ALMA NELSON MANOR
Facility I.D. Number 0032730
550 S. Mulford Road
Rockford, IL 61108
Date of Survey 06/30/2000
Incident Report Investigation 05/29/2000 and 06/23/2000
The facility shall notify the resident's physician of any significant change in a resident's condition that threatens the health, safety or welfare of a resident. The facility shall obtain and record the physician's plan of care for the care or treatment of such change in condition at the time of notification.
The facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psycho social well-being of the resident, in accordance with each resident's comprehensive assessment and plan of care. Adequate and properly supervised nursing care and personal care shall be provided to each resident to meet the total nursing and personal care needs of the resident.
General nursing care shall include at a minimum the following and shall be practiced on a 24-hour, seven day a week basis:
All treatments and procedures shall be
administered as ordered by the physician.
Objective observations of changes in a resident's condition, including mental and emotional changes, as a means for analyzing and determining care required and the need for further medical evaluation and treatment shall be made by nursing staff and recorded in the resident's medical record.
All medical treatment and procedures shall be administered as ordered by a physician. All new physician orders shall be reviewed by the facility's director of nursing or charge nurse designee within 24 hours after such orders have been issued to assure facility compliance with such orders.
This REQUIREMENT is not met as evidence by:
Based on record review and interview the facility failed to:
a) follow physician's orders for the administration of Diabeta and Insulin;
b) provide treatment/services to a resident with low blood sugar;
c) call physician immediately when a resident had a significant change in the level of consciousness and abnormal blood sugars levels; and
d) establish and implement specific policy and procedures when a resident exhibits symptoms of hypoglycemia and/or hyperglycemia.
These are applicable for one (R1) or nine residents in the sample and 5 (R18, R19, R20, R21, R22) of 24 in the expanded sample.
The findings include:
1. Per interview with E1 on 06/23/2000 at 11 a.m. in the conference room, E1 stated that R1 was a newly diagnosed Diabetic as of 05/24/2000.
Review of R1's Physician Orders of 05/24/2000 revealed Diabeta 2.5 mg one by mouth every day.
Review of R1's Medication Administration Record (MAR) for 05/25, 05/27, and 05/28/2000 reveals that R1 received the Diabeta 2.5 mg twice on each of those days. The order had been transcribed to the MAR as daily but staff wrote the times to be given as 0800 and 1600.
R1's nurses' notes of 05/27/2000 at 11:30 p.m., 05/28/2000 at 2305, and on 05/26/2000 at 0500 revealed that R1 had episodes of low blood sugars (low, 41, and low, respectively).
E1 indicated per interview on 06/23/2000 at approximately 11 a.m. in the conference room that low on some of the Accucheck machines means the blood sugar is below 50. Other Accucheck machines give a specific number even if the blood sugar is below 50.
R1's symptoms during these times according to the nurses' notes were: cold to touch, sweating all over, slightly responsive, little jerking of hands and body, unresponsive to verbal/tactile stimuli, pale looking, and breathing labored with gurgling sounds.
R1's nurses' notes of 05/27/2000 reveal that R1 was given 3 tubes of glucotose at 11:30 p.m. in his room.
E2 was asked, on 06/23/2000 at approximately 9 a.m. at the first floor main nurses' station, if there was a policy for the use of glucotose. E2 stated, "No, there is not".
Review of nurses' notes of 05/28/2000 at 2310 Z3 ordered "D50 one ampule Intravenous (IV) now and to discontinue Diabeta 2.5 mg, give Diabeta 1.25 mg twice a day and do Accuchecks four times a day for 2 day".
Nurses' notes of 05/26/2000 at 0510 reveal Z2 was called and orders were given to "give one ampule of D50 IV now and hold the Diabeta 1.25 mg".
R1's nurses' notes of 05/28/2000 at 2332 and on 05/26/2000 at 0520 reveal that R1 became alert and responsive after treatment with the Dextrose 50.
E4's written statement (date unknown) reveals, "At approximately 1715 E5 alerted E4 of R1's condition. E4 rushed into R1's room and saw R1 respirations labored and continued unresponsive condition".
