COUNTRYSIDE H.C.C.
Facility I.D. Number 0036632
1635 E. 154th St.
DOLTON, IL 60419
Date of Survey: 4/5/01
Notice of Violation:7/18/01
Complaint Investigation
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 resident’s 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.
Personal care shall be provided on a 24-hour, seven day a week basis. This shall include, but not be limited to, the following:
All necessary precautions shall be taken to assure that the residents’ environment remains as free of accident hazards as possible. All nursing personnel shall evaluate residents to see that each resident receives adequate supervision and assistance to prevent accidents.
AN OWNER, LICENSEE, ADMINISTRATOR, EMPLOYEE OR AGENT OF A FACILITY SHALL NOT ABUSE OR NEGLECT A RESIDENT. (Section 2-107 of the Act)
The facility must ensure that each resident receives adequate supervision and assistance devices to prevent accidents.
This REQUIREMENT is not met as evidenced by:
Based on closed record review, review of Dolton Police Depts. Death Investigation report, review of Dolton Fires Depts. Investigation narrative, review of the Coroner’s report, staff, and other interviews, it was determined that the facility failed to monitor, and attend to 1 of 5 resident’s sampled who required close supervision while receiving a tub bath. This resulted in the resident drowning.
On 07/18/00 review of R#2's closed medical record denotes, R #2 had a medical diagnoses of cardiovascular accident with left side hemiparesis, contractures of the upper and lower extremities, seizure disorder, tardive dyskinesia, dyspagia, dementia with delusions, and asphasia.
Minimum Data Set (MDS) documentation denotes, R#2's cognition was severely impaired, and the test for balance while in a sitting position, and trunk control not able to attempt test without physical help. The nursing progress notes dated 07/16/00 denotes, on 07/16/00 at approximately 3:25p.m. (Parapharased) staff were summoned to the 1st. Floor tub room. Located in the A wing across from the nurses station. On arrival E #5 and E #7 observed R #2 in the bathtub with white frothy secretions coming from her mouth. Resident #2 was coughing, and had shallow respirations. Finding include:
Resident #2's respiratory rate 16, pulse 72, blood pressure faint, and R #2's skin color was fair. Resident #2 was suctioned, and oxygen was started at 3 liter via nasal cannula. Staff placed a call to 911. The Dolton Fire Depts. EMS unit arrived. Resident #2 was transferred to St. Margaret Hospital at approximately 4:00p.m. via CoMed ambulance service.
At approximately 5:40p.m., E #2 received a call from St. Margaret Hospital informing the facility, that R #2 had expired at 5:17p.m. of cardio pulmonary arrest. Review of the Dolton Police Depts. Death Investigation report dated 07/16/00 denotes, St. Margaret Hospital Hammon Indiana, charge nurse stated, the victim (R #2) was wet from head to toe and the xray revealed water in the lungs.
The emergency room physician pronounced R #2 at 17:15 hours as having no signs of life, and listed the cause as cardio pulmonary arrest, and drowning. Interview by the reporting officer with E #4 denotes, E #4 stated, he left the victim ( R #2) unattended in the tub filled with water for approximately 3 minutes. Review of the Dolton Fire Depts. Supplemental EMS incident form dated 07/16/00 denotes per responding personnel partner (EMS) “1 attendant (CNA) in the nursing home, told the responding personnel he left R #2 unattended in the tub for 3 minutes”.
Interview with E #3 on 07/18/00 at approximately 11:00 a.m. in the 1st floor conference room Employee #3 stated, on 07/16/00 she was assigned to R #2. At approximately 3:15 p.m. E #3 asked E #4 to help her give R #2 a bath.
Once R #2 was placed in the bathtub, (per E #3 there was only 3 inches of water in the bathtub) E #3 left R #2 with E #4, to go and make R #2's bed. A few minutes later E #5 called out asking E #3 to call 911, and to bring the blood pressure cuff, and the stethoscope to the tub room.
Interview with E #4 on 07/19/00 at approximately 8:08a.m. via telephone from the facility to the department.
Employee #4 stated, on 07/16/00 between 3:15p.m. and 3:20p.m. E #3 asked E #4 to help her give R #2 a bath.
Employee #4 stated, once R #2 was in the bathtub E #3 left the tub room to make R #2's bed. Employee #4 stated, R #2 began to cough up a white substance. Employee #4 called for help.
Employee’s #5, and E #7 responded.
Employee’s #4, #5, and #7 lifted R #2 from the tub, and placed her on the floor.
Employee #7 called for someone to call 911.
Employee #5 called for someone to the bring the breathing machine (Oxygen).
Employee #4 stated, a few minutes later the Paramedics arrived, and E #4 left the tub room. Resident #2 was transferred to the hospital. Employee #2 stated, he stayed with R #2 while she was in the tub, never leaving R #2 unattended. Stating, “I held R #2 up while she was in the bathtub”.
