STATE OF MICHIGAN DEPARTMENT OF HUMAN SERVICES

Transcription

1 STATE OF MICHIGAN DEPARTMENT OF HUMAN SERVICES BUREAU OF CHILDREN AND ADULT LICENSING JENNIFER M. GRANHOLM GOVERNOR ISMAEL AHMED DIRECTOR January 28, 2008 Amy Borzymowski Alterra Healthcare Corporation 3100 Old Centre Avenue Portage, MI RE: License #: Investigation #: AH A Wynwood of Portage, a Brookdale Community Dear Ms. Borzymowski: 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 facility s authorized representative 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, Patricia J. Sjo, Licensing Staff Bureau of Children and Adult Licensing Garfield Clinton Township, MI (586) Enclosure cc: D. Gajeski P.O. BOX LANSING, MICHIGAN (517)

3 MICHIGAN DEPARTMENT OF HUMAN SERVICES BUREAU OF CHILDREN AND ADULT LICENSING SPECIAL INVESTIGATION REPORT I. IDENTIFYING INFORMATION License #: Investigation #: AH A Complaint Receipt Date: 10/05/2007 Investigation Initiation Date: 10/05/2007 Report Due Date: 11/04/2007 Licensee Name: Alterra Healthcare Corporation Licensee Address: Suite West Washington St. Milwaukee, WI Licensee Telephone #: (810) Administrator: Authorized Representative/ Name of Facility: Facility Address: Daniel Gajeski Amy Borzymowski Wynwood of Portage, a Brookdale Community 3100 Old Centre Avenue Portage, MI Facility Telephone #: (269) Original Issuance Date: 10/01/1998 License Status: REGULAR Effective Date: 10/18/2005 Expiration Date: 10/17/2006 Capacity: 72 Program Type: AGED 1

4 II. ALLEGATIONS A resident's physician was not immediately notified when she injured her finger. A resident did not receive prompt medical care for her injured finger. III. METHODOLOGY 10/05/2007 Special Investigation Intake 2008A /05/2007 Special Investigation Initiated - Telephone Interviewed administrator, Daniel Gajeski, and the health care coordinator about an incident report they submitted on 10/3/07. 10/05/2007 Contact - Document Received Resident A's progress notes and two employees statements received from the facility. 10/09/2007 Referral - Protective Services Telephone call to Kalamazoo County Department of Human Services Adult Protective Services (APS). 10/10/2007 Contact - Telephone call made Interviewed Mr. Gajeski. 10/10/2007 Contact - Telephone call made Interviewed Resident A's authorized representative. 10/10/2007 Contact - Telephone call received Interviewed a direct care staff person. 10/10/2007 Referral - Other In telephone call to the Department of Community Health, Bureau of Health Systems, Hospital and Special Services, I informed two hospice licensing officers of the hospice nurse's actions with Resident A. 10/10/2007 Exit Conference with Mr. Gajeski. 10/10/2007 Exit Conference given in voic message left for the facility's authorized representative, Kelly Rubin. 01/23/2008 Comment: my area manager informed me that Amy Borzymowski is now the facility s authorized representative. 2

5 ALLEGATION: A resident's physician was not immediately notified when she injured her finger. INVESTIGATION: Resident A is age 101. On 10/3/07, the facility submitted an incident report that Staff 1 noticed Resident A's right hand was swollen and bruised at 6:30 p.m. on 10/1/07; Resident A told Staff 1 that it happened at a doctor s appointment when she caught her fingers in a belt loop; Resident A s physician was notified at 6:34 p.m. on 10/1/07. The facility s nurse stated that a mobile x-ray found Resident A s right hand was fractured where the ring finger meets the hand. Resident A s progress notes document that on 10/1/07, Resident A s right hand was swollen, bruised, and painful, and Resident A said it happened in the car. When informed, Resident A s physician ordered an x-ray. When notified of the x-ray results on 10/2/07, Resident A s physician ordered that the hospice nurse put a splint on Resident A s hand. Resident A s authorized representative was updated on Resident A s condition. When Resident A s authorized representative visited at 1:00 p.m. on 10/2/07, he said that he knew Resident A had hand pain the day before when Resident A was getting out of the car. Resident A s hand continued to be swollen on 10/3/07. The hand splint arrived on 10/4/07, and a hospice nurse put it on her hand. When staff tried to put the splint on her hand on 10/5/07, Resident A said No, I hate it. The third finger on her right hand continued to be swollen and bruised. Starting on 10/2/07, staff elevated Resident A s hand and provided Tylenol, as ordered by her physician. According to Staff 2 s written statement, Resident A resisted getting out of her authorized representative s car when returning to the facility at 11 a.m. on 10/1/07. Staff 2 observed Resident A s hospice nurse and Staff 3 trying to get Resident A out of the car. Staff 3 got in the driver's side of the car to help Resident A sit up. Staff 2 went to the passenger side of the car and put her arms around Resident A's waist to help her out of car. Resident A yelled and was combative. The hospice nurse yelled Resident A's name and told her to stop. When Resident A started putting her arm up like she was going to hit, the hospice nurse used both of her hands to grab Resident A's right arm and right hand, and pulled on Resident A to get her to sit up more. Resident A screamed when this was done and told the hospice nurse that she hurt her finger. Resident A started crying and said that her finger was broken. According to Staff 3 s written statement, she was helping Resident A s authorized representative get Resident A out of his car on 10/1/07 when Resident A s hospice 3

