RICK SNYDER GOVERNOR State of Michigan DEPARTMENT OF HUMAN SERVICES BUREAU OF CHILDREN AND ADULT LICENSING MAURA D. CORRIGAN DIRECTOR November 7, 2014 Kathy Dunbar Sunrise of North Farmington Hills 29681 Middlebelt Road Farmington Hills, MI 48334 RE: License #: Investigation #: AH630263159 2014A1005027 Sunrise of North Farmington Hills Dear Ms. Dunbar: 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. P.O. BOX 30650 LANSING, MICHIGAN 48909 www.michigan.gov (517) 284-9700
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. Sincerely, Lilly Anne, Licensing Staff Bureau of Children and Adult Licensing 4th Floor, Suite 4B 51111 Woodward Avenue Pontiac, MI 48342 (248) 860-0965 enclosure P.O. BOX 30650 LANSING, MICHIGAN 48909 www.michigan.gov (517) 284-9700
MICHIGAN DEPARTMENT OF HUMAN SERVICES BUREAU OF CHILDREN AND ADULT LICENSING SPECIAL INVESTIGATION REPORT I. IDENTIFYING INFORMATION License #: Investigation #: AH630263159 2014A1005027 Complaint Receipt Date: 09/09/2014 Investigation Initiation Date: 09/12/2014 Licensee Name: Twenty Pack Management Corp. Licensee Address: Suite 304 1701 Highway A1A Vero Beach, FL 32963 Licensee Telephone #: (772) 492-5002 Administrator: Authorized Representative/ Name of Facility: Facility Address: Kathy Dunbar Kathy Dunbar Sunrise of North Farmington Hills 29681 Middlebelt Road Farmington Hills, MI 48334 Facility Telephone #: (248) 538-9200 Original Issuance Date: 02/02/2004 License Status: REGULAR Effective Date: 02/05/2014 Expiration Date: 02/04/2015 Capacity: 75 Program Type: ALZHEIMERS AGED 1
II. ALLEGATION(S) Resident is supposed to have two staff for transfers. Suspected abuse Violation Established? Yes No III. METHODOLOGY 09/09/2014 Special Investigation Intake 2014A1005027 09/12/2014 Special Investigation Initiated - Telephone 09/16/2014 Contact - Document Received 09/18/2014 Contact - Telephone call made. Additional information obtained. 09/22/2014 Contact - Telephone call made. Additional information obtained. 10/06/2014 Inspection Completed On-site 10/29/2014 Exit Conference with Kathy Dunbar 11/06/2014 Exit Conference with Kathy Dunbar ALLEGATION: Resident is supposed to have two staff for assistance with transfers Hospital suspects possible abuse INVESTIGATION: Adult Protective Services (APS) forwarded this complaint. The complainant alleged that Resident A fell on 5/28/14 and she was supposed to have two workers with her at all times. The complainant stated that on 8/12/14 the resident s leg was black and blue, resident was in pain, and facility insisted that Resident A had an infection: x-rays found that her leg was broken. The doctor told them that the injury was consistent with physical abuse. I was not able to reach the complainant at the phone number provided. Later, a letter from the complainant stated that Resident A has severe dementia and she is unable to communicate. The complainant repeated her concerns as stated above and she added that when Resident A fell in the bathroom on 5/28/14 she sustained trauma to the head and a broken tooth. Complainant wrote that the original service plan required one person to assist with all transfers and while she was in the bathroom. In July 2014, Resident A s service plan was revised to require two-person assistance with all transfers and when she is in the bathroom. Complainant wrote that Resident A now lives in a nursing home. 2
Resident A s authorized representative (AR) filed the same complaint. I spoke with him on 9/22/14 and he said that a police report was filed. His written complaint included that Resident A s admitting physician stated, Pathological fracture distal left tibia/fibula due to severe osteoporosis. The actual initiating event is uncertain. I conducted an unannounced on-site investigation on 10/06/14. I reviewed Resident A s facility record including her service plan and the incident reports; employee records were reviewed. I interviewed Kathy Dunbar, and employees Michelle Bailey, Kiara Johnson, Robin Cameron, and Shunticia Parks. Resident A s facility record showed that she was admitted to the home on 6/27/13. Her diagnoses included but are not limited to osteoporosis, dementia, and hypertension, depression with anxiety. Care notes written on 5/28/14 at 12.33 pm reveal that Resident A s tooth was missing prior to her fall later that same day. Documentation by Ms. Dunbar showed, [Resident A s] care manager reported that [resident s] mid lower tooth was missing this morning. This writer found the tooth in her bed son notified. [Resident A] was already scheduled to see the dentist on Friday. The tooth appears to have broken off at the gum. Care notes written at 8:48 pm on 5/28/14 showed, [Resident A] fell off the toilet at approximately 1:20 pm today. She hit her head 911 was called