COLUMBIA CONVALESCENT CENTER
I.D. Number: 0037556
253 BRADINGTON DRIVE
COLUMBIA, ILLINOIS 62236
Survey Date: 5/19/99
The facility shall notify the resident’s physician of any accident, injury or significant change in a resident’s condition that threatens the health, safety or welfare of a resident, including, but not limited to, the presence of incipient or manifest decubitus ulcers or a weight loss or gain of five percent or more within a period of 30 days. The facility shall obtain and record the physician’s plan of care for the care or treatment of such accident, injury or change in condition at the time of notification.
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.
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.
AN OWNER, LICENSEE, ADMINISTRATOR, EMPLOYEE OR AGENT OF A FACILITY SHALL NOT ABUSE OR NEGLECT A RESIDENT. (A, B) (Section 2-107 of the Act)
These regulations are not met as evidenced by:
Based upon record review, interviews, observation and review of facility investigation report, it is determined that the facility staff failed to:
1) Immediately inform the attending physician and relative of R1 of a significant change to
R1's left eye;
2) Provide care to R1 in accordance with comprehensive assessment relative to R1's inability to maintain an upright, sitting position, which resulted in R1 falling and sustaining an injury; and
3) Provide care in a manner in which to avoid injuries from occurring to a resident.
Findings include:
Review of facility record reveals R1 to be admitted to the facility on 7-12-92 with a diagnosis in part of Congestive Heart Failure, Osteoarthritis, Degenerative Joint Disease and Glaucoma. R1 is 96 years old, dependent upon staff for personal care and is moderately impaired in cognitive skills.
Review of R1's Minimum Data Set (MDS), Quarterly review dated 2-5-99, reveals R1 to be assessed as non-ambulatory and requiring assistance of two persons to turn and position in bed and to transfer from bed to chair. The quarterly MDS of 2-2-99 reveals R1 would not be able to be tested for balance in sitting without physical assistance from staff to sit upright. The MDS also reflects R1 to have limited range of motion in all extremities and to be at a high risk for falls.
On 4-30-99, E3 was getting R1 dressed for breakfast. Per interview and signed statements, E3 states she had sat R1 on the side of the bed after partially dressing R1. E3 states she had placed her knee up against R1 to stabilize R1 at which time E3 reached behind herself to obtain a bottle of lotion. E3 states R1 tilted over “dead weight”, E3 heard a “bump” sound and R1 had fallen into the footboard of the bed. E3 states she raised R1 upright and R1 said “Oh, my eye”. E3 proceeded to finish dressing R1 and, with assistance of E4, transferred R1 from bedside to wheelchair and R1 was pushed to the dining room.
Although E3 was questioned as to why R1's eye was swollen, E3 did not report to anyone that R1 had fallen into footboard of bed. E3 denied knowing the origin of R1's injury to the left eye. R1's eye continued to swell and R1 was later transferred to an area hospital with a diagnosis of intraocular hemorrhage of the left eye, per record review.
Nurses notes of 4-30-99 reveal R1 to have swelling to the left eye which was observed by E2, E3, E4, E5, E8, E9 and E10 at approximately 6:45a.m. when R1 was taken to the dining room. All state that R1's eye was swollen, with bruising to left side of face and that this was not a normal condition for R1. E3 was questioned at this time by E4, E5, E7, E8, and E10 as to what had happened to R1 since E3 provided morning care to R1. E3 denied knowing what caused injury to R1's left eye.
Nurses notes reflect at 7:30a.m. R1 was examined by E7 who noted R1's left eye to be bruised and swollen and R1 was not able to swallow medication that a.m. E7 states per interview that these were not normal conditions for R1.
Further interview with E7 on 5-10-99 reveals E7 to learn during shift change report of R1 sustaining skin tears to her left arm. Staff asked E7 to come to the dining room and look at R1's eye. Upon examination, E7 states R1's left eye was swollen with bruising noted to the left side of face. E7 asked R1 what had happened but R1 did not respond. When E7 tried to apply an ice pack to R1's eye, R1 said “Oh” and put her hand up as if to push E7 away. E7 confirms nurses note of 4-30-99 0730 that E7 was unable to examine R1's left eye due to swelling and R1 complaining of eye hurting.
There is no notation in the medical record that indicates R1's physician was notified of R1's left eye being swollen until 1220 when E7 applied ice to R1's left eye again, however per interview of E7 on 5-14-99, E7 stated an attempt to notify Z1 was made at 10:22 a.m. E7 spoke to Z10 who would have Z1 return call. When Z1 returned call to facility at 11:15 a.m., E7 informed Z1 of R1's left eye continuing to swell and that an ice pack had been applied. Z1 gave E7 an order to apply an ice pack three more times on 4-30-99.
