State of Michigan DEPARTMENT OF HUMAN SERVICES June 24 ...

RICK SNYDER
GOVERNOR
State of Michigan
DEPARTMENT OF HUMAN SERVICES
BUREAU OF CHILDREN AND ADULT LICENSING
MAURA D. CORRIGAN
DIRECTOR
June 24, 2013
Anna Hinton
Pioneer Resources
1145 E Wesley Avenue
Muskegon, MI 49442
RE: License #:
Investigation #:
AS610014931
2013A0356026
Lawrence Home
Dear Ms. Hinton:
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.
• Indicate how continuing compliance will be maintained once compliance
is achieved.
• Be signed and dated.
Upon receipt of an acceptable corrective action plan, a six-month provisional license will
be issued. If you do not agree to a provisional license, you must notify this office in
writing and an administrative hearing will be scheduled. You must still submit an
acceptable corrective action plan.
If you desire technical assistance in addressing these issues, please contact me. In any
event, the corrective action plan is due within 15 days.
P.O. BOX 30650 • LANSING, MICHIGAN 48909-8150
www.michigan.gov • (517) 335-6124

Please review the enclosed documentation for accuracy and contact me with any
questions. In the event that I am not available and you need to speak to someone
immediately, please contact the local office at (616) 356-0100.
Sincerely,
Elizabeth Elliott, Licensing Consultant
Bureau of Children and Adult Licensing
Unit 13, 7th Floor
350 Ottawa, NW
Grand Rapids, MI 49503
(616) 901-0585
enclosure

MICHIGAN DEPARTMENT OF HUMAN SERVICES
BUREAU OF CHILDREN AND ADULT LICENSING
SPECIAL INVESTIGATION REPORT
I. IDENTIFYING INFORMATION
License #:
Investigation #:
AS610014931
2013A0356026
Complaint Receipt Date: 04/08/2013
Investigation Initiation Date: 04/08/2013
Report Due Date: 06/07/2013
Licensee Name:
Licensee Address:
Pioneer Resources
1145 E Wesley Avenue
Muskegon, MI 49442
Licensee Telephone #: (231) 773-5355
Administrator:
Licensee Designee:
Name of Facility:
Facility Address:
Anna Hinton, Designee
Anna Hinton
Lawrence Home
1228 Lawrence Avenue
Muskegon, MI 49442-2272
Facility Telephone #: (231) 773-7049
Original Issuance Date: 06/07/1993
License Status:
REGULAR
Effective Date: 01/11/2012
Expiration Date: 01/10/2014
Capacity: 6
Program Type:
PHYSICALLY HANDICAPPED
OFFICIAL FORMER AIS/MR
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II.
ALLEGATION(S)
• Resident A choked on a piece of meat that resulted in anoxic
encephalopathy followed by death.
• Resident A had decubitus sores on her coccyx and feet.
III.
METHODOLOGY
04/08/2013 Special Investigation Intake
2013A0356026
04/08/2013 Special Investigation Initiated - Face to Face
Face to face interviews with staff.
04/08/2013 Contact-Document Received & Sent
Garland Kilgore, ORR
04/08/2013 Contact-Document Received & Sent
Anna Hinton, Pioneer Resources
Licensee Designee
04/08/2013 Contact - Face to Face
Garland Kilgore, Muskegon Co. CMH ORR Director.
04/08/2013 Contact - Face to Face
Anna Hinton, Pioneer Resources and Tracy Kroll, Lawrence Home
Manager.
04/08/2013 Contact - Document Received
Documents gathered at Pioneer Resources Office.
04/09/2013 Contact - Document Sent
CIR done and sent to area manager.
04/09/2013 Contact - Telephone call made
APS referral made to Centralized Intake/Jacob took report and to
Sheen Chandler, APS supervisor in Muskegon.
04/09/2013 Contact - Telephone call made
Muskegon Police Department
04/09/2013 Contact - Document Sent
Email to Garland Kilgore and Anna Hinton, Pioneer Resources.
04/10/2013 Contact - Telephone call made
Report made to Fruitport Police Department regarding death of
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esident. Officer Jeffrey Whelen took report.
04/12/2013 Contact - Telephone call made
Telephone call to Kathleen Robison, legal guardian for Resident A.
04/15/2013 Contact - Telephone call made
Telephone conversation with Jamie Wiersma, Harbor Hospice.
04/18/2013 Contact - Document Received
Records received from Harbor Hospice.
04/23/2013 Contact - Telephone call made
Interview with Hackley Hospital ER doctor, Mary Boyer, MD.
