COTTONWOOD HEALTH CARE CENTER I.D. NUMBER 0034371 820 EAST FIFTH STREET P.O. BOX 950 GALESBURG, ILLINOIS 61402 As a result of a survey conducted by representative(s) of the Department, it has been determined the following violations occurred. "A" VIOLATION(S): 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. Adequate and properly supervised nursing 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 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. Each resident shall have an up-to-date care plan based on the resident's individual needs and goals to be accomplished, physician's orders, and personal care and nursing needs. The facility shall not neglect a resident. These regulations are not met as evidenced by: Based upon interviews and review of medical record documents, it was determined that the facility failed to respond to 1 of 1 residents in need of emergency care on the night of 12/08/98. Facility staff failed to monitor the alcohol intake of 1 resident known to ingest alcohol whenever it could be obtained. Facility failed to monitor 1 resident who was described as being "intoxicated" for any potential adverse reactions. Findings include: Interview with E5 on the morning of 12/18/98 revealed that E5 went to E3 on the night of 12/8/98 and told E3 that R1 was sitting in a wheelchair in resident's room and a "gurgling" noise was audible coming from R1. E3 did not go immediately to the room of R1. Interview with E3 on the morning of 12/18/98 verified what E5 had said when interviewed. E3 stated that E5 sometimes used the incorrect medical terms, so action on the part of E3 was not immediate. E3 stated it was probably ten to fifteen minutes before E3 went to R1's room on the night of 12/08/98. E3 stated a question remains in the mind of E3 that maybe R1 would be alive if response time had been quicker by E3. E6 was interviewed on the evening of 12/17/98 and the morning of 12/18/98. E6 stated that E7 had tried to get R1 to go to bed on the night of 12/08/98. R1 refused, so E7 went to the room of R1 to try to persuade R1 to go to bed. This was at approximately 11:00 p.m. R1 was observed sitting in room in a wheelchair with head tilted back toward the floor and "turning blue". E6 stepped outside the room and called for E3 who came immediately. Cardiopulmonary resuscitation (CPR) was started by E3 and E6 while E3 called for an ambulance. E6 and E3 continued CPR until the police arrived to relieve them. E6 stated mouth of R1 was checked before CPR was initiated and nothing was found inside the mouth. Documentation in record of R1 reads: "12/08/98 11:05 p.m. In wheelchair, unresponsive, unable to detect pulse or respiration. CPR initiated. 911 called. 12/08/98 11:11 p.m. Officers arrived at facility. 12/08/98 11:13 p.m. Rescue squad arrived at facility, took over CPR. 12/08/98 11:30 p.m. Ambulance left with resident on cart. 12/08/98 12:50 a.m. Hospital called, expired 12:01 a.m. On 12/18/98 when reviewed, death certificate listed causes of death to be: "a) endobronchial aspiration." "Interval between onset and death" is listed as, "Minutes." Additional cause of death on death certificate was, "emphysema." E3 stated there was a 10-15 minute interval between time "gurgling" was reported and assistance was given. Record revealed that R1 was a 47 year old male with diagnoses that included history of alcoholism, intertrochanteric fracture of the right femur 9/98, and history of seizure activity. Record contained no previous documentation of any problems with excessive secretions being present in mouth. R1 has a court appointed guardian. Interview with Z2 was done on 12/18/98 at 12:10 p.m. Z2 stated alcoholism was a reason that R1 was admitted to the facility and had a guardian appointed. Z2 stated no knowledge had been provided from the facility regarding R1's alcohol level when Z2 was contacted about the death. Z2 was not told that R1 had been drinking alcohol in the hours prior to death. Z2 stated toxicology tests were being done. Z2 stated this information was provided by E8. Interviews with E1, E2, E3, E4, and E6 revealed that all were aware that R1 had been drinking alcohol on 12/08/98 during the hours before death. No staff interviewed knew when alcohol was consumed. When interviewed, E6 stated it was clear at 10 p.m. when E6 arrived at the facility for work that R1 had been drinking alcohol and was "pretty well inebriated." E4 was interviewed on the evening of 12/17/98 by telephone. E4 was read information from the record dated 12/08/98. E4 verified that E4 had made the entry which read, "12/08/98 9:45 p.m. Resident found lying on floor of wing 2 bathroom, became very upset with assist back up into wheelchair. States all he wanted to do was urinate and rest. Alcohol present. Using profanity, slurring words. Hair, face, clothing wet from water on floor. Assisted to wheelchair, continues to use profanity all through transfer. Refuses to have vital signs taken. Refuses to let aide clean him or change clothes. Went into another resident's room and refused to leave. Verbally abusive to staff. Monitoring. When questioned, E4 stated writing of alcohol present meant the odor of alcohol was present. E4 stated R1 was in the front living area of facility when E4 left at the end of the shift. Documentation made by E3 at the beginning of the night shift read, "12/08/98 10:05 p.m. Sitting in wheelchair at desk, appeared sleeping. No respiratory distress noted. Wheeled to room. 12/08/98 10:30 p.m. Remained sitting in chair, condition same, went for assist to transfer to bed." Documentation and interviews indicate that resident was alone and unsupervised, with all staff present to care for R1 aware that resident had been drinking to excess and had a history of seizure activity. When told that resident was alone in room "gurgling", E3 failed to provide immediate response. All staff interviewed were unaware how long R1 had been drinking alcohol. All staff interviewed did not know where R1 was in facility when alcohol was consumed. All staff were aware that in the past resident would leave facility without permission and go to town drinking. Because of recent fracture R1 could not go to town. E6 stated that E6 had been told R1 was outside the back of the facility drinking with two friends and a relative of another resident. E1 stated when interviewed that R1 had gotten another resident to go to a store for R1 and purchase a fifth of vodka. No amount of consumption by R1 in what period of time could be determined by surveyor or E1. Z3 was interviewed on 12/18/98 at 11:30 a.m. Z3 stated knowledge that R1 collapsed at the facility and was dead at the hospital on arrival. Z3 stated report from emergency room physician noted possible causes of death to be cardiopulmonary arrest, seizure aspiration, or intoxication aspiration. Current care plan of resident provided to surveyor by E2 stated R1 is receiving anticonvulsant medications, which could have an adverse effect when mixed with alcohol consumption. Care plan also addressed resident's wanting alcohol, but did not provide any approaches for staff to use to monitor or check for possible alcohol consumption.