Spoke with daughter son notified. The incident report included, [Resident A was assisted onto the commode by her care managers. When the care manager stepped out of the bathroom momentarily, [Resident A] fell forward and landed on the floor. The report noted that the Resident went to the hospital and that the x-rays and CT scans found no fractures and no brain hemorrhages. Notifications were made as required and corrective actions included, There will be one care manager with her at all times when she is in the bathroom. Ms. Dunbar said that two staff transferred Resident A to the toilet, one care manager left, and the other one stepped just outside of the bathroom to give the resident some privacy. After this incident, Resident A s service plan was updated to require that one staff remain in the bathroom with the resident. Care notes regarding Resident A s leg revealed that on 8/12/14 at 5:47 pm, [Resident A s] left leg was discolored and swollen she was having pain...tylenol 325 (ii) was given Left leg had increased in size. Discoloration remained and areas of redness had appeared. Toes and side of left foot were red and hot to touch. Multiple red areas were forming on leg around discolored area. They were hot to touch and a line of redness going up the outside of leg above the knee. Small open lesions in various areas began to appear on front of leg, small blister areas were appearing while waiting for 911 to arrive. 911 transported [Resident A] to Beaumont ER at 4:50 pm. The care note included that the family followed the ambulance to the hospital, and that hospice and the physician were notified. The incident report was consistent with documentation in the care note. 3
Ms. Dunbar and Ms. Cameron are both nurses and their description of Resident A s leg was consistent with the care notes. Both were concerned that the resident had developed an infection possibly from foot care provided on 8/11/14 by a podiatrist. Ms. Dunbar said she spoke with the hospice nurse who had seen the resident on 8/11/14, the podiatrist who had provided foot care treatment on 8/11/14, and staff members who had cared for the resident. Ms. Dunbar said that the hospice nurse saw the resident after lunch and she didn t see anything wrong with the leg. The podiatrist reported that he didn t notice any problem with her leg. Ms. Dunbar said that Ms. Johnson was Resident A s care manager for the afternoon shift on 8/11/14, and Ms. Johnson told her Resident A was crying during dinner and at bed time - cause unknown. Ms. Dunbar stated that the night shift told her nothing unusual occurred during the night. Ms. Johnson said she was hired in June 2014 and that she went through the required training program. She said that on 8/11/14 the hospice aide bathed Resident A and the aide didn t report any problems to her. Prior to supper, she helped the hospice aide transfer Resident A to her wheelchair and there were no problems during the transfer no indication of pain when Resident A was moved. Ms. Johnson said that during supper she noticed that Resident A was crying and although Resident A can t communicate, she asked what was wrong, but she can t answer, so she was not able to determine what was wrong. Ms. Johnson said that after supper she took Resident A back to her room. She said, When I first got to her room, she had tears on her cheeks and I asked her what was wrong I got no response. Ms. Johnson said that she used her walkie-talkie to call for assistance to transfer Resident A. Ms. Johnson said, No one came so I put her to bed by myself. I didn t pick her up [in my arms]. I did it the same way as when two of us do it. I reached my arms under her arms, stood her up on her feet. I did a slow pivot towards the bed, sat her on the side of the bed, and brought her legs up onto the bed. Ms. Johnson stated that during this time Resident A made no noise or indication of pain, or anything. Ms. Johnson expressed concern that Resident A was uncomfortable as reason for the tears and she wanted to make her comfortable by putting her in bed. Ms. Johnson said that when she undressed Resident A to put her into her pajamas, she didn t see anything wrong with Resident A s leg. Ms. Bailey said that the night shift didn t report any problems during the night. She said that she knew Resident A had seen the podiatrist the day before and that, When I got her dressed that morning I saw something on her middle toe; it was discolored some bruising [location was unclear]. [Resident A] was fidgety when I got her dressed. She winced a lot which is unusual for her. I forgot to tell the nurse about the bruising but I noted it in the daily log. Then after lunch, another staff helped transfer her back to bed. We noticed her left leg was swollen and [there was] a large bruise. I reported it to the nurse. The daily log revealed Ms. Bailey noted, When getting [Resident A] dressed this morning I noticed she had a big bruise on her left leg. It hurts her when it gets touched or any movement on t it. 4