06/12/2013 Contact- Jamie Wiersma
Nurse, Denese Badgerow no longer working for Poppen House
06/12/2013 Contact-Telephone call made
Dr. Harriman, Harbor Hospice, Poppen House
06/13/2013 Contact-Telephone call received
Dr. Harriman, Harbor Hospice, Poppen House
06/18/2013 Exit Conference-Anna Hinton, Licensee
ALLEGATION: Resident A choked on a piece of meat that resulted in anoxic
encephalopathy followed by death.
INVESTIGATION: On 04/07/2013 (Sunday), I received an email from Garland
Kilgore, Director of the Office of Recipient Rights, Muskegon County Community
Mental Health. Mr. Kilgore reported that on 04/03/2013; Resident A choked on a
piece of meat at the facility. Staff attempted but was unsuccessful in getting the
piece of meat out and Resident A was transported to Hackley Hospital Emergency
Room where the piece of meat was extracted. Resident A had suffered from anoxic
encephalopathy, was discharged to Hospice Care on 04/04/2013 where she
subsequently died on 04/05/2013.
On 04/08/2013, I conducted face-to-face interviews of the Lawrence Home staff with
Mr. Kilgore, Ms. Hinton and Tracy Kroll, Lawrence Home Manager at the Pioneer
Resources office on Wesley Ave.
On 04/08/2013, direct care staff, Lasharra Crews reported that she had fixed the
plate for Resident A and that plate of food consisted of broccoli, toast, mashed
potatoes, gravy and pot roast. Ms. Crews stated she cut the broccoli into “little
chunks, bite sized pieces” but she did not cut the toast. Ms. Crews further stated that
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the mashed potatoes and gravy did not need cutting but she did cut the pot roast up
for all of the residents including Resident A.
Ms. Crews stated there were four residents’ plates that she was preparing and she
went down the line and cut all of the pieces of meat. Ms. Crews showed Mr. Kilgore,
Ms. Hinton, Ms. Kroll and I how she moved down the line cutting up all of the pieces
of meat on the plates. Ms. Crews stated she thought she cut the meat into
approximately one inch pieces and that she tried to make them all the same size.
Ms. Crews stated she noticed that the meat was tough but added that she didn’t
have a problem cutting it up. Ms. Crews reported that Resident A was eating on her
own and stated that “usually I feed her or watch her eat but I took on too much that
day and went to the sink to rinse dishes in the kitchen”.
Sitting at the table that day was Resident A, Resident B and direct care staff, Andrea
Crow. Ms. Crow had finished assisting Resident B with eating and had gone outside
to take a break. Staff Bernadette (aka Bonnie) Bryant was assisting Resident C at
the counter while he ate. Ms. Crews reported that while at the sink, she heard
someone gasping and went to see what was going on. That is when she noticed that
Resident A was choking. Ms. Crews stated she began to administer the Heimlich
maneuver and back blows in an attempt to assist Resident A. Ms. Crews stated she
immediately called 9-1-1 to request help for Resident A and Ms. Bryant took over
with the attempts to assist Resident A. Ms. Crews reported that staff continued trying
to dislodge the food item until EMS arrived. Ms. Crews stated that Resident A did not
lose consciousness at any point while at the facility and that she followed the
ambulance to Hackley Hospital ER. Ms. Crews reported that she saw the piece of
meat that was removed from Resident A while at the hospital and it had a large
piece of fat attached to it that she did not see when she was cutting the meat up.
On 04/08/2013, I interviewed direct care staff Bernadette (aka Bonnie) Bryant at
Lawrence Home. Ms. Bryant confirmed that she was on duty at the time of this
incident and reported that she had been in a resident room with a new employee,
Andrea Crow. Both staff were assisting Resident D clean up after she had a bowel
movement. Ms. Bryant stated that after assisting Resident D she sat at the counter
and began to feed Resident C. During this time Ms. Crow had assisted in feeding
Resident E who was sitting across the table from Resident A. Once Ms. Crow
finished assisting Resident C she stepped outside of the facility to take a break. Ms.
Bryant stated Ms. Crews was in the kitchen with the water running but she came out
because she heard something. Ms. Bryant stated she and Ms. Crews first checked
Resident F but then discovered it was Resident A. Ms. Bryant stated she
immediately began administering the Heimlich maneuver and back blows to
Resident A but her efforts were not successful. Ms. Bryant then ran to the door and
requested that Ms. Crow come in to assist. Ms. Crow then began administering the
Heimlich maneuver and back blows while Ms. Crews was on the telephone with 9-1-
1. Ms. Bryant reported that Ms. Crews did not work on Resident A but that she made
the telephone call to 9-1-1.
