State of Michigan DEPARTMENT OF HUMAN SERVICES

Transcription

1 RICK SNYDER GOVERNOR State of Michigan DEPARTMENT OF HUMAN SERVICES BUREAU OF CHILDREN AND ADULT LICENSING MAURA D. CORRIGAN DIRECTOR June 10, 2011 Kathleen Swantek Blue Water Developmental Housing, Inc. Ste Gratiot Marysville, MI RE: License #: Investigation #: AS A Oak Leaf Dr Dear Mrs. Swantek: Attached is the Special Investigation Report for the above referenced facility. Due to the violations identified in the report, a written corrective action plan is required. The corrective action plan is due 15 days from the date of this letter and must include the following: How compliance with each rule will be achieved. Who is directly responsible for implementing the corrective action for each violation. Specific time frames for each violation as to when the correction will be completed or implemented. How continuing compliance will be maintained once compliance is achieved. The signature of the responsible party and a date. If you desire technical assistance in addressing these issues, please feel free to contact me. In any event, the corrective action plan is due within 15 days. Failure to submit an acceptable corrective action plan will result in disciplinary action. P.O. BOX LANSING, MICHIGAN (517)

2 Please review the enclosed documentation for accuracy and feel free to contact me with any questions. In the event that I am not available and you need to speak to someone immediately, please feel free to contact the local office at (586) Sincerely, Karen LaForest, Licensing Consultant Bureau of Children and Adult Licensing Garfield Clinton Township, MI (586) enclosure P.O. BOX LANSING, MICHIGAN (517)

3 I. IDENTIFYING INFORMATION MICHIGAN DEPARTMENT OF HUMAN SERVICES BUREAU OF CHILDREN AND ADULT LICENSING SPECIAL INVESTIGATION REPORT License #: Investigation #: AS A Complaint Receipt Date: 05/27/2011 Investigation Initiation Date: 05/31/2011 Report Due Date: 07/26/2011 Licensee Name: Blue Water Developmental Housing, Inc. Licensee Address: Ste Gratiot Marysville, MI Licensee Telephone #: (810) Administrator: Licensee Designee: Name of Facility: Facility Address: Kathleen Swantek Kathleen Swantek Oak Leaf 3405 Oak Leaf Fort Gratiot, MI Facility Telephone #: (810) Original Issuance Date: 11/19/1993 License Status: REGULAR Effective Date: 06/04/2010 Expiration Date: 06/03/2012 Capacity: 6 Program Type: PHYSICALLY HANDICAPPED CLF/DD 1

4 II. ALLEGATION(S) Resident A was confined to a recliner, restricting movement by a gait belt connected around her waist. III. METHODOLOGY 05/27/2011 Special Investigation Intake 2011A /31/2011 Special Investigation Initiated - Telephone Spoke to area supervisor of the corporation regarding details of allegations. 05/31/2011 Contact - Telephone call made Left message for area supervisor regarding an on-site investigation date. 06/01/2011 Contact - Telephone call made Interviewed complainant via telephone. 06/08/2011 Inspection Completed On-site Conducted on-site investigation with ORR advisor and interviewed several employees and reviewed documentation. 06/08/2011 Inspection Completed-BCAL Sub. Compliance 06/08/2011 Exit Conference Conducted a telephone exit conference with Ms. Swantek. ALLEGATION: Resident A was confined to a recliner, restricting movement by a gait belt connected around her waist. INVESTIGATION: The recipient rights officer and I conducted an onsite investigation at the facility on June 8, We interviewed Employees 1, 2, 3, 4, 5, 6, and 7. Resident A was not interviewed due to her level of cognitive functioning impairment and lack of verbal skills. According to the complainant via telephone conversation on June 1, 2011, Resident A, who was recently admitted to the group home as a new placement in April of 2011, was in a recliner chair in the living room area and had a gait belt fastened around her waist prohibiting her from getting out of the chair. The incident was 2

