FAIRVIEW HAVEN ID NUMBER 0008524 605-609 N. FOURTH ST. FAIRBURY, IL 61739 As a result of an incident survey conducted by representative(s) of the Department on March 31, 1999, it has been determined the following violations occurred. "A" VIOLATION(S) 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 nursing personnel shall teach and assist residents with safe transfer activities in an effort to help them retain or regain their maximum level of independence. 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 residents's medical record. All necessary precautions shall be taken to assure the safety of residents at all times. The DONS/HSS shall oversee the nursing services of the facility. This person's duties shall include Planning an up-to-date resident care plan for each resident based on the resident's individual needs and goals to be accomplished, physician's orders, and personal care and nursing needs. 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 abuse or neglect a resident. (Section 2-107 of the Act) These requirements are not met as evidenced by Based on facility and hospital record review, and staff interview, the facility failed to prevent neglect of R1. The facility failed to properly transfer R1 to prevent injury; failed to communicate possible incident during the transfer; failed to follow facility procedure for reporting incidents; failed to accurately assess the extent of injury to R1; failed to notify the physician regarding injuries and condition; continued to transfer R1 up to the chair in the presence of injury and pain still without notifying the physician; failed to promptly assess R1 at change of shift after report of possible injury and pain. These failures contributed to injury and delay of treatment of R1. Findings are as follows: 1. R1 was 105 years old and had diagnoses including diabetes, arteriosclerotic heart disease, renal insufficiency, degenerative arthritis, history of hip fractures, and thrombocytopenia. According to the assessment of 2/11/99, R1 required significant or total assistance for all ADLs and was high risk for falls. R1 had been non-weightbearing and required a mechanical sling lift with 2 assists for all transfers. 2. According to facility investigation notes and interview with E4 and E5, on 3/19/99 at approximately 3:30pm, R1 was transferred by E4 and E5 from the bed to the commode, and from the commode to the wheelchair, by lifting R1 manually under the arms, not with the mechanical sling lift. R1 was later transferred at approximately 8:00 p.m. from the wheelchair to the bed by the mechanical lift by E4 alone without 2 assists. 3. Nurses notes indicate the following events: a. 3/19/99: "2000 - Res. c/o pain lt. foot during HS cares. ROM done with lt. foot, et c/o pain w/manipulation, No swelling or discoloration noted. Tylenol supp. 650mg. given rectally for disc." "2100 - Res. sleeping. No change in appearance of lt. foot." "2210 - lg. eccymotic area - blue/ purple in color noted rt. axilla area. Area swollen. No warmth to touch." b. 3/20/99: "0100 - Aide called nurse to resident's room. Res. c/o R' shoulder pain. Res. noted to have dark purple blue bruising from scapula on posterior side to sternum on anterior side of body. Raised area of dark purple on R' breast are. Also warm to touch. Res. also noted to have bruising on both feet, tender to touch, no swelling. Res. unable to communicate the origin of bruising. Tylenol supp. given per order for pain. Continue to monitor." "0300 - Bruising now noted larger, moving to L' breast inclusive. Repositioned for comfort." "0330 - Res. resting comfortably in bed. Scrape on L' shin noted as well, cleaned and dressed." "0500 - Res. {up} with cares. Pain to touch on R' shoulder and arm. Sling lift used in transfer. Resident tolerated well. Continue to monitor." "0900 - Noted large ecchymotic area from right shoulder across chest to left shoulder, down R' arm and under breast and axilla. Very quiet and despondent at table refusing breakfast." "1030 - Called to resident's room by CNA. Resident c/o pain L' leg. Depressed area {lower} L' shin. Swollen between L'shin and ankle. S/S possible fracture noted. Z5 paged. When we got no response Z1 notified." "1200 - Z5 ret. called back. Orders to transfer to ...ER: r/o L' ankle fracture, r/o R' shoulder dislocation. Eval. for blood dyscrasia. ...ambulance notified for transport. E2 notified........" c. 3/21/99: "1400 - ...hospital nurse called to inform us that R1 had expired..." 4. Review of emergency room report revealed the following: "...patient's stool is strongly hemocult-positive." "...platelet count of only 51..." "The patient's X-rays were notable for a fracture of the humeral neck on the right side, which was somewhat impacted and mildly displaced. The patient also had fractures of the distal tibia and fibula on the left with a few degrees of anterior angulation of the tibia." "DIAGNOSTIC IMPRESSION: 1. GI bleed. 