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Ms. Bryant stated that Resident A usually ate by herself but staff would watch or sit
by her to monitor her eating. Ms. Bryant stated she did not observe the plate when
Ms. Crews served it to Resident A but she did observe the plate as it sat on the table
after the incident and that the meat appeared to be cut in bite sized pieces but the
broccoli did not. The toast on Resident A’s plate was not cut and there was one bite
out of it. Ms. Bryant added that there was a memo at the facility stating that Resident
A’s “food should be cut into bite sized pieces.”
On 04/08/2013, I interviewed Laura Danicek, lead direct care staff at Lawrence
Home for 13 years. Ms. Danicek was on her way to the facility when she passed the
ambulance on its way from the facility to the hospital. Ms. Danicek was not present
when the event occurred but arrived at the facility after Resident A had left. Ms.
Danicek observed Resident A’s plate of food and stated the broccoli appeared to be
the frozen type that came in larger pieces and it did not appear to be cut any further
than it was taken from the bag. Ms. Danicek reported that the meat on Resident A’s
plate was “not bite sized” for Resident A and the potatoes had some lump to them
and were not all the way mashed. Ms. Danicek saw the piece of meat that was
extracted from Resident A when she went to the hospital and described it as a
“pretty big piece of meat, not a bite sized piece of meat” for Resident A.
On 04/08/2013, I interviewed direct care staff Andrea Crow. Ms. Crow reported that
she was with Ms. Bryant in a resident bedroom assisting with personal care of
Resident D. Ms. Bryant instructed Ms. Crow to go ahead and assist Resident E with
eating. Ms. Crow stated she finished assisting Resident E with eating and stepped
outside of the home to take a break. Ms. Crow stated that shortly thereafter Ms.
Bryant came running out requesting that she come back into the facility because
Resident A was choking. Ms. Crow said she began doing the Heimlich maneuver
and administering back blows to Resident A. Ms. Crow stated Resident A was
making “very shallow breathing sounds.” Ms. Crow stated that when she became
tired, Ms. Bryant stepped in to help and when EMS arrived, they sat Resident A
down on a chair. Once EMS had arrived, they did not administer any further
assistance, they checked Resident A’s chest and back with a stethoscope and
stated they heard air going in and Resident A was still conscious.
Ms. Crow reported that she observed the plate of food that Resident A had been
consuming and the “meat chunk” appeared to be 1 inch in size and stated that she
would consider that a “bite sized” piece. Ms. Crow stated the broccoli pieces looked
big to her and did not appear to be cut up. In addition, there was a piece of toast and
some potatoes that did not appear to be mashed but cut up into pieces that were
approximately 1 ½ inches in length. Ms. Crow added that Resident A had been
eating independently with no staff supervision prior to this incident occurring.
On 04/08/2013, Interviewed Patricia Hurlbert, direct care staff at Lawrence home for
20 years. Ms. Hurlbert stated she worked the morning shift on the date this incident
occurred. Ms. Hurlbert stated she made Resident A breakfast that consisted of
waffles with syrup “cut up fine” applesauce and instant breakfast. Ms. Hurlbert
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eported that Ms. Danicek assisted Resident A “a little bit” with eating. Prior to
leaving her shift on that date, Ms. Hurlbert stated she made Resident A more food
that consisted of applesauce, a piece of cheese and a piece of meat cut up on
bread. Ms. Hurlbert stated, again, that Ms. Danicek sat with and assisted Resident A
with eating. Ms. Hurlbert reported that Resident A’s special dietary needs had been
addressed in a staff meeting and had been documented on facility paperwork. Ms.
Hurlbert stated staff was aware the special dietary needs of Resident A were part of
her written assessment plan.
On 04/12/2013, I interviewed Resident A’s legal guardian, Kathleen Robison via
telephone. Ms. Robison stated she saw the piece of meat that Resident A choked on
and described it as being “as big as an egg.” Ms. Robison stated she had been
under the impression that someone (staff) would be monitoring Resident A while she
ate. Ms. Robison reported the doctor had ordered that Resident A’s food be cut into
“bite sized pieces” but acknowledged that these directions may not have been
specific enough.
On 04/18/2013, I received the discharge summary from Mercy Health Partners:
Hackley Campus. Dr. Lajide Lawoyin was the author of this report and the attending
physician on the date Resident A presented at Hackley Hospital. Dr. Lawoyin
documented that Resident A, presented in the ER on04/02/2013 as “she had been
eating and despite being edentulous had been given meat, the sufficient size to
obstruct her trachea when she aspirated the chunk of meat.” Resident A “was
brought to the Emergency Department, there were no advanced directives, the meat
bolus was evacuated and the patient was initially intubated.” The report documented
that Resident A will be discharged on 04/03/2013 to Hospice House with diagnosis
of airway obstruction secondary to food bolus. Dr. Lawoyin documented the
discharge diagnosis as follows:
