BEL-WOOD NURSING HOME
Facility I.D. Number 0004499
6701 W. Plank Road
Peoria, IL 61604
Date of Survey:06/19/01
Notice of Violation:07/31/01
The facility shall assure that residents plans of care are individualized, written in terms of short and long-range goals, understandable and utilized; and their needs are met through appropriate staff interventions.
The facility shall notify the residents physician of any accident, injury, or significant change in a residents condition that threatens the health, safety or welfare of a resident. The facility shall obtain and record the physicians plan of care or treatment of such accident, injury or 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 psychosocial well-being of the resident, in accordance with each residents 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.
Objective observations of changes in a residents condition 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 residents medical record.
All nursing personnel shall evaluate residents to see that each resident receives adequate supervision and assistance to prevent accidents.
Each resident shall have a comprehensive assessment of the residents needs, which include medically defined conditions and medical functional status, sensory and physical impairments, nutritional status and requirements, psychosocial status, discharge potential, dental condition, activities potential, rehabilitation potential, cognitive status, and drug therapy.
Each resident shall have an up-to-date resident care plan based on the residents comprehensive assessment, individual needs and goals to be accomplished, physicians orders, and personal care and nursing needs. The plan shall be in writing and shall be reviewed and modified in keeping with the care needed as indicated by the residents condition.
An owner, licensee, administrator, employee or agent of a facility shall not abuse or neglect a resident.
These requirements are not met as evidenced by:
1) R1 was admitted on 4/30/98 with diagnoses of Insulin Dependent Diabetes, Congestive Heart Failure, and Coronary Heart Disease. Per interview with E3 per telephone on 6/1/01 at 1020, E4 per telephone at 1000, E6 in administrator's office on 5/31/01, and E7 in administrator's office on 5/31/01, R1 is alert and oriented to time, person, and place. Per record review, on 5/20/01 at approximately 10:15PM R1 was admitted to the emergency room with diagnoses of Congestive Heart Failure and Pneumonia versus Pulmonary Embolism. Z2 was interviewed at 1015 on 6/8/01 and Z4 was interviewed per telephone on 6/1/01 at 2:50PM. Both validated upon interview that R1's final admitting diagnoses were Myocardial Infarction and Congestive Heart Failure.
R1 was interviewed in her room at 12:40PM on 5/31/01. R1 was oriented as to number of years in facility, date, time, place, meal served at supper on 5/20/01, number of days of hospitalization, number of days in Intensive Care Unit, fall incident in the past, and facility procedure concerning a "head of house". During the interview on 5/31/01 R1 stated she told "the nurse", E2, "that she was not feeling good at around supper time at 5:30PM." R1 stated that E2 told her to "go lie down." "I went to my room, changed my clothing to go to bed and sat in my chair here in my room. It was around 6:15PM when I got finished dressing. Then I started hollering for help because I knew something was wrong and I needed to go to the hospital. I couldn't breathe." "The first time the nurse came was when E2 brought me my medicine and E2 was late getting medicine here. It was around 8:30PM. E2 told me to take my medicine and go to bed. I did not know the nurse that was here. She wasn't a regular nurse that works here. No one but my little aide came back to help me. She finally got me help." R1 stated she knew something bad was happening and wanted to go to the hospital. R1 stated, "the oxygen was not even applied until shortly before the ambulance came." R1 stated, "I just couldn't breathe and it just kept getting worse. I could have died. I just don't want it to happen to anyone else."
E3 was interviewed per telephone on 6/1/01 at 10:20AM and E4 was interviewed per telephone at 10:00AM. The facility did an investigation and obtained written statements from both staff persons. Both staff stated R1's symptoms warranted a nursing response, physician notification, and the initiation of oxygen by approximately 6:15PM. Both stated they were aware of changes of condition about 2 to 3 hours before they could get the nurses to respond. Both E3 and E4 stated that E1, nursing supervisor, and E2, medication nurse for that unit, were frequently made aware of R1's condition and concerns on 5/20/01 from 6:15PM on. In their interviews, E3 and E4 stated that at 6:15PM both nurses were aware of R1's "difficulty breathing, being cold, clammy; but, they did not provide oxygen until around 8:30PM and did not notify the physician until around 9:00PM." E3 stated that R1 was short of breath, diaphoretic, flushed, cold, and pulse oxygen level was 80% at 6:15PM. R1 was "begging to go to the hospital by 8:00PM and when I did the second pulse oxygen study at around 8:15PM." E3 and E4 both stated that R1 kept saying, "I'm sick. I want to go to the hospital. I'm dying." Both stated that in the end R1 could be heard moaning all the way down the hall.
