STATE OF MICHIGAN DEPARTMENT OF HUMAN SERVICES BUREAU OF CHILDREN AND ADULT LICENSING JENNIFER M. GRANHOLM

ISMAEL AHMED

GOVERNOR

DIRECTOR

September 1, 2009

Linda Eckelstafer 6135 112th Street Howard City, MI 49329

RE: License #: AM620268875 Investigation #: 2009A0868040 Peaceful Acres AFC

Dear Ms. Eckelstafer: Attached is the Special Investigation Report for the above referenced facility. No substantial violations were found. 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 (989) 758-1987.

Sincerely,

Ronald R. Verhelle, Licensing Consultant Bureau of Children and Adult Licensing 1475 S. Bamber Road Mt. Pleasant, MI 48858-8010 (989) 772-8474 enclosure

P.O. BOX 30650 • LANSING, MICHIGAN 48909-8150 www.michigan.gov • (517) 335-6124

MICHIGAN DEPARTMENT OF HUMAN SERVICES BUREAU OF CHILDREN AND ADULT LICENSING SPECIAL INVESTIGATION REPORT

I. IDENTIFYING INFORMATION License #:

AM620268875

Investigation #:

2009A0868040

Complaint Receipt Date:

07/13/2009

Investigation Initiation Date:

07/13/2009

Report Due Date:

09/11/2009

Licensee Name:

Linda Eckelstafer

Licensee Address:

6135 112th Street Howard City, MI 49329

Licensee Telephone #:

(616) 636-4777

Administrator:

Linda Eckelstafer

Name of Facility:

Peaceful Acres AFC

Facility Address:

6135 112th Street Howard City, MI 49329

Facility Telephone #:

(616) 636-4777

Original Issuance Date:

03/01/2007

License Status:

REGULAR

Effective Date:

07/25/2007

Expiration Date:

07/24/2009

Capacity:

12

Program Type:

MENTALLY ILL DEVELOPMENTALLY DISABLED AGED 1

II.

ALLEGATIONS •

III.

On July 6, 2009, Resident A went home to visit a relative and returned to the facility later in the day. The next morning Resident A was unresponsive and transported to Butterworth Hospital. This resident had ingested antifreeze.

METHODOLOGY 07/13/2009

Special Investigation Intake 2009A0868040

07/13/2009

Special Investigation Initiated -Telephone Interviewed the licensee, Linda Eckelstafer. Reviewed an Incident/Accident Report.

07/13/2009

Referral - Adult Protective Services

07/13/2009

Referral - Law Enforcement Placed voice mail message with Michigan State Police Trooper 1.

07/15/2009

Inspection Completed - On-site Interviewed the licensee's husband; Staff 1. Reviewed Resident A's Assessment Plan for AFC Residents, Resident Care Agreement, and Health Care Appraisal. Inspected attached and unattached garages.

07/20/2009

Contact - Document Sent Requested Butterworth Hospitalization Summary.

07/15/2009

Contact -Telephone Call Made Re-interviewed the licensee, Linda Eckelstafer.

07/27/2009

Contact -Telephone Call Made Interviewed Michigan State Police Trooper 1.

08/10/2009

Contact - Document Received Reviewed Butterworth Hospitalization Summary.

08/14/2009

Contact - Document Received Reviewed Michigan State Police Report.

08/19/2009

Exit Conference Conducted exit conference with licensee, Linda Eckelstafer.

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ALLEGATION: •

On July 6, 2009, Resident A went home to visit a relative and returned to the facility later in the day. The next morning he was unresponsive and transported to Butterworth Hospital. This resident had ingested antifreeze.