2. Thrombocytopenia. 3. Multiple fractures." 5. Review of X-ray reports from the hospital dated 3/20/99 revealed the following: "Fracture in the neck of the right humerus..... bones are diffusely demineralized." "...Comminuted fracture of the left distal tibia and fibula...bones are diffusely demineralized." 6. Review of facility investigation materials and interview per phone with E4 on 3/24/99 revealed that E4 thought E4 may have heard a "pop" during the transfer of R1 at 3:30pm and also thought that R1's legs may have bumped the siderail. E4 stated that R1 was heavy and hard to lift, and also thought that they had transferred R1 back to the bed to finish putting on the brief before transferring R1 to the wheelchair. E4 stated that E4 did not know that R1 was always supposed to be a mechanical lift, because E4 had helped transfer R1 before with just picking R1 up. E4 stated that E4 did not report to the nurse at that time about hearing a pop or bumping the siderails. E4 stated that R1 appeared to have an "ugly frown" on R1's face while up in the chair after transferring. E4 also stated on an interview that after E4 put R1 to bed with the lift approximately 8:00pm, E4 noticed while removing R1's stocking that R1's foot did not look or feel "right." E4 stated that E4 got E8 to look at it, and E8 said that the foot was OK. At 10:00 bed check, E4 got another staff person to help with R1, E4 thought it was E9. E4 stated that when they moved R1 to remove R1's gown, R1 screamed. E4 stated that was when E4 noticed a large bruise under the right arm. E4 got E8, who looked at it and stated that R1 had a similar condition last year sometime. E4 stated that E4 still did not report hearing the popping or bumping the siderails at that time. Review of notes and interview with E2 revealed that E4 did not report hearing a popping or bumping the siderails until after E2 had begun investigating the incident on 3/22/99. 7. Interview with E5 per phone on 3/24/99 revealed that E5 assisted with the manual transfer of R1 at 3:30pm, from the bed to the commode. E5 stated that they then stood R1 at the commode to finish cleaning up and apply the brief, then transferred R1 to the wheelchair. E5 stated that E5 does not recall any particular difficulty with the transfer, any popping or bumping the siderails. E5 stated that the lift was in the room, that E5 was aware that the lift was used with R1, but that E4 had asked E5 to help, so E5 did. E5 stated that E5 did not give anymore care to R1 that evening and was not aware of any problem until approximately 8:30 when E4 came to E5 and stated that E4 was afraid there might be something wrong with R1. E5 told E4 to tell E8, and did not know anymore that went on from that time until later hearing that R1 had a broken leg and shoulder. 8. Interview with E9 on 3/24/99 approximately 1:30pm revealed that E9 had not assisted or observed any transfer of R1 the evening of 3/19/99. E9 stated that E9 first knew about something when E4 came to E9 about 8-8:30pm very nervous saying E4 was worried that there was something wrong with R1's foot. E9 stated E9 got E8 and looked at foot. E8 had said there wasn't anything wrong with the foot. About 10:00pm, E4 asked E9 to do bed check with E4. When they started to do R1, they saw blood on the pillowcase and gown on the left side, and they saw a skin tear on the left lower arm. E9 stated that E4 got real anxious when they saw the blood. Also, R1's left foot looked "lumpy", and the outer foot had dark bruising. E9 got E8 and also got linen. When E9 got back to the room E8 had left the room. Then we turned R1 to change R1, and R1 cried out in pain. E9 stated that R1's shoulder looked "pushed up" and "didn't look right." E8 was called into the room again, and E8 said E8 was not sure what was wrong. 9. Interview with E8 per phone on 3/24/99 approximately 2:00pm revealed that E8 was first called to R1's room by E4 to look at R1's left foot. E8 stated that R1 complained of pain, R1 did range of motion (ROM) that seemed a little wider than usual at the ankle, that the right was stiffer. E8 stated that there was no swelling or discoloration. E8 stated that R1 was occasionally "whiny," but that R1 was frequently "whiny" so did not think it unusual. E8 then gave R1 a Tylenol suppository for general discomfort. E8 stated that about an hour later E8 checked on R1, lifted up the cover and noted no change in R1's foot, and no unusual position. E8 stated that E8 was unaware of any problem at that time. E8 stated that about 10:15pm, E8 was again summoned to the room, when a large bruise was noted on the right chest area, about 5 x 5cm, slightly raised, soft, and extending into the axilla. E8 stated that R1 had a similar condition a couple of months ago. E8 stated that ROM of the shoulder seemed usual for R1. E8 stated that E8 did not recall observing any blood or skin tear at that time. When questioned by the surveyor, E8 stated that E8 did not consider calling the physician at that time because there were no other abnormalities, and E8 did not think R1's condition warranted a call to the physician. E8 also stated that E8 did not consider doing an incident report due to bruising of unknown origin, because of R1's previous condition. 