The record review indicates that the vital signs were taken only one time on 5/20/01 from 5:30PM to 10:00PM, with nurses unable to validate any further vital sign assessments. E1 and E2 cannot remember doing a full assessment of breath sounds and physical condition more frequently then just at 9:15PM. E2 documented the vital signs on 5/20/01 at 9:15PM as: "pulse 120, respirations 36, blood pressure 172/96, temperature 98 degrees, oxygen saturation 88%". The nurse notes also indicate that E2 was aware of R1's changes at 5:50PM and 8:30PM. Per record review, E1 documented in the Universal Progress Notes the vital signs at 9:15PM as: "temperature 98, pulse 55, respirations 36, blood pressure 172/96, very anxious, requesting to go to ER". The time frames of the nurses notes do not match the time frames mentioned in the multiple statements of staff and R1. They do not show the sequence of events as they occurred. The nurses notes and staff both indicate that the ambulance arrived around 10:00PM and R1 was transported to the hospital.
E3 and E4 stated the only one that took vital signs on R1 was E4. Per the investigation report E4 indicated the vital signs were taken between 8:40PM and 9:00PM and were as follows: "blood pressure 138/90, pulse 174, respirations 42, and oxygen saturation 76%". These vital signs do not appear on R1's record.
Per hospital admission history and physical dated 5/20/01 R1 was admitted to the hospital with "blood pressure 148/70, pulse 108, respirations 24, temperature 97.7%, on 1.5 liters of oxygen... poor air movement in bilateral lungs, positive wheeze, positive rules at bilateral bases, 2+ edema bilaterally... Congestive Heart Failure secondary to Pneumonia versus Pulmonary Embolisms."
Z1 and Z2 were interviewed and stated that they "could not guarantee that an earlier response would have changed R1's outcome, but that it could have. Rapid response to a myocardial infarction is always warranted." Z2 stated he would have had R1 "transferred to the hospital if he had been notified that she was requesting this and had the symptoms as indicated at the time." 2) R3 was admitted on 6/9/97 with diagnoses of Dementia and Cerebral Vascular Accident. R3 is dependent on staff for all activities of daily living. On 5/30/01 R3 was admitted to the hospital with Sepsis, Severe Dehydration, and Urinary Tract Infection.
The only nurses notes are as follows: 5/26/01 "128/76."; and 5/30/01 7-3 "T-97.4, P94, R20, B/P 134/94. Up in high back wheelchair for breakfast per lift. Fed per private CNA. Appetite very poor. Hesitates to swallow. Very lethargic this AM. Speech therapist here for swallow evaluation. Resident refused lunch, letting all liquid run out of her mouth. 12:30PM Supervisor notified of apparent declining condition, B/P 130/88, T 97.2, P 88, R 16. 1:10PM Transported to hospital per ambulance..."
The universal progress note indicate on 5/14/01 that R3 was being transported for a blood transfusion. The next note on this form is by Z1, physician's assistant, on 5/30/01 at 0845, "Husband called with concern about decline in oral intake... staff concur - state better today tho: ... obtain urinalysis and labs in AM. Start Cipro after urinalysis... will call husband." Next note is by supervisor at 12:30PM, "Staff reports further decline - speech pathology unable to get resident to swallow anything. Eyes open to stimuli but will not follow commands - urine very strong smelling. Skin warm and dry, pale, 97.2-88-16- 130/88. Notified husband of decline and he opted for hospital evaluation to rule out CVA verses UTI... Z1 notified... resident admitted with UTI, Severe Dehydration et Sepsis."