Ms. Cameron said that after lunch on 8/12/14 Ms. Bailey asked her to look at Resident A s leg because it was swollen and it had a big bruise on it. Ms. Cameron said, I looked at it and immediately notified Kathy [Ms. Dunbar]. We looked at it together. I saw bruising on her leg and it was swollen. During the exam, she moved her other leg as if maybe she was in pain. She didn t make any noise. There was no grunting or wincing. She had reddish marks on her leg going from side-to-side; there was no red line. Hospice was notified. About 4 pm, Kathy called me to her office. Family was present. [Kathy and I] thought the swelling had increased. [There was] a red ling going up the leg. She had a blister and it looked like another one was beginning. We thought it might be an infection and [a family member] shared that same concern. [Afterwards] We checked [with staff] and there was no known fall or event that could have caused the injury. Ms. Dunbar said that when Resident A was sent to the hospital it was due to the sudden changes in her leg because they were worried it might be a Beta-Hemolytic Strep infection; a rapidly developing infection. Ms. Dunbar said that no one reported a fall or had knowledge about what could have caused the injury. Ms. Dunbar offered the possibility that Resident A rotated/moved her leg while she was given foot care treatment by the podiatrist which could have caused or precipitated the injury. Resident A s annual service plan was updated July 14, 2014. It showed that Resident A will need care managers to achieve safe transfers do not anticipate that she will pivot during the transfer, as she may not. The service plan also showed that Resident A will require the assistance of two care managers to transfer her from her wheel chair to the toilet... Sometimes she becomes fidgety and when this happens, assist her to the bathroom [Resident] will not be left alone in the bathroom. One care manager should be with her at all times when being assisted in the bathroom. Ms. Johnson s employee record showed she was hired in June 2014 and there was documentation on her training. Her file contained documentation that on 8/13/14 Ms. Parks (supervisor) completed a Performance Counseling & Improvement Plan for Corrective Action. The document acknowledged that Ms. Johnson admitted that she performed a one-person transfer on a resident whose ISP states that the resident is a two-person transfer. Ms. Johnson received a Final Written Warning regarding her performance. Interview with the Farmington Hills Police Department on 11/03/14 determined that a police report has been filed and the matter is being looked into. APPLICABLE RULE R 325.1931 Employees; general provisions. (2) A home shall treat a resident with dignity and his or her 5
personal needs, including protection and safety, shall be attended to consistent with the resident's service plan. ANALYSIS: CONCLUSION: Resident A s service plan requires that two people transfer her from the wheel chair to the bed, and a staff person admitted that she transferred Resident A by herself 08/12/14. Thus, staff did not treat the resident consistent with her service plan. VIOLATION ESTABLISHED APPLICABLE RULE MCL 333.20201 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. (2) The policy describing the rights and responsibilities of patients or residents shall include as a minimum: (l) A patient or resident is entitled to be free from mental and physical abuse and from physical and chemical restraints, except those restraints authorized in writing by the attending physician for a specified and limited time or as are necessitated by an emergency to protect the patient or resident from injury to self or others, in which case the restraint may only be applied by a qualified professional who shall set forth in writing the circumstances requiring the use of restraints and who shall promptly report the action to the attending physician. In case of a chemical restraint a physician shall be consulted within 24 hours after the commencement of the restraint. ANALYSIS: CONCLUSION: Interviews and documentation found no clear evidence to support the allegation that Resident A s injury was due to physical abuse. The allegation of physical abuse could not be substantiated or refuted. VIOLATION NOT ESTABLISHED 6
IV. RECOMMENDATION Contingent upon receipt of an acceptable corrective action plan, I recommend licensure remain unchanged. 11/6/14 Lilly Anne Date Licensing Staff Approved By: 11/7/14 Betsy Montgomery Date Area Manager 7