5 reported on May 27, 2011 by the complainant who arrived at the home for an unannounced visit on the morning of May 27, I interviewed the complainant on June 1, 2011 via telephone. The complainant reported that around 8:30 am on May 27, 2011 she knocked on the facility front door and Employee 3 answered the door but appeared to be blocking the entrance way into the home as to not allow her to enter. The complainant stated that she could observe Resident A sitting in a recliner with a gait belt secured around her and it appeared to be attached to the back of the recliner. The complainant stated that the resident was attempting to get out of the recliner. The complainant then stated that Employee 3 went over to the recliner, reached over Resident A and released the gait belt in which Resident A immediately got up and was walking around. When the complainant asked Employee 3 what was this (meaning Resident A in the recliner with the gait belt around her) the complainant stated Employee 3 responded by saying I put her in for a second; I didn t want her to trip over the wheelchair. The complainant stated she witnessed that one staff was getting the laundry and another staff was sitting at the table eating breakfast and Employee 3 stated that Resident A would grab her food. Employee 3 told the corporate area supervisor, who arrived at the home as soon as he was aware of what occurred, that the midnight employee, Employee 1, placed Resident A in the recliner when she awoke early because she was attempting to hit other residents in the home and that Employee 1 felt it was best to keep Resident A in the recliner with the gait belt around her. The area supervisor reported that although Resident A was having behaviors and that staff thought for other residents safety, that this was a way to handle the situation, he stated that it is the corporate policy that any restriction of movement of a resident is prohibited and that using the gait belt in that manner is not justifiable. The complainant reported that Resident A does have behavioral problems such as grabbing at others, pulling hair and stealing food, doing this for attention, but stated she does not have severely aggressive behaviors such as biting, pushing or pulling or leaving injuries on others. On June 8, 2011 I went to the Oak Leaf home accompanied by the recipient rights officer to interview all employees involved. Employee 1 was interviewed and stated that on the midnight shift of May 27, 2011, Resident A got up early and was attempting to hit and pull the hair of other residents and throw plates. He decided to place the gait belt loosely around Resident A s waist in the recliner chair to prevent her behaviors and for the safety of the other residents. Employee 1 stated that Resident A did not make attempts to get out of the chair. He stated he did this around 6:55 am and that he has never done this before. Employee 1 stated that the home will place a gate between the kitchen and dining room because Resident A will not only grab food but will touch the hot stove during meal preparation times. Employee 2 was interviewed by the recipient rights officer and I on June 8, 2011 at the group home. Employee 2 stated that on the early morning of May 27, 2011, she heard Resident A go into the bedroom of the other two female residents and when Employee 2 ran to the other resident s bedroom, she found Resident A was going to 3

6 hit one of the other residents. Employee 2 stated she intervened and Employee 1 came to redirect Resident A and Employee 2 stated that Employee 1 agreed to handle Resident A. Employee 2 stated she comforted the other residents who were upset and crying. Employee 2 stated that Employee 1 could not control Resident A s behavior and she did see that he had secured a gait belt around her in the recliner chair. Employee 2 was asked if she questioned Employee 1 on this procedure and she stated she did not. Employee 3 was interviewed by the recipient rights officer and I on June 8, 2011 at the home. According to Employee 3, she arrived at the home at approximately 8:00 am and Employee 4 and Employee 5 were already present as the day shift employees arriving at 7:00 am. Employee 3 stated that she observed Resident A with the gait belt around her waist as Resident A sat in the chair and thought why would someone do this? Employee 3 stated that as she was about to unfasten the gait belt, the telephone rang and she answered it and then the door bell rang with the supports coordinator at the door. Employee 3 stated that she did not attempt to block the support coordinator s view but was surprised she was there for a visit. When she let the supports coordinator into the house, Employee 3 stated she then went over to Resident A and unfastened the gait belt to let her out of the chair. Employee 3 stated that she did not place the gait belt around Resident A and fasten it, that she was in the chair in this position when she arrived. Employee 3 did not know how long Resident A had been in the chair but stated that Employee 1 left at 7:00 am so it would have been at least an hour. Employee 3 stated she had let her manager know of the situation. On June 8, 2011, the recipient rights officer and I interviewed Employee 4 at the group home. Employee 4 stated she arrived to work the morning of May 27, 2011 at 7 am. Employee 4 stated that she did observe Resident A with the gait belt around her and she did not remove it and did not ask Employee 1 why this was fastened around Resident A s waist while in the chair. Employee 4 stated that Resident A was smiling and not attempting to get out of the chair. Employee 4 further reported that the previous afternoon shift, Employee 6, who she worked with, had placed Resident A in the chair and placed the belt around her but that Resident A was attempting to get up. Employee 4 stated she told Employee 6 you cannot do that, take off the belt and Employee 4 stated that Employee 6 immediately removed the belt. Employee 4 stated these are the only two times she observed the gait belt secured around Resident A. On June 8, 2011 the recipient rights officer and I interviewed Employee 5 at the group home. According to Employee 5, the gait belt was loosely fastened around Resident A while she was in the chair when Employee 5 arrived at 7:00 am. Employee 5 stated that Employee 1 left and said nothing about Resident A and that Resident A was just sitting there playing with the belt and that she did not think anything of this and thought this was an approved procedure. Employee 5 stated she is a substitute staff and has only worked twice with Resident A. 4