Interview with Z #2 on 07/19/00 at 2:40p.m. via telephone stated, an autopsy had been done on R #2. The preliminary report denotes, the cause of death was drowning. Water was found in R #2's stomach, and lungs.
On 01/30/01 review of the final Corner’s report dated 11/01/00 established the cause of death, Asphyxia due to Drowning.
Date of Survey:4/11/01
Notice of Violation:7/18/01
Complaint Investigation
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 resident’s 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.
A regular program to prevent and treat pressure sores, heat rashes or other skin breakdown shall be practiced on a 24 hour, seven day a week basis so that a resident who enters the facility without pressure sores does not develop pressure sores unless the individual’s clinical condition demonstrates that the pressure sores were unavoidable. A resident having pressure sores shall receive treatment and services to promote healing, prevent infection, and prevent new pressure sores from developing.
AN OWNER, LICENSEE, ADMINISTRATOR, EMPLOYEE OR AGENT OF A FACILITY SHALL NOT ABUSE OR NEGLECT A RESIDENT. (Section 2-107 of the Act)
Based on the comprehensive assessment of a resident, the facility must ensure that a resident who enters the facility without pressure sores does not develop pressure sores unless the individual’s clinical condition demonstrates that they were unavoidable; and a resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing.
This REQUIREMENT is not met as evidenced by:
Based on direct observation, clinical record review, and staff interview the facility: physical, mental, and psychosocial well-being of the resident, in accordance with each resident’s
1) failed to ensure that residents (R#1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13) who entered the facility without pressure sores did not develop pressure sores, and
2) failed to provide turning & repositioning (R#1, 2, 3) incontinence care (R#3) supportive deices (R# 2 & 3), and nutritional support (R#2) to promote healing, prevent infection, and prevent new sores from developing for 3 residents.
Findings include:
1) R#2 was readmitted to the facility on 1/5/01 with no decubitus ulcers. The nurses’ note dated 1/5/01 states, “Has no skin problems or lesions present in past 7 days, all skin intact.”
2) R#2 developed 16 decubitus ulcers between 1/17/01 and 3/23/01. The resident was hospitalized on 3/23/01. The nurses’ notes documented the following:
1/17/01 Right Buttock-Stage II-2X3
1/17/01 Left Buttock-Stage II-1X1
1/17/01 Left Foot-Stage II-3X3
2/09/01 Left Great toe-Stage I-1X1
2/09/01 Coccyx-Stage II-1X1
2/23/01 Right Hip-1X1
2/23/01 Left Foot #1-1X1
2/23/01 Left Foot #2-4X2
2/23/01 Right Foot #1-2X2
2/23/01 Right Foot #2-2.5X3
2/23/01 Left Hip-8X7
2/23/01 Left Knee-1X2
2/23/01 Lower Back-3X2
2/23/01 Left Upper Back-3X1
2/23/01 Right Upper Back-2X2
The wounds addressed in the nurses’ notes on 2/23/01 were listed with sizes, but the staging, color and drainage information was non-specific. The nurses’ note of 2/23/01 stated that all of these wounds were Stage II or Stage III and “pink, reddened, greenish-yellow” and “purulent”.
3/14/01 Left Foot #3-Stage II-4.5X4
3/14/01 Left Elbow-Stage II-3.5X2
3/14/01 Left Shoulder-Stage II-4X3
The wounds above were photo documented on 3/14/01; they were not addressed in the nurses’ notes until 3/19/01. On interview 4/3/01, when brought to the attention of E#2, there was no response.
On interview 4/9/01, E#4 indicated that R#2 developed the above listed ulcers because of age and poor nutrition.
3) R#2 did not receive the necessary treatment and services to promote healing, prevent infection and prevent new sores from developing as evidenced by the following:
According to R#2's Clinical Record:
4) According to the facility’s “Weekly Pressure Ulcer Report” between 1/04/01 and 03/23/01 at least 13 residents developed pressure sores within the facility. (R#1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13). In addition, there is a “Lower Extremity Ulcer Report” that includes acquired wounds, however, the report does not distinguish between pressure ulcers and vascular ulcers.
5) On 4/2/01 it was observed that R#1, a resident with multiple decubitus ulcers was not repositioned every 2 hours according to the posted turning schedule. The schedule indicated that the resident is to be on her back from 11 a.m. until 1 p.m. and on the right side from 1 p.m. until 3 p.m. The resident was observed to be on her back from 11:35 a.m. until 2:45 p.m.