6 nurse came up behind to help. Then Staff 2 arrived to help. Staff 3 went to the driver s side of the car and helped Resident A sit up. Staff 2 came around to get her out of the car. Resident A was combative. The hospice nurse yelled at Resident A saying, Stop, you are fine. As Staff 2 and Staff 3 were trying to get Resident A out of the car, the hospice nurse started to pull on her right arm and hand. [Resident A] yelled, Ouch, you are breaking my finger. After she got out of the car, Resident A continued crying about her finger. Resident A s authorized representative took her to her room to calm her down. The hospice nurse said she would come back and check on Resident A. Resident A s authorized representative stated that Resident A has a bad knee due to subluxation, so it is always difficult for her to transfer in and out of a car. Resident A uses a wheelchair for mobility because she cannot stand for long due to her bad leg, and she has a history of body aches from arthritis. Resident A s authorized representative related the same story of the events of 10/1/07 as provided by Staff 2 and Staff 3. He said that he tried getting Resident A out of the car on 10/1/07, but she would not move. After waiting a long time, he went inside to obtain staff assistance. He added that he did not know who injured Resident A s hand, but he thought it happened when she was getting out of his car. Resident A s authorized representative stated that under the circumstances, the staff did a good job of getting Resident A out of the car. He said that Resident A was unusually upset and confused that day. She was not her usual self, probably because she had a urinary tract infection. She was confused and rambling, talking more than unusual while at the doctor appointment the morning of 10/1/07. Resident A s authorized representative stated that Resident A immediately said that her hand hurt while still at the car. After she got out of the car, Resident A s authorized representative stayed with her for a while in her room and visited again later in the day on 10/1/07. Resident A kept saying that her hand hurt, and Resident A only complains if she has a real problem. He stated that Resident A is alert and cooperative, and she told him that her finger got broken while fighting in the car. He volunteered that Resident A loves this hospice nurse, and the nurse is very good. Resident A s authorized representative stated that he did not have an opinion on whether Resident A received prompt medical treatment for her injured hand. He said that her fingers should not have been pulled. Staff 2 s written statement included that the hospice nurse was being completely inappropriate the way she was talking with [Resident A] and when she grabbed her" and that the hospice nurse "was just escalating the problem and getting [Resident A] more upset". Staff 3 s written statement included that the hospice nurse s yelling made everything worse. Staff 2 stated that Resident A screamed whenever staff tried to examine her hand after the altercation in the car on 10/1/07. Staff 2 stated that Resident A 4

7 exaggerates, saying that staff try to poison her when giving her pills, and she has been more confused lately. Resident A s hand did not look out of joint or injured, and it was not swollen when Staff 2 got off duty at 2-2:30 p.m. on 10/1/07. The facility's nurse stated that she counseled Staff 2 that she should have immediately reported that Resident A said her finger was injured. APPLICABLE RULE R Reporting of incidents, accidents, elopement. (3) The home shall report an incident/accident to the department within 48 hours of the occurrence. The incident or accident shall be immediately reported verbally or in writing to the resident's authorized representative, if any, and the resident's physician. ANALYSIS: Resident A s physician was not immediately notified when Resident A said her hand was injured on the morning of 10/1/07. Resident A said her finger was broken at 11 a.m., and her physician was notified at 6:34 p.m. Repeat violation established [Reference the Licensing Study Report for 3/21/07 and Special Investigation Report 2007A of 5/07] CONCLUSION: VIOLATION ESTABLISHED ALLEGATION: A resident did not receive prompt medical care for her injured finger. INVESTIGATION: Staff 2 stated that she did not think that Resident A was injured on 10/1/07. Resident A often said she had a problem when she did not. Staff 2 did not see any injury on Resident A between 11 a.m. and 2:30 p.m. on 10/1/07. Mr. Gajeski stated that although Resident A said her finger was broken, Resident A s hospice nurse said there was no injury. Staff 2 was the supervisor of resident care during the day shift on 10/1/07. 5

8 APPLICABLE RULE MCL Policy describing rights and responsibilities of patients or residents; adoption; posting and distribution; contents; additional requirements; discharging, harassing, retaliating, or discriminating against patient exercising protected right; exercise of rights by patient's representative; informing patient or resident of policy; designation of person to exercise rights and responsibilities; additional patients' rights. (1) A health facility or agency which provides services directly to patients or residents and which is licensed under this article shall adopt a policy describing the rights and responsibilities of patients or residents admitted to the health facility or agency. Except for a licensed health maintenance organization which shall comply with section 21086, the policy shall be posted at a public place in the facility and shall be provided to each member of the facility staff. Patients or residents shall be treated in accordance with the policy. For Reference MCL ANALYSIS: CONCLUSION: (2) The policy describing the rights and responsibilities of patients or residents shall include: (e) A patient or resident is entitled to receive adequate and appropriate care, and to receive, from the appropriate individual within the facility, information about his or her medical condition, proposed course of treatment, and prospects for recovery, in terms that the patient or resident can understand, unless medically contraindicated as documented by the attending physician in the medical record. The hospice nurse said that Resident A s hand was not injured. Staff 2 did not observe any injury to Resident A. VIOLATION NOT ESTABLISHED 6

9 IV. RECOMMENDATION Contingent upon receipt of an acceptable corrective action plan, it is recommended that the status of the license remain unchanged. Patricia J. Sjo Licensing Staff 1/24/08 Date Approved By: 1/25/08 Betsy Montgomery Date Area Manager 7