10. Interview with E7 per phone on 3/24/99 approximately 11:00am revealed that on the shift 24 hour report sheet there was something about a popping in R1's foot. On initial rounds, R1 was sleeping soundly. At the 1:00am bed check on 3/20/99, E7 was called to R1's room, when bruising was noted across the right scapula around to the right breast area. There did not seem to be more pain than usual when they log-rolled R1 to the side to change and reposition R1. E7 gave R1 a Tylenol suppository at that time. E7 stated that when E7 checked on R1 later R1 was asleep. E7 stated that at the 3:00am bed check the bruising had extended across to include the left breast. There were no complaints of pain at that time. E7 stated that the early morning staff called E7 for assistance with AM cares and getting R1 up about 6:00am. E7 stated that at that time there seemed to be no increase in size of the bruising, no warmth, but some swelling. E7 also stated that there was a "scrape" on R1's left shin, which E7 cleaned and dressed. E7 stated that E7 applied R1's hose, and noted the left foot to have some resistance, and there was no swelling. E7 stated that R1 moaned some, but did not seem to be in excruciating pain, and did not yell when E7 put on R1's hose. E7 stated that they got R1 up in the wheelchair with the basket-typed mechanical lift (not the kind R1 usually used but was a lift). E7 noted that while R1 usually sat with feet crossed, that morning R1's feet were not crossed after R1 was up in the chair. When questioned by surveyor, E7 stated that E7 did not consider not getting R1 up in the chair due to R1's previous history of bruising, and that the left side looked the same as the other side. Also, E7 stated that E7 did not consider calling the physician due to R1's previous condition of the blood disorder, and that the physician only ordered warm packs to the area that time. E7 stated that E7 reported to day shift so that they could call and get the order for the warm packs. 11. Interview with E6 on 3/24/99 at approximately 9:30am, revealed that E6 went to do AM care for R1 about 6:00am on 3/20/99. E6 stated that E6 first noted that R1's feet were apart, and that R1's feet were usually crossed all the time. E6 stated that the left foot also looked like footdrop, and that this was unusual for R1. E6 stated also that the foot moved very loosely and at just above the ankle, not at the ankle joint. E6 stated that E6 used to work in rehab, and noted that R1's feet usually were stiff, and at this time the left foot was not stiff. E6 also stated that R1 "screamed" when lifting R1's shoulder to wash under the arm. E6 stated that at that time E6 got E7, who looked at the foot and the shoulder, and stated that the foot was not broken. E6 stated that they preceded to get R1 up with the lift, and that R1 "squealed" while getting R1 up. E6 stated that R1 "squealed through breakfast," and was put back to bed after breakfast. E6 stated they left the sling under R1 because moving R1 seemed to cause pain. E6 stated that the foot continued to not look right, that it seemed to be mottled and had movement above the ankle. E6 stated that they later went down to get R1 up again, and again R1 screamed when they moved R1. E6 told E3, and E3 told them not to get R1 up. E6 stated that E6 believed it was at that time that the physician was called. 12. Interview with E3 on 3/24/99 approximately 10:30am revealed that the report E3 received at 7:00am on 3/20/99 was, "{R1's} got that bruising like she had before." E3 was also told that R1 had complained of pain in the left foot on PMs and during the night, but that the ROM was OK. E3 stated that R1 was already up in the chair and at the breakfast table when E3 got out of report, so did not look at R1 closely at that time. E3 did note that at the table, R1 was not eating, even the chocolate milk that R1 always took, and was kind of bent over the table. E3 also stated that R1's face felt unusually cold. E3 then instructed the staff to put R1 back to bed as soon as possible after breakfast. E3 stated that E3 thought it was about 