BRENTWOOD NORTH NURSING AND REHABILITATION CENTER
3705 DEERFIELD ROAD
RIVERWOODS, ILLINOIS 60015
Survey Date: 5/21/99
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.
Treatments and procedures shall be properly carried out.
All necessary precautions shall be taken to assure the safety of residents at all times.
An owner, licensee, administrator, employee or agent of a facility shall not abuse or neglect a resident.
These regulations are not met as evidenced by:
Based on record review, direct observation, staff and resident interviews, and review of facility records, the facility failed to ensure one resident was given a treatment in a safe manner resulting in burns sustained during a sitz bath.
The example is:
R 22 is an 86 year old with diagnoses including acute cerebral vascular disease, malignant neoplasm of lung, left mastectomy secondary to breast cancer, CVA with left sided weakness. Facility assessment dated 4/21/99 shows R 22 has short term memory impairment, has moderately impaired decision making skills (needs supervision), is totally dependent on staff for transfer and toilet use. The assessment shows R 22's mental function varies over the course of the day, R 22 is easily distracted and has episodes of disorganized speech.
Interview with E 1 reveals R 22 was alert, not oriented to place or time. When surveyors asked E 1 if R 22 could answer appropriately if asked if she was hungry E 1 stated "No" R 22 could not answer a question like that in an appropriate manner.
On 5/17/99 nurses note show R 22 was observed to have an "opened boil" to the right labia majora. R 22 was seen by a gynecologist on 5/17/99 who recommended sitz baths twice a day.
Interview with E 1 on 5/21/99 reveals that she and E 2 and E 3 gave R 22 her first sitz bath the evening of 5/19/99 at about 6:15pm. E 1 stated this was the first treatment of a sitz bath she had ever given. E 2 stated she had given this type of treatment before. E 1 stated she obtained the water for the sitz bath in a plastic basin from the coffee/tea urn in the kitchen. E 1 stated she wanted to let the water cool while R 22 was being prepared for the sitz bath. Water measured from the coffee urn on 5/20/99 at approximately 3:40 p.m. measured 180 degrees (per surveyor thermometer number 403).
Interviews with both E 1 and E 2 on 5/21/99 reveal some time elapsed before R 22 was placed on the sitz bath which had been placed on the toilet. E 1 stated she placed approximately 500cc of water into the sitz pan and R 22 was placed on the pan. E 1 stated she tested the water with her elbow and a F 1500 digital thermometer (meant for human oral temperature use) and measured the water temperature at 106 degrees. (The F 1500 thermometer only goes up to 110 degrees fahrenheit.) E 1 and E 2 both stated that after about 5 minutes R 22 seemed "restless" and was "bearing down" and R 22 was removed from the sitz bath. Both E 1 and E 2 stated they believed that during a sitz bath resident skin is not to be in contact with the water. E 1 stated the sitz bath was to "steam the boil." E 2 stated "the heat from the water will dilate the blood vessels." Facility policy and nursing practice indicate the sitz bath is used for cleansing an affected area with warm water flowing over the area.
R 22 was placed in bed after being removed from the sitz bath and when she was turned over E 1 and E 2 observed "60% of the right buttock and 40% of the left buttock had the first layer of skin peeled off." The physician was called and R 22 was transferred to the hospital for treatment for burns to the skin.
Interview with Z 1 on 5/21/99 reveals R 22 sustained first and second degree burns to the skin. Surveyor observed R 22 in the hospital on 5/21/99. Both buttocks showed first and second degree burns totaling 10cm by 10cm in size with sloughing of the left upper buttock and the entire area was beet red. R 22 appeared to be in a great deal of pain as evidenced by moans, facial grimacing, and stating she was in pain. When asked if she remembered the incident, R 22 replied "I screamed."