1. Airway obstruction secondary to food bolus.
2. Anoxic encephalopathy secondary to airway obstruction.
3. Down’s syndrome
4. Severe Mental Retardation.
5. Hepatitis B.
6. Hypothyroidism.
7. Unexplained weight loss.
8. Normocytic anemia.
On this same report, I reviewed the Emergency Department physician notes dated
04/02/2013 dictated by Dr. Mary Boyer, MD. Dr. Boyer documented that she called
an anesthesiologist to assist because “the patient with her Down’s syndrome has a
large tongue, scoliosis and abnormal anatomy. The anesthesiologist was able to
successfully intubate the patient. When the anesthesiologist was placing the airway,
she sucked out a very large bolus of meat and another bolus of meat and then was
able to successfully intubate” Resident A. At that point, “there were breath sounds
on both sides” and Dr. Boyer placed Resident A on a ventilator.
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On 04/23/2013, I interviewed Hackley Hospital Emergency Room Doctor, Dr. Boyer.
Dr. Boyer reported that the meat that was removed from Resident A was not
measured but it “was not a bite sized piece of meat.” Dr. Boyer stated that she
thought the home staff did all they could do to assist Resident A after discovering
her in distress.
On 04/23/2013, I reviewed Resident A’s AFC Health Care Appraisal signed by Dr.
Jeff Crandle DO and dated 03/01/2013. Dr. Crandle documented that Resident A
should be on a “general diet, bite size pieces of meat.”
On 04/23/2013, I reviewed Resident A’s Assessment Plan for AFC Residents.
Resident A’s self-care skill assessment documented that Resident A needs help with
eating/feeding. The assessment plan documented that Resident A does attempt to
feed herself at times but she is very shaky so she will be assisted by staff to eat her
meals, she will drink through a straw per her choice. On that same document,
Resident A’s health care assessment indicated that Resident A does have a special
dietary need and documented that Resident A is on a general diet with everything
cut into bite size pieces, regular liquid. The assessment plan was completed on
03/05/2013 by Ms. Kroll and signed by Resident A’s legal guardian, Ms. Robison,
Amy LaLone; CMH supports coordinator and Ms. Kroll, home manager in March
2013.
On 04/23/2013, I received and reviewed the picture taken of the meat bolus that was
removed from Resident A at Hackley Hospital. The meat did not appear to be a bite
sized piece of meat.
On 06/18/2013, I conducted an exit conference with Licensee, Anna Hinton. Ms.
Hinton stated she is in agreement with the information stated in Rule 310 (1) (b). Ms.
Hinton stated that Ms. Crews did not follow the instructions and recommendations of
Resident A’s physician and did not cut Resident A’s food into proper bite sized
pieces. Ms. Hinton stated in regard to Rule 303 (2), staff should have been
monitoring Resident A while she self-fed as that is documented in the assessment
plan. Ms. Hinton stated staff should have been following the assessment plan in
regards to eating/feeding for Resident A. Ms. Hinton stated that she agrees with the
analysis and conclusion for Rule 303 (2). Ms. Hinton reported that Ms. Crews is no
longer employed at the facility and that more training will be provided to direct care
staff. Ms. Hinton stated she understands the meaning of a provisional license and
she accepts the issuance of such a license.
APPLICABLE RULE
R 400.14310 Resident health care.
(1) A licensee, with a resident's cooperation, shall follow the
instructions and recommendations of a resident's physician or
other health care professional with regard to such items as any
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of the following:
(b) Special diets.
ANALYSIS:
Dr. Crandle documented on Resident A’s health care appraisal
that Resident A should have food cut into bite sized pieces.
Ms. Crews & Ms. Bryant stated Resident A’s meat was cut into
bite sized pieces.
Ms. Bryant stated Resident A’s broccoli did not appear to be cut
into bite sized pieces.
Ms. Crow stated the meat appeared to be cut into a “meat
chunk” approximately 1 inch in size and that it appeared to be
bite size to her.
Ms. Danicek reported the broccoli and meat pieces she
observed on Resident A’s plate were not cut into bite sized
pieces. Ms. Danicek reported the meat bolus she viewed at the
hospital was not cut in to a bite size piece.
Ms. Robison reported the meat bolus extracted from Resident A
at the hospital was “as big as an egg” and not cut into a bite
sized piece.
Dr. Lawoyin documented that Resident A; despite being
edentulous had been given meat, the sufficient size to obstruct
her trachea.
Dr. Boyer stated the meat extracted from Resident A was not a
bite sized piece of meat but two “very large meat bolus’”.
There was a memo posted in the facility that documented that
Resident A’s food should be cut into bite sized pieces.
Licensing Consultant saw a picture of the meat bolus and it did
not appear to be a bite sized piece of meat.
