D'ADRIAN CONVALESCENT CENTER
1313 D'Adrian Professional Park
Godfrey, IL 62035
Date of Survey 05/12/00
Complaint Investigation 0042130, 0042143, 0042172
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.
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.
The DON shall oversee the nursing services of the facility including:
Planning an up-to-date resident care plan for each resident based on the resident's comprehensive assessment, individual needs and goals to be accomplished, physician's orders, and personal care and nursing needs. Personnel representing other services such as nursing, activities, dietary, and such other modalities as are ordered by the physician shall be involved in the preparation of the resident care plan. The plan shall be in writing and shall be reviewed and modified in keeping with the care needed as indicated by the resident's condition. The plan shall be reviewed at least every three months.
AN OWNER, LICENSEE, ADMINISTRATOR, EMPLOYEE OR AGENT OF A FACILITY SHALL NOT NEGLECT A RESIDENT.
Based on record review of R#1; Incident Reports dated 2/2/00, 2/4/00, 2/15/00, 2/18/00, 4/27/00, 5/6/00, and 5/9/00; staff interviews and physician (Z#1) interview, it was determined that the facility failed to adequately supervise R#1 to prevent severe head injury.
Per interview of Z#1 (per phone on 5/12/00 at approximately 10am), R#1 is currently in the Intensive Care Unit of St. Anthony's Hospital due to head injury sustained while at the facility. Per Z#1 "this resident has had too many falls (incidents) for this type of resident. His mental/medical status had not changed nor had his medicines."
Review of Incident Reports on 5/11/00 and 5/12/00 indicated that R#1 has had nine (9) reportable incidents since February, 2000. The latest three incidents 4/29/00, 5/6/00 and 5/9/00 have all resulted in severe injuries.
On 4/29/00 at 1:20pm on Saturday, R#1 "tipped his Merry Walker over". He received a laceration to his head and a fractured nose.
On 5/6/00 at 8:30 pm on Saturday, R#1 was found on the floor of his room with a 2" laceration above his left eye.
On 5/9/00 at 6:30am, R#1 again tipped over his Merry Walker.
Per E#1, on 5/11/00, it was noted that the Merry Walker had been modified with "outriggers" left and right side after the incident 4/29/00. That incident was not witnessed. Per E#2, E3 and E4 however, chair was on its side.
On 5/9/00, R#1 tipped chair forward. E#1, 2, 3, 4, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 24, 25 interviewed on 5/11/00 and 5/12/00.
Per E#10 on 5/11/00 at 2:05pm, R#4 had a habit of reaching out for people. He would lean side to side and forward in the Merry Walker.
Per E#10 on 5/11/00 at 2:50pm, R#1 almost tipped Merry Walker over once before when near nurses station when front wheel got caught.
Per E#23 on 5/12/00 at 10:30am, R#1 has a history of getting out of bed when he is wet. Has done this several times.
Per the CNA assigned to hall 200 (R#1's room on 200) and one of two CNA's on hall 100 - both were taking a break on 5/6/00 at 8:30pm when R#1 was found out of bed and injured. This (per staff) left one CNA to cover both halls (100/200) rather than the assigned three (3) CNAs.
On Saturday 4/29/00 at 1:20pm, both E#9 and R#8 stated they were "in the lunch room" during the time of incident. Per review of schedule, there were only six (6) CNAs assigned on the 3pm-11pm shift on 4/9/00 for all 4 halls/75 residents.
The facility failed to address the recommendations of the physical therapist on 5/3/00 when a recommendation to increase supervision was made. The care plan fails to address any change on R#1's care plan since 2/2000 despite numerous injuries.
There is no tracking mechanism in place to keep track of the number of incidents, location of incidents and method of injury. Per E#1, he keeps a record of each incident, but it is "not tracked".
R#1 is an 88-year-old male with severe Alzheimer's and combative behaviors. He has a history of agitation.