PEDIATRIC REHAB INSTITUTE
Facility I.D. Number 0042788
7464 N. Sheridan Road
Chicago, IL 60626
Date of Survey 7/25/00
Incident Report and Complaint Investigation
The facility shall have a written program of Nursing Services, providing for a planned medical program, encompassing nursing treatments, rehabilitation and habilitation nursing, skilled observations, and ongoing evaluation and coordination of the resident's individual habilitations plan.
Nursing care (including personal, habilitative and rehabilitative care measures) shall be practiced on a 24 hour, seven day a week basis in the care of residents. Those procedures requiring medical approval shall be ordered by the attending physician.
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.
1) Record Review on 06/15/2000 at approximately 11:00 a.m. revealed R1, age 2, male admitted 05/11/2000 has a diagnosis of Developmental Delay, Gastroesophageal Reflux Disorder, Gastrostomy tube, Tracheostomy, Respiratory Distress. R1 expired on 06/09/2000. R1 had a history of tracheostomy extubation (removing his tracheostomy) on 06/05/2000, 06/04/2000, 05/29/2000. R1's Nursing Care Plan is as follows:
Review of Facility Investigation Report dated 06/12/2000 revealed that on 06/09/2000 E6, registered nurse "at approximately 5:10 a.m. went to R1's room to do trach care. E6 observed R1 lying on his back with a blanket loosely over R1's head, which is regular behavior for R1. E6 pulled back the receiving blanket, R1 was pink in color and his head was turned to the right. E6 noticed that the tip of the end of the tracheostomy cannula was out to R1's left side of his neck ties. E6 attempted to arouse R1, E6 checked respirations and none noted, pulse not palpable. E6 re-inserted the 4.0 Neo-Shiley Tracheostomy and began artificial respirations with ambu bag. R1 was bagged twice without resistance. Respiratory therapist call to room and E6 left room to get crash cart and dial 911"
Interview with E6 on 06/21/2000 at 6:05 a.m. revealed E6 did not observe client after approximately 1:30 a.m. until approximately 5:10 a.m. when E6 found R1 not breathing and with no pulse. E6 stated he made rounds at approximately 2:00 a.m. to 2:15 a.m. E6 stated he checked R1 from the door and did not do a face to face check of R1 to monitor his trach placement and tie or to see if he had an obstructed airway. E6 stated that R1 does sleep with covers over his head. Additional interview with E6 revealed he did not know R1 had a history of taking his tracheostomy out and did not know client had taken his tracheostomy out on 06/05/2000, 06/04/200, and 05/29/2000.
E5, Certified Nurses Assistant, was interviewed on 06/21/2000 at 5:10 a.m. E5 stated R1 was assigned to her on 06/09/2000. E5 revealed she last observed R1 face to face when she changed his diaper between 12:00 a.m. and 12:30 a.m. E5 stated after she made rounds and changed clients who were wet she went into the dayroom and talked with other staff until after 3:00 a.m., when she made rounds of her clients again. E5 said she did not observe R1 face to face but observed him from the doorway. E5 said she did not check to see if he was wet at any additional time after she changed his diaper at approximately 12:00 a.m. to 12:30 a.m. E5 revealed R1 does sleep with his cover over his head. Upon E5 completing rounds after 3:00 a.m. (states it took approximately 15 minutes) she returned to the dayroom until approximately 5:00 a.m. E5 said shortly after 5:00 a.m. E5 she went to room 117-2 and got an individual up who has to eat early and go to school. E5 did not observe R1 face to face to assess his condition after R1's diaper was changed on 06/09/2000 at approximately 12:00 a.m. to 12:30 a.m.
Interview with E7, Certified Nurses Assistant, on 06/21/2000 at 5:40 a.m. revealed E7 made rounds of all clients on the first floor which took approximately 15 minutes. E7 stated at approximately 1:30 a.m. she took all the clients' temperatures which included R1. E7 stated it took approximately 40 minutes to complete all the clients' temperatures. E7 stated she went into the dayroom until approximately 3:00 a.m. then made rounds of the clients she was assigned to which took approximately 45 minutes after which time she returned to the dayroom until approximately 4:45 a.m. E7 stated the last time she saw R1 was at approximately 1:30 a.m. and he was on his back with a blanket over his head and R1 got mad at E7 for taking blanket down. After E7 took the temperature, R1 pulled the blanket back over his head and turned to the side.
Interview with E3, Respiratory Therapist, on 06/19/2000 at 1:20 p.m. revealed E6 yelled to her at approximately 5:00 a.m. to come to R1's room. When she arrived, she observed R1's trach was out and E3 put it back in. E3 said the tracheostomy ties were not tied when she was with R1, the left tie was unsecured. E3 said R1 appeared rigid when E3 touched his arm to get a response. E3 stated R1 was not soft like he should have been when she touched his skin, lips were blue and cold. Additional interview with E3 revealed R1 did cover his head with bed covers when in bed but she did not see R1 anytime on the morning of 06/09/2000 until approximately 5:00 a.m. because R1 was no longer receiving direct care under respiratory therapy.