9-9:30am, E3 was called to R1's room. E3 stated that the bruising was extensive across the chest, was very dark and swollen, and "looked nothing like what {R1} had before." E3 also stated that the left foot had an obvious indentation above the ankle. E3 stated that the leg was immobilized with pillows at that time. At that time E3 attempted to notify Z5, and had to make several calls before getting a hold of Z1 about 10:30am who ordered R1 to be transferred. E3 notified the family and E2. E3 stated that Z5 finally called back and ordered the transfer to the hospital of family's choice, with diagnoses of rule out left ankle fracture, rule out right shoulder dislocation, and evaluate for blood dyscrasia. E3 stated that R1 left the facility by ambulance at noon. E3 stated that the hospital called the facility the next day to report that R1 had expired. 13. Interview with Z1 per phone on 3/24/99 approximately 4:30pm stated that Z1 put "sustained a fall" in Z1's dictation because that was Z1's initial assumption, but that the facility had told Z1 that they really did not know what happened. When questioned by surveyor as to whether injuries could have been sustained by bumping into the siderails, Z1 stated, "no way." Z1 stated that with the severity of the bruising across the entire chest, the scenario that Z1 theorized was that R1 may have leaned over the siderails, pressing chest against siderail or possibly falling over the siderail, and possibly got leg caught in the siderail. When question by surveyor as to whether the injuries could have been caused by an improper transfer under the arms, Z1 stated, "possibly, if they dropped {R1}." Z1 stated that the extent of the bruising, even considering the thrombocytosis, and the fractures, had to be due to high pressure or a fall. Z1 also stated that with R1 being non- weightbearing, there would be a fair degree of osteoporosis, but that there would still be "quite some force" to cause those injuries. 14. Interview with E2 on 3/24/99 approximately 5:00pm revealed that R1 normally did not have enough spontaneous movement to lean over the siderail or move around as in the scenario described by Z1. However, E2 stated that during the course of Z2's investigation, staff stated that the morning of 3/20/99, R1 was thrashing R1's legs back and forth in bed as if in pain. 15. Interview with E10 per phone on 3/25/99 approximately 3:00pm revealed that E10 was in the room at 3:30pm on 3/19/99, and recalls that E4 and E5 used a chair type lift technique with R1, holding under arms and under legs. E10 stated that after finishing on the commode, E4 and E10 transferred R1 to the wheelchair, using the same type of transfer technique. E10 stated that E10 does not recall any popping noise or bumping the siderail. E10 thought that E4 and E5 together put R1 to bed about 7:30pm. When E10 went in to help clean R1 up at that time, R1 was crying when turning R1 toward the west. E10 stated at that time they noticed the ankle bruising. E10 went and got E8, and E8 didn't think there was a problem. E10 stated that E10 was not involved in any care for R1 the rest of the evening. 16. Failure to accurately assess R1 including vital signs and failure to notify the physician of progressive bruising and pain contributed to a delay in treatment for R1. According to nurses notes and staff interview, on 3/19/99 at approximately 8:00 p.m., R1 was first noted to have a possible injury to the left ankle. At 10:00 pm bruising was first noted around the right axilla area. At 1:00 am on 3/20/99 it was documented in nurses notes that, "Res. C/o pain. Dark purple blue bruising from scapula...to sternum... dark purple on R's breast area...bruising on both feet...Tylenol supp. Given." No vital signs, further assessment, or physician notification were documented at the time. At 3:00 am it was documented that "bruising now larger...to left breast inclusive..." Again no vital signs or physician notification was documented. At 5:00 am it was noted "pain to touch on R' shoulder and arm..." Again no vital signs or physician notification were documented. According to nurses notes and staff interview, at approximately 6:00 am R1 was transferred from the bed to wheelchair per sling lift and taken to dining room. At 9:00 am the large ecchymotic area and despondency at breakfast was again noted. According to incident report and nurse notes, vital signs were not taken until approximately 10:30 am when the physician was called. Vital signs were within normal limits for R1, according to prior records and staff interview. Interview per phone with E2 on 4/1/99 confirmed that there was no evidence that vital signs were taken until mid-morning of 3/20/99..R1 was transferred to the hospital per ambulance at noon.