CONCLUSION:
VIOLATION ESTABLISHED
R 400.14303
Resident care; licensee responsibilities.
(2) A licensee shall provide supervision, protection, and
personal care as defined in the act and as specified in the
resident's written assessment plan.
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ANALYSIS:
Resident A’s self-care skill assessment on the assessment plan
documented that Resident A needed help with eating/feeding
and that she will be assisted by staff to eat her meals.
Ms. Crews reported that Resident A was eating on her own and
she had gone to the sink to rinse dishes in the kitchen.
Ms. Bryant and Ms. Crow reported that they were assisting
other residents with eating and Ms. Crews was in the kitchen
while Resident A ate on her own.
Ms. Hurlbert stated she cooked food for Resident A while Ms.
Danicek fed Resident A.
Ms. Robison was under the impression that someone would be
monitoring Resident A while she ate.
Resident A’s self-care skill assessment stated that Resident A
needs help with eating/feeding and that she will be assisted by
staff to eat her meals.
Resident A was self-feeding with no close supervision at the
time she choked on the piece of meat.
CONCLUSION:
VIOLATION ESTABLISHED
ALLEGATION: Resident A had decubitus sores on her coccyx and feet.
INVESTIGATION: On 04/07/2013, I received an email from Garland Kilgore,
Director of the Office of Recipient Rights, Muskegon County Community Mental
Health. Mr. Kilgore reported that on 04/03/2013 Resident A choked on a piece of
meat at the facility, was transported to Hackley Hospital ER and then to Poppen
House Hospice Care. While at Hackley Hospital or Poppen House, it was discovered
that Resident A had decubitus sores on her coccyx and the heels of both feet. The
decubitus sores were at an advanced state on her coccyx and foot wounds
appeared as blister type sores.
On 04/08/2013, I conducted face-to-face interviews of the Lawrence Home staff with
Mr. Kilgore, Ms. Hinton and Ms. Kroll at the Pioneer Resources office.
On 04/08/2013, Ms. Crews reported that she did not see any bedsores or decubitus
ulcers on Resident A. Ms. Crews stated she never showered Resident A but would
assist her with toileting and changing of her briefs and at no time saw anything that
would indicate she was getting sores. Ms. Crews stated that on 03/27/2013, she
took Resident A to Dr. Crandle for leg edema. The doctor ordered x-rays of the left
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foot and at the appointment, both socks were removed and there was no mention by
the doctor of a sore on Resident A’s foot at that time. Ms. Crews stated that
Resident A would move around a lot, she did not sit for any length of time. Ms.
Crews added that if Resident A had developed decubitus sores, “we could not have
missed this, we are on our toes with our residents and we could not have missed the
sores.”
On 04/08/2013, Ms. Render stated she bathed Resident A on 04/01/2013. Ms.
Render stated she did not note any sores on Resident A but that she did note some
redness where Resident A’s brief’s ride in the groin area, around the body where the
top of the pull ups would be and in the coccyx area. Ms. Render reported that
Resident A saw Dr. Crandle on 03/27/2013 and he did see the sores on Resident
A’s feet which at the time looked like a wart or a callus, not open sores as shown in
the pictures Mr. Kilgore showed her.
On 04/08/2013, Ms. Davis reported that she did not know that Resident A had any
sores on her body. Ms. Davis stated she had never showered Resident A but got her
ready for bed on 04/01/2013. Ms. Davis stated that she toileted Resident A, took her
socks off and did not notice any marks or anomalies on her feet. Ms. Davis stated
when she would toilet Resident A, Resident A would hold onto and pull herself to a
standing position by using a grab bar. Ms. Davis stated she would then have “full
view” of her buttocks area and stated that her skin appeared to be red but was intact
on 04/01/2013. Ms. Davis added that Resident A moved around a lot while awake
and was never in one spot for an extended period of time. When Resident A was
sitting, Ms. Davis stated that staff would put a sheepskin blanket on the chair, her
legs would be elevated for 30-45 minutes at a time in order to help with the edema
she had and her feet would rest on a bean bag pillow.
On 04/08/2013, Ms. Bryant reported that she dressed Resident A on 04/02/2013.
