BARBARA P. SMILEY LIVING CENTER
ID Number: 0016121
6847 NORTH ALLEN ROAD
PEORIA, ILLINOIS 61614
Survey Date: 8/31/99
The facility shall have written policies and procedures governing all services provided by the facility which shall be formulated with the involvement of the administrator. The policies shall be available to the staff, residents and the public. These written policies shall be followed in operating the facility and shall be reviewed at least annually.
The facility shall provide all services necessary to maintain each resident in good physical health. These services include, but are not limited to, the following:
Nursing services to provide immediate supervision of the health needs of each resident by a registered professional nurse or a licensed practical nurse, or the equivalent.
Residents shall be provided with nursing services, in accordance with their needs and which shall include, but are not limited to, the following:
The Health Services Supervisor’s participation in:
Development of a written plan for each resident to provide for nursing services as part of the total habilitation program.
Modification of the resident care plan, in terms of the resident’s daily needs.
An owner, licensee, administrator, employee or agent of a facility shall not abuse or neglect a resident. (Section 2-107 of the Act)
These regulations are not met as evidenced by the following:
Per record verification and interview, the facility nursing services neglected to provide nursing services to R1 in regards to adequate monitoring and supervision of R1 when a condition change had been identified.
The facility nurses neglected to include services necessary to maintain R1 in good physical health in regards to her history of constipation. The facility nursing failed to develop a written plan of care for R1 to ensure adequate and appropriate nursing interventions. In addition, the facility nursing services neglected to provide immediate supervision, including adequate monitoring and timely action toward R1's health needs on 07/27/1999 at 7 p.m. when she began exhibiting abdominal distention, the physician was not notified nor was any additional monitoring done. Consequently, R1 was transferred to the emergency room at approximately 4:54 a.m. on 07/28/1999 and expired at approx. 6:45 a.m., 2 hours later, from an acute bowel obstruction.
Per the IPP dated 02/11/1999, R1 was a 40 year old female who functioned in the profound range of mental retardation. Additional diagnosis include history of constipation, inconsistent nutritional intake, chronic ear infections, cerebral palsy, seizure disorder and scoliosis. R1 required total assistance of all activities of daily living. R1 was non-ambulatory, non-mobile, wore a body jacket when in the wheelchair and had AFO’s on both lower extremities. R1 was non-verbal, incontinent of bowel and bladder and was totally fed by staff. She was on a pureed high protein/high calorie diet. R1 received routine medications which included a multivitamin, Valporic Acid 15ml qid. (Four times a day), and 2 teaspoons of bran twice daily for her constipation. R1 received prune juice at breakfast, Metamucil 5 ml po q(by mouth every) a.m., Milk of Magnesia 15ml/cascara 5ml po q d(every day), and Dulcolax 10mg suppository rectally prn. R1's ideal body weight was 92#. Current weight as of 07/22/1999 was 79.2#.
The facility neglected to provide all services necessary to maintain R1 in good physical health in regards to preventing constipation and meeting her nutritional/fluid intake needs. Per review of R1's medical care plan, R1's history of constipation and inconsistent nutritional intake were not charted. No information in the IPP under the Medical Data section was found which addressed her constipation, inconsistent nutritional intake or hydration in light of the medications for constipation. Adequate hydration was required. According to the IPP and E3, R1 was totally fed food and fluids. Per interview with E3 and verified by E2, intake records were kept on food only and did not include any information on fluid intake. Per E3 on 08/20/1999, R1's food intake was fairly good but stated R1 had difficulty taking fluids because the position of her jaw allowed a lot of spillage. This was not addressed in either the IPP or nursing care plan and was confirmed by E2 and E3. E3 stated “on average, R1 would drink her chocolate milk and the supplement, but nothing else”. R1's intake would have been 3 cartons of milk and 8 oz. of supplement per day. This would have been approx. 32 oz. per a 24 hour period of time. No assessment was done to indicate what amount would have been adequate, what her average intake was and how to ensure that good hydration was achieved and maintained. Interview with E3 indicated that she was unaware of the medication for constipation and the importance of adequate hydration. Per interview with E3, the nurses “always told them to push fluids” but no emphasis was made on how important it was for health reasons and what problems could arise if hydration was not adequate.