6) On 4/2/01 R#3 was observed to be seated in a Geri-chair from 11 a.m. until 2:45 p.m. when staff were requested to place her in bed for observation. The resident was noted to have a strong urine odor. R#3 has severe contractures to both lower extremities resulting in her knees being continuously pulled up to her chest. When transferred, it was noted that the pad an dthe sheet on the Geri-chair were soaked with urine and had rings from dried urine. The resident’s decubitus ulcer had no dressing. E#4 stated that the resident pulls it off. R#3 has a previous history of decubitus ulcers including a current Stage II on her coccyx (as documented in the nurses’ notes). There is no order for a protective cushion to be used in the chair and none was observed.
Date of Survey:4/11/01
Notice of Violation:7/18/01
Complaint Investigation
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 resident’s 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 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. (Section 2-107 of the Act)
The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property.
This REQUIREMENT is not met as evidenced by:
Based on direct observation, record review, staff interview and physician interview, the facility failed to ensure that one resident (R#2) was free from neglect by:
1) failing to assess R#2 for pain and failing to implement a pain management program;
Finding include:
According to the nurses’ notes on 1/1/01 and 1/2/01, R#2 had a fall which resulted in a left hip fracture on 1/1/01. On interview on 4/2/01 at 1:00p.m., Z#2 stated that prior to the fall, R#2 was ambulatory with a walker. On interview on 4/9/01, E#8, E#9, and E#10 confirmed that R#2 was ambulatory prior to the fall.
According to interviews with Z#3 on 4/9/01 at 4:30p.m. and Z#4 on 4/4/01 at 4:30p.m., Z#2 decided that the corrective surgery should not be done because of R#2's age.
The nurses’ notes on 1/5/01 document that the resident was returned to the facility on 1/5/01 with an untreated fractured hip. On readmission, the nurses’ note states, “No skin breakdown noted”.
1) From 1/5/01 until discharge to the hospital on 2/23/01, the facility documented in the nurses’ notes that R#2 experienced pain that ranged from mild to severe, the inability to straighten her left leg, intolerance to being touched, and the inability to reposition herself.
There is no assessment that comprehensively documents and describes the resident’s level of pain in order to address the need for pain management. The nurses’ notes described her pain as:
1/5/01 14:41:04 Expression: “pained”
1/5/01 14:44:57 Pain: “sharp radiating”
1/5/01 14:59:01 Musc/skeletal cond: “(deep and aching)(sharp) tender on palpation)(severe pain) in left hip(s) Fracture”
1/5/01 15:12:43 Resident Complaints: “resident experiencing generalized pain (severe pain)
1/5/01 15:47:28 “Resident will not straighten left leg out, tender to touch, resident yells when you try touch site.”
The nurses’ note on 1/5/01 states that an order was received for Vicodin 500mg 1 tablet every 4 hours as necessary (PRN) for pain. The Medications Administration Record (MAR) for 1/5/01 indicates that no Vicodin was administered.
The nurses’ notes continue to document episodes of pain such as:
1/21/01 “(severe pain) related to it hip fx keeps leg drawn up” sharp severe pain unchanged continues to complain of tenderness when touched”PRN med relief described as, “minimal relief” (20 days after the fall)
1/28/01 “Noted to be on fetal position always.
Unable to straighten legs, resident screams in pain” (27 days after the fall)
2/5/01 R#2's pain is described as “steady”, has joint pain experiencing pain UNABLE TO VOICE. The nurses’ notes goes on to address ACTIONS: as “PAIN MED. TO BE ORDER”. According to the MAR., no pain medication was administered on 2/5/01. (35 days after the fall)
3/13/01 “Res still have pain, grimaces, screams when turned or touched” (71 days after the fall).
There is no indication in the nurses’ notes or the physician progress notes that the physician was aware of R#2's level of pain. On interview on 4/4/01 at 4:30p.m., Z#4 stated that he was not aware that R#2 was having severe pain and could not tolerate being touched, that if he had known, he would have changed her medications to include a “patch” mediation because R#2 “cannot ask” for pain medication.
The resident had an order for Vicodin 500mg every 4 hours PRN to be given for pain. The mediation was administered sporadically as evidenced by the documentation on the MAR. On admission to the hospital on 3/23/01, the R#2 was given a Duragesic Patch for pain control according to Z#4 on interview 4/4/01.
There was a least 6 days between 1/5/01 and 3/23/01 when the nurses notes documented that R#2 was in pain and no medication was administered. (1/5/01, 1/25/01, 2/5/01, 2/9/01, 3/19/01, and 3/20/01)
On interview 4/3/01 at 11:15a.m., E#5 stated that he worked at the facility for about 1 month and had taken care of R#2. He further stated that the resident was in pain and he could tell because of the “look on her face when she was turned and the noises she made.” E#5 also stated that he tried to limit moving her to the times that she was changed because it was so painful for her.
On interview, on 4/9/01 at 3:35p.m., E#7 stated that she had cared for R#2. She further stated that R#2 was always in pain (after the hip fracture) when touched. E#7 stated that she could tell because “moans and groans”.