INVESTIGATION: The licensee, Linda Eckelstafer said Resident A went home to visit Relative 1 at noon on July 6, 2009, as he has done for the past two years. Ms. Eckelstafer said Resident A returned to Peaceful Acres AFC at 6:30 pm and retired to his private bedroom for the entire evening. Ms. Eckelstafer said Resident A was angry with Relative 1 upon returning home, but he typically returned angry after visiting this particular relative. Ms. Esckelstafer said Resident A stayed up most of the night watching television and did not wake up for breakfast. Ms. Eckelstafer indicated that Resident A frequently stays up late watching television and gets up late in the morning. Ms. Eckelstafer said she checked on Resident A in his bedroom at 10:30 am the next day on July 7, 2009, and he was unresponsive. Ms. Eckelstafer said she finger swept Resident A mouth searching for an obstruction, but there was none. Ms. Eckelstafer said her staff called 911 and she followed the operator’s instructions. Ms. Eckelstafer said Resident A was transported by ambulance to Butterworth Hospital and it was determined that he had ingested antifreeze. Ms. Eckelstafer said the Michigan State Police were notified and Trooper 1 launched an investigation of Resident A’s Relative 1 since they suspected intentional poisoning. Ms. Eckelstafer said Resident A was placed on life support. Ms. Eckelstafer said Resident A has been assigned an emergency guardian and could be placed in a nursing home upon hospital discharge. Linda Eckelstafer, said Resident A’s Relative 1 visited on August 6, 2009, and boasted of removing antifreeze and coke cans from her truck prior to his poisoning. Ms. Eckelstafer said Relative 1 also boasted about his life insurance policy’s ability to cover intentional death or suicide. Ms. Eckelstafer said the Michigan State Police were interested in this information and that they suspected Relative 1 of attempted homicide. Linda Eckelstafer said Resident A regained consciousness on July 15, 2009. Ms. Eckelstafer said Resident A could not recall drinking antifreeze or that Relative 1 gave it to him. Ms. Eckelstafer said Resident A had no explanation of what happened to him. Ms. Eckelstafer said she has never observed Resident A ingest any toxic substance and there is no mention of him doing this in his case history. A July 7, 2009, Incident/Accident Report authored by the licensee, Linda Eckelstafer, was reviewed. This report indicated, “(Relative 1) brought (Resident A) home around 6:30 pm on July 6, 2009. (Resident A) went to his bedroom to watch television. (Resident A) sleeps during the day and watches television at night. On July 7, 2009, at 10:60 am we went to wake (Resident A) and he was unresponsive. I checked for foreign objects in his mouth, had staff dial 911, and followed the operator’s orders. The hospital

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informed us that (Resident A) had drunk antifreeze. (Resident A) is on life support. (Resident A’s) children called the police because they suspect (Relative 1) poisoned him. The police came and we cooperated fully.” The licensee’s husband, Staff 1, said Resident A was unresponsive on July 7, 2009, when they checked on him in the morning. Staff 1 said 911 was immediately telephoned and medics transported Resident A to Butterworth Hospital. Staff 1 said Butterworth Hospital determined Resident A had drunk antifreeze and placed him on life support. Staff 1 said antifreeze at Peaceful Acres AFC is stored in an unlocked unattached garage several yards away from the facility and that it was not disturbed. Staff 1 indicated that he has never observed Resident A ingest a toxic substance. This consultant inspected the attached and unattached garages. There was no antifreeze located in the attached garage. Two containers of antifreeze were stored in the unlocked unattached garage. These antifreeze containers were covered with dust and did not appear tampered with at the time of the on-site inspection. This licensing consultant directed Staff 1 to place the antifreeze and any other toxic substances in the unattached garage under lock and key despite the distance of the garage from the facility. Michigan State Police Trooper 1 said she interviewed Resident A at Butterworth Hospital after he regained consciousness. Trooper 1 said Resident A did not know why law enforcement was investigating the reason for his hospitalization. Trooper 1 said Resident A was adamant about not trying to commit suicide or drinking antifreeze accidentally. Trooper I said she interviewed Resident A’s Relative 1 on July 15, 2009, and Relative 1 said she did not poison Resident A with antifreeze. Trooper 1 said Relative 1 had made comments to the licensee, Linda Eckelstafer, about discarding antifreeze and a pop can which allegedly contained a mixture of antifreeze and soda. Trooper 1 said Relative 1 also informed Ms. Eckelstafer that Resident A had drank more anti-freeze than anybody else and lived. Trooper 1 said Relative 1 also made comments that her son had drunk anti freeze at the age of fourteen and survived the experience. Resident A’s Butterworth Hospitalization Summary was reviewed. This document indicated Resident A was admitted on July 7, 2009, in respiratory failure due to a possible suicide attempt by the ingestion of an unknown substance. This document indicated upon evaluation Resident A was in respiratory failure due to ingesting ethylene glycol. This document further indicated Resident A was started on hemodialysis and discharged from Butterworth hospital to an extended care facility on July 16, 2009. Resident A’s May 8, 2009, Health Care Appraisal was reviewed. This appraisal indicated Resident A was diagnosed with a history of cardiovascular accidents and alcoholism. Resident A’s May 5, 2009, Resident Care Agreement was reviewed. This agreement indicated Resident A required daily supervision of activities including medications.