Nurses' notes of 05/29/2000 at 1715 reveals, "Alerted house nurses to assist with R1's condition. R1's Accucheck low reading at 1705".
R1 expired at 1725 (at the facility).
Review of facility's written internal investigation of this incident includes an interview from E4 on 06/12/2000. It reveals: "According to E4 the charge nurse....she stated that patient's Accucheck read "low" and she did not attempt to give R1's scheduled medications because R1 was unresponsive. E4 continued with med pass..."
E5's written statements in the facility's investigation on 06/10/2000 reveals:
"...R1 looked sweaty and was breathing like he was sleeping at 4:30 p.m. The nurse did his "Accucheck" in his finger, and when E5 asked the nurse (E4) why R1 was so sweaty and pale, E5 stated E4 said that people with low blood sugar levels look like that. This was around, per E5, 4:40 p.m. E5 went to R1's room around 5 p.m. to assist him with his dinner. He would not "wake up". R1 looked real pale and around his lips were real white. E5 ran to get E4..."
E4's written statements of the incident of 05/29/2000 reveals... 'I did receive a briefing on R1 of the events that occurred 24 hours prior regarding R1's low glucose reading... At approximately 1700, I approached the room of R1 to check Accucheck. The results of the Accucheck read "low". R1 was unresponsive to his name called. No signs of labored breathing was noted... I did not attempt to give R1 scheduled medications due to R1's unresponsive condition. At that time other residents on D-wing were waiting to receive their scheduled meds before eating supper. I proceeded down D-wing hall continuing passing medications (scheduled).
At approximately 1715 CNA alerted me of R1's condition. I rushed into R1's room and saw R1 respirations labored and continued unresponsive condition. I ran up to the nursing station to alert the staff nurses of R1's sudden condition and asked the staff nurses for assistance. I placed a call to Z1. Z4 was the on call Dr...While on the phone with Z4 another agency nurse that was working ... informed me that R1 had expired...The charge nurse (E3) questioned me regarding R1's Accucheck and results. I told E3 R1's Accucheck read "low" when I checked it at approximately 1700 and stated R1's condition at that time...This was my first experience of a resident/patient death as a LPN I had to deal with...'.
Telephone interview with E4 on 06/23/2000 at 8:30 a.m. reveals: "I was on duty the night of R1's death and have been a nurse for 2 years". E4 was asked what would she have normally done if she found a resident unresponsive and why she continued to pass meds? E4 stated "I would have called the supervisor but due to being inexperienced, I did not think. I had complaints from relatives about things not being done. There were other diabetic residents who were upset because they wanted their medications (insulin) and I had their Accuchecks to do. That's why I continued to pass meds. I did not have enough help and had more than 25 residents with only myself and 2 CNAs and one CNA was from the agency."
Interviewed E3 by telephone on 06/23/2000 at 10:45 a.m. regarding the incident on 05/29/2000 with R1. E3 stated, "I couldn't remember the exact time but it was past 5 p.m. I was paged and asked to go to R1's room. I went to R1's room and saw E4, E5 and another agency nurse 'helping' R1. I saw that R1 was basically unresponsive. E4 asked me to take R1's blood pressure or call the doctor. I asked E4 what happened. I looked at R1's chart and checked Accucheck (record) and noted E4 wrote blood sugar at 4 p.m. and it was low." I asked E4 what time she took blood sugar and E4 said at 4 p.m. I asked E4 how was R1 at that time. E4 indicated unresponsive. E4 indicated she continued to pass meds. I asked E4 if she asked for help at that time and E4 indicated she was too busy. E4 only asked for help at 5 p.m. when R1 was already dead. R1 was basically dead when I arrived and that was about 5:15 p.m. I told E4 she needed to ask for help".