Ms. Bryant stated Resident A used a wheelchair but was ambulatory and moved
with assistance. Ms. Bryant reported that she put Resident A’s pink slippers on her
on 04/02/2013 and noticed that her feet were “puffy and swollen” but that there were
no sores on her feet. Ms. Bryant explained that staff would always prop Resident A’s
feet up when she sat in the recliner. Staff would lay the sheepskin blanket down first
and then prop her feet up with a bean bag pillow. Ms. Bryant stated they were
instructed by the Occupational Therapist to use the sheepskin in order to prevent
skin breakdown. Ms. Bryant stated Resident A moved around a lot and that she
would only stay in one spot during the day for approximately 15 minutes at a time
and then she would want to move. Ms. Bryant stated Resident A was non-verbal but
she would point to where she wanted to go and staff would always accommodate
her. In regards to the breakdown on Resident A’s coccyx, Ms. Bryant reported that
Resident A would pull herself up on the grab bar in the bathroom and her buttocks
area would be right where Ms. Bryant could see skin up close and after viewing the
pictures of the skin breakdown taken at the Poppen Hospice House, Ms. Bryant
reported that on 04/02/2013, she did not see or notice breakdown of the skin in her
private area. Ms. Bryant stated staff would have noticed that amount of breakdown
10

had Resident A had it at this time. Ms. Bryant added that she did notice a discharge
coming from Resident A’s vaginal area and this discharge had a “strong smell” but
Ms. Bryant stated she was sure it was from the vaginal area and not a result of an
open bedsore.
On 04/08/2013, Ms. Danicek reported that she did not know anything about Resident
A having bedsores. Ms. Danicek stated she did not see any redness on Resident A’s
feet or around her coccyx area. Ms. Danicek stated on 03/26/2013, she noticed
some swelling of Resident A’s feet so she showed Ms. Knoll who immediately made
an appointment with Dr. Crandle. On 03/27/2013, staff took Resident A to Dr.
Crandle to address the swelling in her feet. Ms. Danicek stated that she saw no
indication of a pressure sore beginning on Resident A’s feet and if there was, she
would have noticed because “that is a huge sign, the redness is a huge red flag that
they are going to pop open because they start from the inside out.” Ms. Danicek
stated they would use a sheepskin blanket when Resident A would sit on the
recliner. Ms. Danicek reported that Resident A was on the move at all times, she
would not sit for long periods of time. The longest she would ever sit would be at the
most, an hour and a half to two hours. Ms. Danicek then stated that on 04/02/2013,
she toileted Resident A at least four times and when she would toilet Resident A she
would pull herself up and her “butt would be right in your face” and Ms. Danicek
reported that she “saw nothing, no redness, nothing” in or around her coccyx area.
On 04/08/2013, Ms. Crow reported that she had only worked at the facility since
03/19/2013 but she did toilet Resident A and never saw any redness, bruising, and
no marks noticed by Ms. Crow in or around the coccyx area. Ms. Crow stated staff
always had Resident A’s feet elevated and up on a bean bag with her pink slippers
on.
On 04/08/2013, Ms. Harris stated she worked third shift and that is the time that staff
would bathe Resident A. Ms. Harris showered Resident A on 03/29/2013 and did not
see any bruising, white marks, blisters with pus, spots on her heels or any marks or
dryness on her skin. Ms. Harris did see swelling in Resident A’s ankles and noticed
that her feet were swollen. Ms. Harris reported that every other hour during the night
time hours, staff would toilet Resident A and when they would put her back in bed;
they would reposition her so she would not be in the same position as before. Ms.
Harris stated Resident A was unable to move herself around in the bed so staff
would use a body pillow to prop her on her side. Ms. Harris added that sometimes
she would put a pink pillow under Resident A’s feet while she was in bed in order to
elevate her feet in bed.
On 04/08/2013, Ms. Phipps stated she gave Resident A her last shower on
04/02/2013. Ms. Phipps stated she saw Resident A’s entire body and noticed some
reddening in her private area, in the front area, crotch area and just below her navel
on the front part of her body. Ms. Phipps stated she did not notice any blistering in
these areas or open areas on the skin. Ms. Phipps stated she showered Resident A
while she sat in a shower chair and she described the way she would shower
11

Resident A by taking her hand with a wash cloth and washing her private area all
around and in the creases. Ms. Phipps reported that she was able to see Resident
A’s bottom area and she did not see any actual breakdown other than redness in the
general area. Ms. Phipps reported that she also toileted Resident A two times during
the third shift hours from 04/01/2013 to 04/02/2013, changed her pull ups and she
was wet on both occasions and did not notice any skin breakdown. Ms. Phipps
reported that both times after she changed Resident A, she positioned Resident A in
the same way, on her back when she put Resident A back to bed. Ms. Phipps stated
on the morning of 04/02/2013, she noticed dry skin on the heel of Resident A’s right
foot.
On 04/08/2013, Ms. Crampton stated she saw no signs of skin breakdown, no
blistering of the skin, no indication that her skin was in the stages of breakdown. Ms.