According to the medication book, for clients receiving Metamucil, the main purpose is to “absorb water and expand to increase bulk and moisture content of the stool. The increased bulk encourages peristalsis and bowel movement”, the med is to be mixed with 8 oz. of water followed with another glass of water as it is considered a bulk laxative. Nursing considerations before giving for constipation, are to determine if the client has adequate fluid intake, exercise and diet. The Milk of Magnesia (MOM) produces “as osmotic effect in the small intestine by drawing water into the intestinal lumen” and is considered a saline laxative. Nursing considerations for the MOM include determining if a patient has adequate fluid intake, exercise and diet. It is contraindicated to be given when a “fecal impaction, rectal fissures or intestinal obstruction or perforation is present”. It is to be given with large amounts of water when used as a laxative. Review of the clinical record and interview indicate that fluid intake, at most, was minimum. Per interview and per review of the nurses notes, R1 was given the MOM the evening that she exhibited abdominal distention even though the nursing considerations recommended against it. The nursing services failed to follow nursing considerations regarding hydration recommendations and failed to follow directions when a fecal impaction or obstruction was suspected and gave the MOM on 07/27/1999 at 6 p.m. per the nurses notes and MAR (medication administration record). Nursing services failed to ensure that the staff caring for R1 was aware of these considerations. The facility nurses failed to inform/train the direct care staff on R1's hydration needs.
The facility nursing also neglected to maintain adequate records of bowel movements (BM) that were current, correct and complete. There is no procedure or policy written in regards to the current method of BM tracking, and per interview of E2, no one staff person or shift is responsible for reviewing and taking action. E1 was unable to present a policy/procedure regarding this information. Per interview with E4, the direct care staff write information on their day sheets which is turned in to the nurse at the end of the shift. The nurse then documents the information on the BM record which is accumulative for all clients residing at the facility. When professional staff were asked, E4, E2, E5 and Z6 each revealed that the bowel movement records are questionably correct. Each staff member interviewed, confirmed that the direct care staff do not always document appropriately, accurately and timely and that the records have been known to be wrong. Example: Upon reviewing the BM sheets for the facility, it was noted that R3 had only 3 stools documented between 07/17/1999 and 07/30/1999 (13 days) and R4 had only 1 documented between 07/17/1999 and 07/29/1999 (12 days). E4 indicated that neither record was correct and stated “I think it poor record keeping, not accurate” and assured the surveyor that both R3 and R4 had more frequent stools than what the staff had documented. R3 and R4 are 2 of 13 clients that are listed on the BM tracking sheet. Z6 indicated the 13 people listed are the clients who the facility has determined to be at risk for complications in regards to constipation. According to E4, 3rd shift is responsible to look at the BM records and take action if someone has not had a BM for an extended period of time. Per E5, the 3rd shift full time nurse, the responsibility to check the sheet is everyone’s but stated that she did not know 3rd shift was responsible for reviewing them. When questioned as to whether she was aware R1 had a history of constipation, she replied no but added that she knew R1 was getting routine meds for constipation. Interview with Z6, who works full time on both 2nd and 3rd shifts stated she was unaware who was responsible, but did state that by the time the 3rd shift gets the information, it is too late to take any action and information is generally passed on to the 1st shift nurse. E4 stated she works full time on 1st shift and does not review the BM record nor does she take any action as the clients are already at day training. In addition, there are no job descriptions for the individual shift responsibilities. Therefore, none of the professional staff took responsibility to ensure that monitoring was consistent, information accurate and timely action was taken. The facility nursing has neglected to ensure that a bowel movement record is maintained accurately and current and is used to assess clients’ needs.
Per review of the BM record for July, R1 had only 4 BM’s between the 15th of July and the 28th of July. Per the record sheet, an “x” (denotes a BM) is marked indicating that a client had a bowel movement. According to the legend on the BM record, the size and consistency should be documented. E4 was asked why the legend was not used, she responded that the “x” indicates “normal soft formed” which is written in at the bottom of the sheet. All bowel movements documented for the 13 people for the entire month of 07/1999 was listed as a “normal soft formed”.