E3's written statements in the facility's internal investigation reveal:
"1715 ...Paged to go to R1's room stat! Writer proceeded to R1's room and found R1 very pale looking and cool to touch. Unresponsive to verbal/tactile stimuli. No breathing noted. Vital signs- no blood pressure, no pulse, no respirations. Both pupils fixed and dilated. Reflexes are absent... E4 was asked about R1's condition at 1600 and E4 replied, "Somewhat unresponsive but he's a Do Not Resuscitate (DNR). I just checked his blood sugar and it was low. Then I proceeded to finish my med pass... E5 was asked about R1's condition and claimed that R1 had been cold and clammy and perspiring a lot since this morning! Also claimed that R1 had been "out of it- no response since 2 - 3 p.m."
Telephone interview with Z1 on 06/23/2000 at 3 p.m. reveals that Z1 could not recall being told that the nurse had continued to pass meds knowing that R1 had a low blood sugar and was unresponsive. Z1 was asked if receiving twice the amount of Diabeta 2.5 mg as ordered had anything to do with his low blood sugars. Z1 stated, "It would make sense." Z1 stated that there should have been a lot of interventions. Z1 also stated he was surprised that there was no protocol for low blood sugars and there should have been a protocol.
On 06/23/2000 at 11a.m. in the second floor conference room E1 and E2 verified that the facility did not have a specific policy and procedure addressing hypoglycemic residents.Per telephone interview of E4 on 06/23/2000 at 8:30 a.m. revealed that she failed to notify the physician when she became aware of R1's low blood sugar and unresponsiveness.
2. During the survey on 06/27/2000 5 additional residents with the diagnosis of Diabetes Mellitus (R18, R19, R20, R21, and R22) records were reviewed and the following problems were noted:
a) R19 was on a sliding insulin scale per review of MAR and should have received 2 units of insulin on 06/23/2000 at 1600 and 2100. There is no evidence that this was done. E7 was asked on 06/27/2000 at 3:10 p.m. on the 300 wing at the nurses' station if she had given the 1600 dose of insulin on 06/23/2000 and she stated, "She could not recall giving it." It also was not documented on the MAR. The 2100 dose also was not documented as being given by E8.
b) Review of R22's Diabetic Flowsheet reveal R22 had low blood sugars in the mornings between 06/15/2000 and 06/23/2000. They ranged from low to 62.
Review of nurses' notes and Diabetic Flowsheet revealed that the physician had not been notified of the morning low blood sugars. E1 reviewed R22's medical record and verified there was no evidence that the physician had been notified.
Interviewed E11 on 06/27/2000 at approximately 3:45 p.m. on the 300 wing nurses' station. E14 made recommendation to "refer low am blood sugar to the doctor- R22 asymptomatic per nursing but consider decreasing p.m. Glyburide".
c) R18 had low blood sugar ranging from 47 on 05/29/2000 and 57 on 06/19/2000 according to R18's Diabetic Monitoring Flowsheet. Review of the June, 2000, nurses' notes, June, 2000, Physician and Orders and current Diabetic Flowsheet there is no evidence that the Physician was notified of the low blood sugars. On 06/27/2000 at 2:30 p.m. on the 200 wing, E10 could not verify that the doctor had been notified.
d) The Diabetic Flowsheet for R21 had low blood sugars ranging from 55 to 68. There is no evidence in the record of the physician being notified. On 06/27/2000 at 3:35 p.m. on the 400 wing, E1 verified that there was no evidence to indicate that physician had been notified.
e) R20 had consistent high blood sugars from 06/16/2000 to 06/22/2000 ranging from 137 to 288 per review of R20's current Diabetic Monitoring Flowsheet. Dr was not notified until 06/22/2000. At that time the doctor gave an order to increase R20's insulin. E9 verified on 06/27/2000 at approximately 3:35 p.m. at the 300 wing nurses' station that there was no documentation that the physician had been made aware of these blood sugars prior to 06/22/2000.
On 06/27/2000 at 2:30 p.m. at the 200 wing nurses' station E10 stated that the doctor should be called when the blood sugar is below 80.
E1 stated on 06/27/2000 at 4 p.m. in the conference room, that there was not a facility policy or procedure on hyperglycemia.