E5, RN - day supervisor, was interviewed in the administrator's office on 5/31/01 and stated that on 5/26/01 R3's husband requested that R3 see Z3, physician, due to R3 not eating. E5 stated she made a note in the communication book for Z3 to see R3 on 6/1/01, but did not go assess R3's condition at that time. E5 stated she saw R3 up in the chair that day and did not see any problem, but she did not assess the allegation that R3 was not eating.
There is no documented assessment of R3's condition from 5/26/01 to 5/30/01; yet the staff indicate they were aware of R3 was not eating per usual, with nutritional intake sheets and fluid intake records showing a decline in oral intake. The nutritional intake sheets show a 0-10% intake since 5/26/01 and the fluid intake sheets show decline in fluid intake with the average intake being approximately 0 to 380cc per shift since 5/26/01. R3 had a physician order to "encourage fluids at least 1500cc/day, intake and output".
R3's plan of care addresses the problems of dehydration and risk for urinary tract infections with approaches not documented as done.
3) R2 was admitted on 5/3/01 with diagnoses of Dementia and Degenerative Joint Disease. Per record review, R2 was independently ambulatory and admitted from another nursing home with a ½ inch skin tear on the right elbow. Per review of incident reports R2 had 8 falls from 5/11/01 to 5/28/01 with a lack of assessment of the injuries sustained from the multiple falls.
Z1, physician's assistant, saw R2 at 10:10AM on 5/21/01 after R2 had fallen two times on 5/20/01. Z1 documented the following, "Staff report fall with head injury. Up with Merry Walker. Alert. PERRLA. MAEW. Gait steady but makes poor transfer... 7cm yellow/dark blue hematoma post medial parietal area. Nontender - abrasion right elbow and right forearm with edema, erythema, mild increased heat. On Keflex until 5/24 or 5/25 for cellulitis of the right lower lip."
The nurses notes of R2's record contain no assessment of R2's parietal bruising. There is no assessment of R2 having any edema with erythema and warmth of the right forearm on the record. The only note assessing the right lower lip is on 5/15/01 at 1230, "On antibiotic for mouth infection, right jaw red and swollen...".
On 5/21/01 at 1600 the nurses notes indicate the following assessment, "Purple bruises noted on bilateral hips and coccyx." There is no assessment as to the size or location of these bruises. There is no further assessment of any bruising until 5/25/01 at 0130, "Found on floor at front of bed - by wall with left hand on foot board - legs out stretched - full ROM - ...no known injuries - tab alarm not in place... bilateral hip blue - to red patches noted prior...". At 0430 R2 was transferred to the hospital, but there is no assessment that indicates why on the nurses notes. The supervisors notes indicate that R2 keeps legs drawn up, received order to transfer to the hospital. Though the hospital records indicate that R2 had a compressed fracture of the right hip, the administrator and DON stated in the end there was no fracture.
Per nurses notes R2 fell on:
5/11/01 at 0120,
5/15/01 at 1900 with skin tear to right lower arm,
5/16/01 at 1225 "left elbow hurts",
5/16/01 at 2150,
5/20/01 at 0520 "abrasion to left elbow",
5/20/01 at 1650 only documented on incident report with assessment of following injuries also only on incident report "hematoma back of head/neuro's monitored...",
5/25/01 0130 "keeps legs drawn up, sent to emergency room.",
5/28/01 1215 "left on floor due to complaints of hip pain... bruising noted on right hip bluish purple with some yellow."
Per DON and Administrator R2 was once again found to have no hip fracture, but as of 5/31/01 R2 was still at the hospital.
R2's care plan was initiated on 5/3/01 and updated on 5/11/01 addressing falls with the following approaches: "encourage slow pace, discuss running or picking items up off floor, encourage to walk close to side rails, enclosed chair walker trial for ambulation, Tylenol for knee pain." Care plan was not updated as to new approaches to prevent further falls and nurses notes do not contain individualized assessments of R2's injuries from falls and changes of condition associated with the injuries from the falls.