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Resident A’s May 5, 2009, Assessment Plan for AFC Residents was reviewed. This plan indicated, “(Resident A) needs supervision, but does not exhibit self injurious behavior. (Resident A) needs supervision for abusive habits.” There was nothing specific in the assessment plan which indicated Resident A would ingest toxic substances. The Michigan State Police Report completed on August 9, 2009, was reviewed. This police report indicated Trooper 1 initiated an attempted homicide investigation focusing on Relative 1 on July 8, 2009, after interviewing two of his children and reviewing Butterworth Hospital’s toxicology findings indicative of ethylene glycol poisoning. This report indicated Resident A’s children suspected Relative 1 of poisoning him during a July 6, 2009, parental home visit. This report indicated Relative 1 had made several incriminating comments regarding Resident A’s ingestion of antifreeze following the incident. This report indicated these incriminating comments were corroborated by the licensee, Linda Eckelstafer. This report indicated Trooper 1 searched Resident A’s private residence, his bedroom at Peaceful Acres AFC, and vehicles and several containers that could have contained toxic substances were seized for forensic study. This report indicated Trooper 1 interviewed Resident A and he failed to recall any events on July 6, 2009, that culminated in his hospitalization. This report indicated Resident A said he was not suicidal nor did he drink any antifreeze on July 6, 2009, in an attempt to kill himself. This report indicated Relative 1 was interviewed and she alleged Resident A ingested the antifreeze at Peaceful Acres AFC, not at her residence. This report indicated Resident A was previously placed at Northview Manor and Trooper 1 interviewed a direct care worker from that facility that remembered him. The report indicated this direct care worker recalled Resident A becoming violently ill after Relative 1 brought him a meatloaf dinner in 2006. This report further indicated case disposition is pending laboratory test results of seized evidence and additional interviews. An exit conference occurred with the licensee, Linda Eckelstafer, on August 18, 2009. Ms. Eckelstafer said all toxic materials were removed from the unattached garage as a precautionary measure after this licensing consultant’s on-site inspection. APPLICABLE RULE 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 became ill after visiting Relative 1. The licensee, Linda Eckelstafer, and Staff 1 said they have never observed Resident A ingest a toxic substance. Resident A’s Assessment Plan for AFC Residents indicated that he has not exhibited any self injurious behavior. This plan further indicated Resident A had not required enhanced supervision to prevent him from drinking toxic substances. Resident A denied drinking antifreeze. The antifreeze was stored in an unattached garage several yards away from the home and it appeared untouched. The Michigan State Police suspect Resident A was poisoned by Relative 1 while visiting away from the facility. The licensee provided supervision, protection and personal care as defined in the act and as specified in Resident A’s Assessment Plan for AFC Residents. CONCLUSION:

VIOLATION NOT ESTABLISHED

APPLICABLE RULE 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:

The licensee, Linda Eckelstafer, and Staff 1 said 911 was called immediately upon discovering Resident A was unresponsive. They provided Resident A with palliative care until the medics arrived.

CONCLUSION:

VIOLATION NOT ESTABLISHED

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R 400.14401

Environmental health. (6) Poisons, caustics, and other dangerous materials shall be stored and safeguarded in nonresident areas and in non-food preparation storage areas.

ANALYSIS

The antifreeze was not safeguarded from residents because it was stored in an unlocked garage.

CONCLUSION

VIOLATION ESTABLISHED

ADDITIONAL FINDINGS: •

Resident A self injected medication without physician approval.

INVESTIGATION: The licensee, Linda Eckelstafer, said Resident A was prescribed Embril as a treatment for his psoriasis. Ms. Eckelstafer said Resident A routinely self-injected this medication as prescribed. Ms. Eckelstafer said she did not secure written approval from Resident A’s physician for self-injection despite his proven ability to perform this function without causing any harm. R 400.14312

Resident medications. (3) Unless a resident's physician specifically states otherwise in writing, the giving, taking, or applying of prescription medications shall be supervised by the licensee, administrator, or direct care staff.

ANALYSIS

VIOLATIONS

Ms. Eckelstafer allowed Resident A to routinely self-inject medication without written consent from his physician. VIOLATION ESTABLISHED

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IV.

RECOMMENDATION Upon receipt of an acceptable corrective action plan, I shall recommend the status of the license remain unchanged. However, this special investigation may be reopened should the state police investigation indicate that Resident A ingested a toxic substance at the facility.

September 1, 2009 ________________________________________ Ronald R. Verhelle Date Licensing Consultant

Approved By:

September 1, 2009 Gregory Rice Area Manager

Date

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