Crampton stated she did notice an odor a couple of weeks prior to this incident and
that it was a “fishy type smell” when she put Resident A’s pull up in the garbage can
and stated this concerned her. Ms. Crampton stated then she addressed this with
other staff and with Resident A’s supports coordinator, LaSonja Foundren. At that
time, Ms. Crampton used a barrier cream which was not a prescription cream but it
was a protective barrier cream that came with the briefs, this cream kept moisture off
of Resident A’s skin. Ms. Crampton reported she used this cream as a protective
measure to keep her skin intact. Ms. Crampton viewed pictures of the decubitus
sores Resident A had on her heels and on her coccyx upon her death and Ms.
Crampton stated she has never seen anything like that on Resident A and whenever
she noticed anything with the residents, “I would tell someone about it.”
On 04/08/2013, Ms. Bennett stated she worked with Resident A and noted that her
feet have been swollen so staff monitored her feet and legs all the time. Ms. Bennett
reported that when they noticed the swelling of Resident A’s legs and feet, staff
would place Resident A in the recliner and elevate her feet. Ms. Bennett stated
Resident A would sit in the recliner for a couple of hours at a time at the most; she
liked to move around a lot with the assistance from staff. Ms. Bennett stated she
would go from the recliner to the wheelchair and then to the table but anywhere she
sat, the lamb skin blanket would be placed under her. Ms. Bennett stated at the time
of Resident A’s death, the doctor was looking in to the swelling of Resident A’s legs
and feet, it was being addressed. Ms. Bennett stated that Resident A was thin and
the skin on her buttocks was “thin and hanging” and that she noticed some
reddening of the skin in that area but the skin was not broken down.
On 04/08/2013, Ms. Hurlbert reported that Resident A’s skin was “flesh on bone” and
on 04/02/2013 Ms. Hurlbert toileted Resident A prior to the end of her shift. Ms.
Hurlbert stated that Resident A would pull herself up using the grab bar in the
bathroom and that her buttocks would be right in front of her face so she would view
her skin very closely and “I did not notice any breakdown” of Resident A’s skin. Ms.
Hurlbert reported that on 03/18/2013, she noticed some reddening of the skin and
used some cream on the red area. Ms. Hurlbert noted that she documented the
application of this cream on record at the facility. Ms. Hurlbert stated that Resident A
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was “moved often, more than every 2 hours” because Resident A always wanted to
be moved elsewhere in the facility, usually near staff. Ms. Hurlbert stated that when
Resident A was sitting, her feet were usually elevated due to the edema in her legs.
Ms. Hurlbert reported that she did not view Resident A’s feet and is not able to
comment on the condition of the skin on her feet. Mr. Kilgore showed Ms. Hurlbert
pictures of the decubitus ulcers on Resident A’s heels and coccyx. Ms. Hurlbert
stated she did not know how Resident A’s skin “could be that way.” Ms. Hurlbert
reported that “whatever was going on just started; I never saw anything like that.”
Ms. Hurlbert added that staff would get tired of listening to her because “I’m on all of
that” such as the integrity of the residents skin. Ms. Hurlbert stated, “We saw none of
that” commenting on the wounds on Resident’s heels and coccyx. Ms. Hurlbert
stated had she noticed any issues with Resident A’s skin, she would have “blown the
phone up” making calls in order to get it dealt with. Ms. Hurlbert stated that Resident
A had an odor to her but that she never saw any indication of infection and that
when she toileted Resident A, she would wipe her well with both wet and dry wipes.
On 04/12/2013, Ms. Robison reported that upon Resident A’s admission to this
facility on 03/12/2013, her skin was intact. Ms. Robison stated that Resident A had
the pressure sores on her skin when she arrived at Hackley Hospital. Ms. Robison
stated on the morning of 04/03/2012, she met staff Ms. Danicek at the hospital. Ms.
Robison reported that Ms. Danicek told her that Resident A had a bedsore while at
the facility and that “she (staff) knew (Resident A) had a bedsore.” Ms. Robison
stated she spoke to Dr. Harriman, Poppen House Hospice doctor about Resident A’s
bedsores and that Dr. Harriman explained to her how quickly decubitus sores can
appear but that the wound on Resident A’s coccyx was open, deep and that
particular sore took some time to get to that point.
On 04/18/2013, I reviewed Harbor Hospice, Poppen House’s skilled nurse Denese
Badgerow report that documented Resident A arrived at Poppen House with
proximal stage 3 ulcers, distal stage 2 on coccyx. There also was an intact fluid filled
blister on right heel, red, purple discoloration with some peeing of skin noted.
On 04/23/2013, Dr. Mary Boyer stated that she does not recall any indication of skin
breakdown on Resident A while in the emergency room at Hackley on 04/02/2013.
Dr. Boyer stated she removed all of Resident A’s clothing and checked her body and
does not recall any anomalies found. Dr. Boyer asked that I review the emergency
department notes to be sure. Dr. Boyer stated that had she noted any skin
breakdown they would be documented in that report as she cannot be completely
certain from memory.
