cards, and told her she did not need to be there. She reported this to the Administrator and wrote a statement, but the Administrator later stated she never received the written statement. Another CNA reported seeing the family member with his leg up on the resident’s wheelchair, pant leg up to his thigh, wearing nylon shorts, and jumping back anxiously when she entered; she reported this to the Business Office Manager. The Administrator and Business Office Manager acknowledged being told that the family member had his leg on a chair and jumped back when staff entered, but stated they were told no body parts were exposed. They did not initiate a formal investigation, did not verify or preserve the date and time of the video footage shown on the family member’s personal device, and did not report the December concerns as abuse allegations, despite the facility’s policy and state rules requiring immediate reporting of suspected abuse or reasonable suspicion of a crime against a resident. The facility’s abuse policy requires that any employee or volunteer who becomes aware of abuse, mistreatment, neglect, exploitation, or misappropriation immediately report it to the Administrator, and that the Administrator or designee report abuse to the state agency per state and federal requirements. Nursing Home 1150B Rules and Regulations further require all employees to report any reasonable suspicion of a crime committed against a resident by calling 911 or the county sheriff. In the December incidents, the Administrator and Business Office Manager relied on unverified video footage from the family member’s personal cell phone, did not confirm the recording’s date or time, did not conduct or document a complete investigation, and did not treat the staff reports as reportable abuse allegations. These actions and omissions demonstrate the facility’s failure to implement its abuse prevention, reporting, and investigation policies for this resident.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a Registered Nurse (RN) was employed with a current and active license, resulting in the RN working unlicensed upon hire. The RN, identified as V4, was found to have an expired license during a background check review. Despite the facility's policy requiring verification of board registrations and certifications before employment, V4 was hired and worked 35 shifts without a valid license. The Administrator, V1, admitted to conducting the background check but overlooked the expiration date on V4's RN license. V4 believed she had renewed her license but could not provide a receipt, and upon contacting the Illinois Department of Financial and Professional Regulation, it was confirmed that the renewal was not processed due to non-payment. During the period V4 worked unlicensed, she administered medications to residents R2, R3, R4, and R5, as documented in their Medication Administration Records (MARs). The facility's staffing included two nurses and five CNAs for day and evening shifts, with V4 working on Hall-Two. The facility's policy on employee screening and training mandates that licensed staff must not have disciplinary actions against their licenses, and criminal background checks are required. However, the oversight in verifying V4's license status led to her working without a valid license, contrary to the facility's policy and state regulations.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to prevent verbal and physical abuse and neglected to accurately assess a resident for injury prior to initiating a transfer. This incident involved a resident, identified as R99, who was admitted with multiple diagnoses including osteoporosis, anxiety, and post-traumatic stress disorder. On the day of the incident, R99 attempted to self-transfer from her recliner and fell, subsequently complaining of right hip pain. Despite these complaints, the attending LPN, identified as V5, did not conduct a proper assessment before transferring the resident back to her chair, which was done in a rough manner, causing further distress to the resident. Witnesses, including a CNA identified as V9, reported that V5 used inappropriate language and displayed aggressive behavior towards R99. V5 reportedly told the resident, "I'm tired of your s**t. If you don't like it, you can go home," and proceeded to lift the resident by her arms without assessing her condition. This action was perceived as abusive by the CNA, who immediately reported the incident to the facility's administration. The resident expressed fear and requested the police and an ambulance, indicating the level of distress caused by the incident. The facility's policy clearly states that residents should be free from abuse and neglect, and any suspicion of abuse should be reported immediately. However, the report indicates that the police were not called, and there was a delay in addressing the resident's request for medical evaluation. The facility's investigation revealed conflicting accounts of the incident, but the decision was made to terminate the LPN involved. The report highlights a failure in adhering to the facility's abuse and neglect policy, resulting in a deficiency in the care provided to the resident.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to employ a full-time Director of Nursing (DON), which has the potential to affect all 43 residents residing in the facility. On September 9, 2024, the administrator, identified as V1, stated that she had been performing the duties of the DON since February 2024 due to the inability to hire a qualified candidate. The facility had been actively searching for a DON but faced challenges, such as candidates requesting a salary of $70 an hour, which the facility could not accommodate. V1 reported working 65-70 hours a week to manage care plans and other DON responsibilities. During the investigation, no observations of a DON were made, and the facility's Quality Assurance Members list did not include a staff member designated as the DON.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to follow a physician's order for wound dressing for a resident with multiple medical conditions, including severe cognitive decline and dependency on staff for all care. The resident, who has a history of picking at their skin, was observed with an umbilicus wound open to air and creamy white drainage, contrary to the physician's order to cleanse the wound, apply xeroform, and cover it with a dry dressing. Staff members, including a CNA and an RN, acknowledged that the resident often removes the dressing, and the wound care orders were not consistently followed, as evidenced by the missing dressing on the morning of the observation. The resident's progress notes documented ongoing issues with the umbilicus wound, including measurements and descriptions of the wound bed and drainage. Despite the physician being aware of the resident's behavior of removing dressings, the facility did not ensure adherence to the prescribed wound care regimen. The facility's policy for skin issues and pressure ulcers requires documentation of all skin concerns, but the report highlights a lapse in following the treatment orders as written, contributing to the deficiency.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to adhere to its Abuse and Neglect Policy, resulting in an incident involving a resident, identified as R99, who experienced both verbal abuse and neglect. R99, who was moderately cognitively impaired and required substantial assistance for chair transfers, fell while attempting to self-transfer from her recliner. A Certified Nursing Assistant (CNA), identified as V9, witnessed the incident and reported that a Licensed Practical Nurse (LPN), identified as V5, responded inappropriately by verbally abusing R99 and physically mishandling her by lifting her roughly by the arms without assessing her condition. The incident was further compounded by the facility's failure to notify the appropriate authorities as required by their policy. Despite R99's requests for police and ambulance assistance, these were not immediately acted upon. The CNA reported the incident to the Assistant Director of Nursing (ADON), but the local police were not informed, which is a breach of the facility's policy that mandates reporting any reasonable suspicion of a crime against a resident to law enforcement. The situation was exacerbated by conflicting accounts from staff and witnesses. While the CNA and a family member reported the LPN's abusive behavior, the resident's roommate and the LPN provided differing accounts, suggesting no abuse occurred. Despite these conflicting reports, the facility's administration recognized the inappropriate nature of the LPN's actions and the failure to follow protocol, leading to the LPN's suspension and eventual termination. However, the lack of immediate action to protect the resident and report the incident to authorities highlights a significant deficiency in the facility's handling of abuse and neglect cases.