R1 had a documented movement on 07/15/1999 and 1st shift on 07/20/1999, five days later. On 07/22/1999, staff documented a BM on 1st shift and another on 2nd shift on 07/24/1999 and 1st shift on 07/27/1999, the day before she died. No indication of the size or consistency of the stool was documented. Interview with E4 indicated R1 had a bowel movement at day training on 07/27/1999 so the nurses didn’t worry. The faxed sheet from day training did not indicate amount or consistency. Interview with E7 who changed R1 on 07/27/1999 said R1 had a medium size stool describing it as “probably about 3" x 3". Z6, who was the nurse on duty when R1 went to the hospital, stated R1 was notably distended Z6 looked up R1's last BM and noted that it was at day training on 07/27/1999. Z6 was unaware of size or consistency but agreed that it would have been beneficial to know. Z1 was asked if she was aware that R1 had only 5 BM’s since 07/16/1999, and stated that she was not. The facility’s nursing staff failed to provide accurate, consistent documentation in regards to R1's bowel movements in order to determine if R1 was constipated, Z6 stated she did not have any training or inservicing on responsibilities including reviewing the BM records and taking further action.
Per the medical record, an entry in the nurses notes by E8 was documented on 07/27/1999 at 7 p.m. which read, “wing staff report abd lg. Upon exam abd soft - distended, had bm @ work today. Routine laxative given tonoc. Ate very little for supper.”. No notification of the physician was noted and no further assessment noted, e.g. vitals, bowel or breath sounds. At 9 p.m., the same nurse writes, “Abd. sl. distended. bsa (bowel sounds auscultated) x 4 without signs of distress, will watch closely”. No vital signs or temperature were taken, physician was not notified. The next entry into the nurses notes is at 2:30 a.m., 5½ hours later, by Z6 and states, “client t&p onto Rside per PA. No s/s (signs/symptoms) of distress. Client alert and responsive. Abdomen continues to be distended.” No bowel sounds, vital signs or breath sounds taken at the time. At 3:30 p.m., Z6 writes “abd very distended, listened for 10 to 15 min for bs (bowel sounds) et B/P”. No additional vital sounds are done. 15 minutes later, at 3:45 a.m., Z6 documents “call to Dr. informing him of client’s deteriorating condition. Respirations quick et (and) belly breathing skin becoming cool to touch @ distal extremities et sl (and slightly) discolored, inability to obtain B/P (blood pressure). Absence of BS (Bowel Sounds and) et abdomen being distended et very hard. Also, informed him of her level of alertness dropping et her becoming lethargic.” According to the nurses notes, 911 call did not come in until 4:30 a.m. with arrival at 4:37 a.m. Z6 did not respond when questioned regarding the time difference. Z6 stated she was aware that R1 had abdominal distention on 2nd shift because she had worked a double shift that evening but had not been directly responsible for R1.
Z6 stated she did not consider calling the physician as she had a bowel movement that afternoon at work shop.
The ER squad, at the time of arrival, noted R1 to be “unresponsive, pupils dilated, trachea midline, no JVD noted, chest intact with very shallow expression. Lungs clear in upper, absent in lower, fast shallow resp, abd extremely hard et distended, skin mottled cold dry. Pt has no movement, unable to auscultate BP (blood pressure) no radial or femoral pulse felt, fast carotid pulse felt...transported”. Time of arrival at the hospital was 4:54 a.m.
Hospital documents that client arrived with eyes open, extremities cold, fingers dusky, legs mottled, abd distended, firm. Unable to hear bowel sounds”. X-ray results of portable abdomen read “large lucency visualized throughout the left abdomen suggestive of free peritoneal air. When the patient is placed in the right decubitus position, the air shifts to the nondependent position”. Interview with Z1 on 07/29/1999 revealed that R1 had a bowel obstruction so severe that it caused a perforation in the intestinal wall where air and stool moved into the abdominal cavity. Z4 wrote “bowel obstruction with marked dilat. (dilation)” confirming that the obstruction was severe. R1 died at approx. 6:45 a.m. with only supportive care being given after the diagnosis had been made.
The nurses neglected to take prompt immediate action when R1's abdominal distention was first noted at 7 p.m. the previous night (07/27/1999). The nurses neglected to provide additional and consistent monitoring and assessment when R1 had a noted condition change. They failed to notify the physician of this change in a timely manner as he was not notified of the abdominal distention until 3:30 a.m. on 07/28/1999. The nurses neglected to maintain the clinical record in an accurate manner in that the time frames of the nurses actions conflict with the information provided by the emergency response team.