On 04/23/2013, I reviewed the emergency department report in which Dr. Boyer
documented that she “log rolled” Resident A “and she has a little breakdown and
redness in the intergluteal area. She had no other abrasions or contusions to her
skin.”
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On 04/23/2013, I reviewed the Occupational Therapy Consultation report dated
03/15/2013 written by Sharon Dolislager OTRL. This report documented that
Resident A is at a very low weight so close monitoring for skin integrity is needed.
Staff had reported some redness on her bottom. A sheep skin was trialed today
under her when she was sitting on the kitchen chair to provide additional padding
and increase comfort.
On 04/23/2013, I reviewed the Muskegon County Community Mental Health updated
psychosocial assessment for Resident A dated 03/25/2013. In this report it
documented that a hospital bed with a gel overlay on mattress to prevent skin
breakdown is required.
On 04/23/2013, Resident A’s assessment plan documented the need for a gel
overlay on mattress for the prevention of skin breakdown. The assessment plan
does not address any other preventative measures for staff to take in order to
prevent skin breakdown.
I viewed pictures of the sheepskin blanket used underneath Resident A wherever
she sat at the facility. I viewed a picture of Resident A’s hospital bed with a gel
overlay.
On 04/23/2013, I reviewed Dr. Jeffrey Crandle’s patient plan for Resident A
stemming from the office visit dated 03/27/2013. Dr. Crandle documented new onset
ankle edema, requested x-rays to be taken of left ankle and elevation of feet during
the day and at nighttime but does not mention any skin or tissue breakdown on
Resident A’s heels on this date.
On 06/12/2013, I interviewed Dr. Gerald Harriman via telephone. Dr. Harriman was
the Harbor Hospice attending doctor for Resident A. Dr. Harriman documented on
04/03/2013 stage 2 x 2 ulcers on Resident A’s coccyx area. Dr. Harriman stated that
a decubitus ulcer can reach a stage 2 or 3 within a short period of time, within 24
hours is uncommon but if the area is a very bony spot, it is possible. Dr. Harriman
reported that breakdown occurs due to circulation being cut off and that a patient
should be turned or moved every 2 hours so the blood continues to circulate and no
skin breakdown occurs. Dr. Harriman reported that the decubitus sores on Resident
A’s coccyx near the anal opening were shearing tears and this could have happened
short term meaning it could have been a matter of hours that the shearing tears
occurred or a matter of days. Dr. Harriman stated the shearing tears could have
happened at the hospital or they could have happened at the facility and the
answers to that are unknown. Dr. Harriman stated that it is difficult to determine
where the actual opening of the skin of the decubitus began however, if staff
reported Resident A as having red skin then this meant the breakdown of the skin
had started and this was stage 1 of the breakdown process. Dr. Harriman stated
staff would have needed to keep the resident off of the affected areas. Dr. Harriman
reported that the sores on Resident A’s heels took hours to days to form.
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On 06/18/2013, I conducted an exit conference with Ms. Hinton. Ms. Hinton stated
she has been doing a lot of research on skin breakdown and has plans for future
staff training on this matter. Ms. Hinton is in agreement with the information, analysis
and outcome of this rule. Ms. Hinton stated she accepted the request for a
provisional license for this facility.
R 400.14310
Resident health care.
(4) In case of an accident or sudden adverse change in a
resident's physical condition or adjustment, a group home shall
obtain needed care immediately.
ANALYSIS:
Mr. Kilgore reported that Resident A had decubitus ulcers or
bedsores on her coccyx and both heels noted upon her death at
Harbor Hospice’s Poppen House.
Seven staff members reported they did not see any indication of
red skin or any manner of skin break down while caring for
Resident A.
Four staff members reported noticing red skin on or near
Resident A’s coccyx and/or heels while caring for her.
Staff reported using preventative measures to prevent skin
breakdown by using gel mattress overlay, sheepskin blanket,
repositioning at 2 hour intervals and often sooner.
Dr. Boyer documented some redness and skin breakdown in the
intergluteal area while Resident A was in the emergency room.
Occupational Therapy report documented that Resident A is at
a very low weight so close monitoring for skin integrity is
needed.
Dr. Harriman reported that stage 2 and 3 ulcers could have
developed in a short amount of time and could have occurred at
the facility or at the hospital.
CONCLUSION:
VIOLATION NOT ESTABLISHED
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IV.
RECOMMENDATION
Contingent upon receipt of an acceptable corrective action plan, I recommend
modification of the license to provisional.
06/24/2013
________________________________________
Elizabeth Elliott
Date
Licensing Consultant
Approved By:
06/24/2013
________________________________________
Jerry Hendrick
Date
Area Manager
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