7 The recipient rights officer and I interviewed Employee 6 on June 8, Employee 6 was told to come to the facility because Employee 4 stated to the interviewers that Employee 6 tied the belt around Resident A the afternoon shift of May 26, Employee 6 stated that he has never done this and at times, the other staff target him and make false accusations. He stated that the most he has done is block Resident A with his leg by lifting it when Resident A would attempt to go and grab other residents food. The recipient rights officer and I interviewed Employee 7 on June 8, 201. Employee 7 stated she discovered later that morning what had occurred with Resident A and stated that she thought staff were doing this for the safety of other residents but it is not an acceptable technique. Employee 7 stated that Resident A is new to the home and staff in the home are not familiar with how to deal with a resident who has behavioral problems. Employee 7 stated she has a meeting with the assigned psychologist to develop a behavioral plan and has some ideas that have been positive and have worked with Resident A (i.e. dancing, rubbing her arm gently, hugging, etc.). Employee 7 also stated that Resident A s medications need to be stabilized so that her behaviors can be better controlled. Employee 7 informed me that an in-service is planned for all of the staff on the use of assistive devices vs. use of restraints by recipient rights. The corporate area supervisor met with the recipient rights officer and me on June 8, 2011 at the group home. I informed him of licensing rules I am substantiating and the need for a corrective action plan. He agreed he would work on correcting the situation and preventing future episodes of this nature. I reviewed the behavioral charts of Resident A and the recipient rights officer stated that the home should have been completing incident reports and should have submitted them to rights so that they could identify Resident A s behaviors and secure the services to address them for the group home. I also informed each staff during my interviews that licensing does not permit a resident to be tied with a belt or any other material in order to restrict a resident s freedom of movement. APPLICABLE RULE R Use of assistive devices. (1) An assistive device shall only be used to promote the enhanced mobility, physical comfort, and well-being of a resident. 5

8 ANALYSIS: CONCLUSION: Based upon the findings of this investigation, Employee 1 did tie Resident A with a gait belt for the purpose of restricting her movement due to her behaviors and for the protection of other residents. The other employees who observed Resident A tied with a gait belt did not question or intervene to release her from the gait belt. This was not used for physical comfort, enhanced mobility or well-being of Resident A, therefore the above rule violation is substantiated. VIOLATION ESTABLISHED APPLICABLE RULE R Resident behavior interventions generally. (2) Interventions to address unacceptable behavior shall be specified in the written assessment plan and employed in accordance with that plan. Interventions to address unacceptable behavior shall also ensure that the safety, welfare, and rights of the resident are adequately protected. If a specialized intervention is needed to address the unique programmatic needs of a resident, the specialized intervention shall be developed in consultation with, or obtained from, professionals who are licensed or certified in that scope of practice. ANALYSIS: CONCLUSION: The use of the gait belt secured around Resident A is not an approved technique in Resident A s written assessment plan and did not ensure her safety, her welfare and the protection of her rights. There is no behavioral plan to address Resident A s unacceptable behaviors. VIOLATION ESTABLISHED APPLICABLE RULE R Resident behavior interventions prohibitions. (2) A licensee, direct care staff, the administrator, members of the household, volunteers who are under the direction of the licensee, employees, or any person who lives in the home shall not do any of the following: (c) Restrain a resident's movement by binding or tying or through the use of medication, paraphernalia, contraptions, material, or equipment for the purpose of immobilizing a resident. 6

9 ANALYSIS: CONCLUSION: Employee 1 admitted to using a gait belt to maintain Resident A in the recliner chair by having it fastened in the back of the chair so that Resident A was unable to get out of the chair. Employees 2, 3, 4, and 5 were complacent and did not question the use of the gait belt on Resident A nor did they release her from the fastened gait belt. Employee 3 did release Resident A from the gait belt upon arrival of the Support Coordinator from Community Mental Health that morning. VIOLATION ESTABLISHED On June 8, 2011 I conducted a telephone exit conference with Kathleen Swantek and informed her of the substantiated rule violations. She stated that they had already begun to work on a corrective action plan to ensure there are no future incidents of this nature. I asked if she had any questions and she stated she did not. IV. RECOMMENDATION Upon receipt of an acceptable plan of correction, the status of the license will remain unchanged. 6/9/2011 Karen LaForest Date Licensing Consultant Approved By: 6/10/2011 Denise Y. Nunn Date Area Manager 7