Interview of E12 on 5-18-99 reveals E2 to state that Z1 would have been notified by E7 between 9:15-9:30 a.m. on 4-30-99, as E2 had asked E7 in passing if Z1 had been notified and E7 said yes. E7 states per interview, swelling continued to R1's eye as E7 was checking on R1 at frequent intervals that morning but did not chart same.
At 12:20 p.m., E7 applied ice again to R1's eye at which time E7 noted the left eye to be more swollen and “serous bloody drainage present”. E7 called Z1 to notify of drainage to eye and spoke to Z10. Z1 returned call to facility at 1:00 p.m. and gave an order to E2 to transfer R1 to the hospital. R1 was transferred to an area hospital at 1:52 p.m .and admitted with a diagnosis of left eye trauma with loss of vision and soft tissue contusion.
R1 was later examined by Z9 and diagnosed as having “left intraocular hemorrhage”. Per written statements, Z2 indicates prognosis for R1 is “poor for left eye” and that this type of injury would be consistent with R1 falling onto a wooden bed post. Z2 also indicates that had R1 received immediate examination and treatment at the hospital, the outcome and present condition of R1's eye would not be the same.
Observation of R1 on 5-7-99 at the hospital revealed R1 to be positioned upright, being assisted to eat lunch by staff. R1 has noted bruising to the left side of face, with bruising extending down to neck area.
Surveyor attempted to interview R1. R1 is hard of hearing and was somewhat agitated and moaning when surveyor attempted to talk to R1. Attempt at interview was discontinued as R1 was visibly in distress.
Also on 4-30-99 E3 provided morning care to R1, including dressing R1. While attempting to put a dress on R1, E3's ring caught the left arm of R1 causing two skin tears. E3 cleansed the areas and applied steri strips to the arm, as reflected in nursing notes of 4-30-99.
Interview of E3 confirms that E3 was wearing a ring that had missing stones and this caused the skin tears.
IMPOSED PLAN OF CORRECTION
COLUMBIA CONVALESCENT CENTER
DATE OF SURVEY: 5/19/99
The facility will ensure that each resident’s physician is notified of any accident, incident or significant change of condition that is threatening to the health and safety of the resident.
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.
The facility will ensure that objective observations of changes in a resident’s condition as a means for analyzing and determining care required and the need for further medical evaluation and treatment are made by nursing staff and recorded in the resident’s medical record.
Residents shall not be neglected in their medical care.
This will be accomplished by:
1. The facility will assess it’s current policies and procedures for
A) physician notification in the event of a resident accident, incident, or condition change;
B) appropriate staff intervention in meeting resident personal care/nursing needs and assistance in movement to assure residents’ health and safety needs are met.)
A system will be developed (such as a flow sheet or log) whereby notification of the Charge Nurse, by nursing staff or other personnel, regarding accidents, incidents, and changes in a resident’s condition will be documented when observed. The time of the response and the nature of the response will also be documented. Documentation of this system will be maintained.
Facility staff will follow these written policies and procedures.
2. Facility staff will make and record in resident’s record objective observations of significant changes in a resident’s condition. The physician will be notified immediately by facility staff of any accident, incident, or significant change in a resident’s condition so a physician’s plan of care and treatment may be obtained. Staff will document in the record this notification, including who was notified, date, time, and physician’s response.
Nurse’s aides will be made aware of specific job duties and responsibilities and their accountability to the facility if a resident is injured due to their action and/or lack of action.
Care plans will address resident safety through general oversight. Facility staff will utilize care plans to assure that each resident’s needs are met through appropriate staff intervention in a timely manner. Supervisory staff/Charge Nurses will ensure that direct care staff are made aware of the care required by each resident they are assigned to.
3. MANDATORY inservices will be held for all licensed and unlicensed nursing staff
within 30 days to address, but not limited to:
A. Proper resident monitoring;
B. Instruction to licensed staff to report resident accidents, incidents
or changes in condition to persons in charge;
C. Nurses’ actions to be taken when an accident, incident, change in a resident’s condition occurs; Documentation guidelines and requirements of the facility;
The disciplinary actions to be taken for any staff failing to report, monitor, or take proper action when there is a change in a resident’s condition or accident or incident involving a resident; and
A. Any new and/or revised policies and procedures for notification of the physician of changes in resident’s condition, any accident or incident.
4. The monitoring responsibility for this Plan of Correction will be as follows:
The Charge Nurse on each shift will monitor staff performance to ensure that resident’s are appropriately cared for and that the resident’s physician is notified when an accident, incident, or change in condition occurs.
The Director of Nursing will review the documentation system identified in I.
The Administrator will be responsible for overall monitoring of this plan of correction.
COMPLETION DATE:Within thirty (30) days of the receipt of this notice.