Interview with E12, LPN on 07/18/2000 at 5:50 a.m. revealed she was unaware of R1's history of removing his tracheostomy. E12 stated she did not see R1 or go into his room on the morning of 06/09/2000.
Interview with E2, Director of Nurses on 06/19/2000 at approximately 10:15 a.m. revealed the facility does not have written specific duties and responsibilities for night shift Certified Nursing Assistant. Additional interview with E2 revealed the facility does not have a written night shift (11-7) protocol for monitoring client but every 2 hours staff are to change clients' diapers. Further interview with E2 revealed the facility does not have a system for coverage while staff are on lunch/break. Follow-up interview with E2 on 06/21/2000 regarding R1 taking his tracheostomy out on 06/05/2000, 06/04/200, 05/29/2000, E2 said "we were monitoring him (R1) more closely". E2 also stated there had not been an Interdisciplinary Team Meeting to address R1's removing his tracheostomy nor had it been addressed in his nursing care plan. E2 stated she was not aware E6 did not know R1 had a history of pulling his trach out.
Interview with E4, physician, on 06/21/2000 at approximately 9:30 a.m. state he was not aware of R1's history of taking his tracheostomy out on 06/05/2000, 06/04/2000, and 05/29/2000. When asked if R1 could breathe on his own he stated "if he could, he would not have died."
Interview with Z2 on 07/10/2000 at approximately 12:30 p.m. revealed R1 was in the initial stages of decannulation. Z2 stated "medical standards are the client needed close monitoring and a cardiac monitor and did not have one. When I saw R1 in the clinic, I wrote orders for him, I did not write a Nursing Protocol for them (facility) since they should have one in place for individuals who are being decannualized."
Review of mobile Intensive Care Unit Report from the Chicago Fire Department on 07/12/2000 dated 06/09/2000 revealed they were called on 06/09/2000 at 5:16 a.m., on scene at 5:21 a.m., patient contact at 5:23 a.m. This report's initial assessment:
Review of hospital emergency service record on 06/26/2000 and 06/27/2000 revealed R1 arrived at hospital on 06/09/2000 at 5:40 a.m., in asystole - full cardiac arrest, no temp, pulse, respiration or blood pressure with grave lividity and rigor mortis. R1 pronounced (dead) at 5:45 a.m.
The facility failed to monitor R1 who was in initial tracheostomy decannulation on 06/09/2000 from 1:30 a.m. to 5:10 a.m. The facility also failed to ensure R1 was monitored and received nursing services in accordance with his medical plan.
2) Record review on 06/21/2000 revealed R4 age 7 1/2 months, female, admitted on 01/26/2000 with a diagnosis of Bronchopulmonary dysplasia, Tracheomalacia, Subglottic Stenosis and Perinentricular White Matter Cysts. R4 is on a mechanical ventilator with a tracheostomy. Additional review revealed on 01/28/2000 "was informed by the CNA, seen the patient turning purple the tracheostomy was accidentally pulled out, patient unresponsive, still breathing, RT (respiratory therapy) called and re-inserted. 911 call". 04/16/2000 5:30 a.m. "resident noted with trach out SPo2 54%, unresponsive, trach re-inserted". 06/06/2000 11:00 p.m. "CNA shouted for help, noted patient cyanotic, unresponsive, trach was out. Re-inserted 911 called". 06/16/2000 "seen resident was just finished being fed, wiggles a lot in apparent SOB (shortness of breath), trach checked noted not in place, resident turns cyanotic, try to re-insert trach with some difficulties, RT call, 911 called".
The facility failed to monitor R4 and take corrective action.
3) Record review on 06/21/2000 revealed R5 age 2 years and 5 months, male, admitted 01/27/2000 has a diagnosis of Cystic Stage 3, Ductus Arteriousus, Tracheostomy, Gastrostomy Tube. Additional review revealed R5 pulled his trach out on 06/05/2000 at 4:00 p.m., 06/06/2000 at 9:00 a.m., 06/06/2000 at 9:00 p.m., 06/12/2000 at 2:00 p.m. and 06/14/2000 at 11:00 p.m. The facility failed to monitor R5 and take corrective action.
4) Record review on 06/21/2000 revealed R6 age 4, male has a diagnosis of Profound Mental Retardation, Myotonic Dystrophy, Gastrostomy Tube and Tracheostomy Tube. R6 "removed trach" on 03/12/2000 at 6:30 a.m., 05/29/2000 at 2:00 p.m. "pulled trach out", 06/01/2000 "trach out", 06/07/2000 "pulled trach out". The facility failed to monitor R6 and take corrective action.
Review of R4, R5, and R6 medical care plans revealed the facility did not address the potential health risks from tracheostomy extubation for R4, R5, and R6.
The facility failed to monitor and provide corrective action for R4, R5, and R6 who have had multiple tracheostomy extubations which have a potential to adversely effect R4, R5, and R6's health and safety.