The facility neglected to provide R1 with nursing services in accordance with her needs.
1) Per the individual program plan (IPP), R2 is a 50 year old female who functions in the profound range of mental retardation. R2 is totally dependent on staff for all activities of daily living. R2 is non-verbal, non-mobile and has a gastrostomy tube for nutritional support. In addition, she has a diagnosis of spastic quadri paresis, cerebral palsy, osteopenia, peptic ulcer disease and seizure disorder. Per a GI consultation report dated 07/20/1999, R2 “has a long history of intermittent intestinal pseudo-obstruction for which she had a gastrostomy tube (G-tube) for drainage” and another consultant’s report dated 03/02/1999 which states “has recurring abdominal distention with fluid from the stomach exuding around her gastrostomy feeding tube.” The facility has neglected to provide R2 with nursing services in accordance with her identified needs regarding the gastrostomy tube. The facility has failed to provide all services necessary to maintain R2 in good physical health and failed to provide immediate supervision of the health needs of R2 regarding complications pertaining to the g- tube and stoma irritation.
Per the clinical record, R2 has a history of malfunctioning gastrostomy tube and has had multiple hospitalizations due to this. Per a GI consultant (Z7) note dated 02/10/1999, R2 has a g-tube that has had some problems with g-tube migration. It states “the stomach draws down and the outside clamp, which is suppose to hold the stomach in place slips because of the constant dressing. The balloon then slips away into the stomach and gets pushed down. This allows acid and bile to come out from the feeding tube hole around the tube and irritate the outside skin.” The note continues to state “the best solution to keep the g-tube snugged back against the inside of the stomach by pulling it back and taping it in place so that it cannot slip. This will both act as a block and not let bile and acid to go around the tube out to the skin outside and keep the tube from blocking the pylorus and causing vomiting”. Per review of the plan of care for R2, no intervention or plan was present addressing this identified need toward assuring proper placement of the tube and prevention of complications. Per a consultant note of 03/02/1999, R2 was seen in the wound clinic for recurring abdominal distention with fluid from the stomach causing irritation around the stoma as the previous consultant had suggested. Again, review of the IPP or plan of care did not reveal any information toward providing nursing care toward these needs to prevent further complications from misplacement or migration of R2's g-tube, or irritation at the stoma site. Review of the care plan updated 01/1999 and 04/1999 states R2 is high risk for impaired skin integrity r/t NPO (related to nothing by mouth) status, w/c (wheelchair) bound and inability to move self and g-tube ostomy site. However the plan states only 1) changes position every 2 hours, 2) provide skin care, 3) assess skin every day, 4) notify dietician et MD of impaired skin integrity and 5) see at wound clinic and TX (treatment) per Dr. orders. There is no mention of the recommendations of either consultant nor is there any interventions provided for the prevention of tube migration and stoma irritation.
Per review of the clinical record, R2 was again admitted to the hospital on 03/15/1999 when she exhibited a fever and slight increase in seizure activity. Per the history and physical written by Z2 dated 03/15/1999, R2 presented with increasing abdominal distention, fever and vomiting. Per the exam, she was noted to have foul smelling drainage emanating from the g-tube site. Per the hospital note dated 07/20/1999, Z2 states, “I saw her back in March of 1999 when she had the onset of worsening obstruction of her stomach with severe nausea, vomiting and some hematemesis (vomiting of blood). At that time, we found that the gastrostomy tube balloon had migrated down into the duodenal bulb, she was having ulcerations around this. As soon as we changed the gastrostomy tube and moved the balloon back into the stomach, she had resolutions of all symptoms”. It continues to state “she presents at this time (07/20/1999) with very similar complaints with decreased stool output, vomiting on several occasions, anemia and heme (blood protein) positive stool”. According to the IPP and the care plan, no information regarding nurses intervention was apparent to maintain R2's health in good physical condition by preventing complications with the g-tube.
Per interview on 07/30/1999, Z2 states that the migration of R2's g-tube was easily preventable provided the nurses secured the tube properly and monitor it “a little closer”. Z2 stated that hospitalization would not necessarily been required if her condition wasn’t as such. Z2 continued to state R2 exhibited very similar symptoms with the first hospitalization where she had a bowel obstruction with the tube migration and symptoms could have been recognized. However, he stated the hospitalization in 07/1999 also treated major irritation of the stomach caused by the misplacement of the tube. This caused the foul smelling drainage and the vomiting of blood.
Per interview with E4, R2's tube is secured but does still migrate. According to the nurse’s notes dated 07/14/1999 at 4 p.m., “client spit up small amount of brownish-colored fluid after staff did mouth care”. The feeding R2 receives is off white and would not turn brown in digestion. No physician notification was noted to have occurred nor was any additional assessments done such as vital signs, bowel sounds, etc. to further determine the seriousness of the symptoms. The next entry was dated 5 a.m. the next morning, 07/15/1999, which noted no emesis. Per the day training note, R2 had a large bowel movement on the 15th. At 10 p.m. on 07/15/1999, the nurse documented “client had emesis after bath this shift, T. 97.1, G-tube infusing easily at this time...” Again, no physician notification of the emesis, no description of the emesis was noted to determine if it was normal feeding or abnormal such as brownish colored or the amount. Per the nurses notes, on 07/16/1999, R2 was given a Dulcolax suppository (she receives on every other day) with no results. Per the nurses notes, R2 then had a Fleets enema at 3:30 a.m. on 07/17/1999 with no results. At 5 a.m. R2 had small amount of dark brown/black drainage from g-tube insertion site and no results yet from the enema given 2 hours before. No notification of the physician occurred regarding the drainage from the stoma site nor the absence of a bowel movement with both the suppository and enema. No further assessment was done by nursing to determine if the symptoms she exhibited were related to tube migration or not. No vital signs were recorded even though drainage at the stoma site was identified. The next entry into the nurse notes did not occur until 2 p.m. that afternoon (07/17/1999) and did not reflect the absence of a bowel movement. At 5 a.m. on 07/18/1999, the nurses notes state “sm amt blackish drainage around g-tube insertion site, slight redness around g-tube about 1 cm. Eroded area remains about 1/4 cm around stoma...still with no bm, fleets enema given, no emesis noted, has been restless tonight, gritting teeth”. According to the medication administration sheet, R2 has no results from the second enema and had gone 2 days without a bowel movement. At 9 p.m., the nurse notes state “feeding infusing without difficulty. Med. (medium) emesis of partially digested feeding...abd rounded and sl distended.” At 10 p.m., Z2 was called and orders received for a tap water enema. No indication in the notes whether the physician had been notified of the vomiting and brown/black g-tube drainage. No vital signs recorded. At 1 a.m. on 07/19/1999, R2 had no results from the tap water enema...“restless gritting teeth”.. again no vitals recorded. At 3 a.m., R2 had sm amt black drainage around g-tube site...tube migrating inward to about 1 inch below “Y”, gently repositioned et placement confirmed”. At 4:15 a.m., R2's “abdomen tensing et relaxing as if pushing to make bowels move”. No vitals recorded. At 5:10 a.m., R2 was diaphoretic, sm amt of black drainage to g-tube still noted and no bm. At 9 a.m., nursing notified physician of drainage and migration. No new orders noted. On 07/19/1999 at 6 p.m., the nurses notes indicate that no stomach contents were aspirated when placement of the tube was checked however air could be heard entering the stomach when an air flush was used. R2 still had no bowel movement. At 12:50 a.m. on 07/20/1999, client began to dry heave. She was immediately turned to her side and began projectile vomiting of foul smelling liquid. R2 was sent to the hospital per ER transport and was admitted with “upper GI bleed, probable malfunctioning gastrostomy tube”. Impression at the time of admission was “suspect with her abdomen distention and obstructive symptoms, a tube migration and obstruction is a possibility.” Per interview with Z2 on 07/30/1999, R2 had GI bleed from tube irritation. According to Z2, this was preventable with securing the tube and closer monitoring.
The facility nursing failed to develop a written plan of care for R2 in regards to her stoma irritation, g-tube malfunctioning and chronic constipation due to megacolon. The facility failed to modify the care plan to reflect her current daily needs after repeated hospitalizations for tube migration and subsequent complications regarding the g-tube. The facility nursing failed to provide adequate, complete and consistent monitoring and assessments of the stoma drainage, vital signs and abdominal distention in a timely manner. The facility failed to take measures to prevent reoccurrence of the migration and stoma irritation by developing an active treatment plan to ensure that R2 received nursing services in accordance with her needs.