FORD COUNTY NURSING HOME
Facility I.D. Number 0000661
RR 2, 1240 N. Market St.
Paxton, IL 60957
Date of Survey 6/28/01
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.
All treatments and procedures shall be administered as ordered by the physician.
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.
These requirements are not met as evidenced by:
According to the physician's order sheet, R2 was a long-term resident who had multiple diagnoses including degenerative joint disorder, osteoarthritis, peripheral vascular disease, congestive heart failure, hypertension, chronic lung disease according to a chest X-ray of 7/9/96, history of CVA and depression. The most recent quarterly assessment of 3/12/01 indicates that R2 had mild cognitive impairment, required extensive assistance for most activities of daily living, but required only supervision for eating. R2 received oxygen per nasal cannula continuously at 2 liters/minute.
Review of nurses notes starting 4/01 and incident reports reveal that on 4/13/01 at 7:00 a.m. R2 spilled hot chocolate on herself, initially causing reddened areas to both inner thighs, left upper leg, left lower abdomen and the left wrist. Staff initially applied ice. By 9:00 a.m., the areas on the abdomen and upper leg developed blisters. At that time, according to the fax report, a fax was sent to the physician's (Z2) office that R2 hot chocolate spilled on these areas, and requesting an order for Silvadene. The size or approximate area involved was not described in the fax.
According to review of April's physician's orders notes sheet, standing orders and interview with nurse (E3) on 4/13/01 approximately 2:00 p.m., standing orders were implemented that day "per nursing home policy", pending physician orders. The treatment started was the application of triple antibiotic ointment (TAO) and gauze pads. E3 stated that a fax was used because if they call the office, many times they cannot speak with the doctor and the doctor doesn't call back. Due to a mix-up in faxes from Z2's office, the order for R2 for Silvadene ointment was not received until 4/17/01, 4 days after the incident.
Review of nurses notes subsequent to 4/13/01 document daily dressing changes with application of TAO and padded dressings, and that blisters were intact. On 4/17/01 treatment was changed to Silvadene. Nurses notes continue with statements that areas are improving slowly, and that some areas burst. On 4/23/01 is noted "Eschar noted. {No} sloughing noted." Notes of 4/27/01 and 4/28/01 also document eshcar formation and serosanguineous drainage. On 4/30/01 notes state "{right} thigh appears much improved. Others remain unchanged." Also on 4/30/01, the nurse practitioner (Z4) examined R2. Progress notes of 4/30/01 state ". . . 2nd degree burns on upper thighs, and one small patch on her abd.. . .wounds are red and pink around the edges. With some yellow debris in the center. I don't think that there is any signs of infection . . .Cont using Silvadene. . . " Telephone interview with Z4 on 6/14/01 at 10:45 a.m. confirmed above statements. Z4 stated she did not recall seeing eschar formation. Z4 did not recall if this was a routine visit or if the facility had called her to see R2. Also, Z4 did not recall ordering or discussing whirlpool treatments. Nurses notes indicate that whirlpool baths were given to R2 starting 5/1/01.
Intermittent nurses notes from 5/1/01 continue to state that areas were healing and no signs of infection. One note of 5/4/01 stated "sloughing noted all three sites. . . slight odor noted. . ." On 5/12/01 3=11 shift is noted "areas granulating ins. Eschar noted X 3. . . " On 5/15/01 is noted "granulation tissue noted. Dry scabbed areas. . . "
On 5/19/01 is noted "continues to heal up with pink edges and yellow eschars. . ." All other nurses notes comment that areas are healing with no signs of infection. Whirlpools continue daily. There are no measurements or description of the size of the areas. There also are no further communication with the physician as to the condition of the areas. On 5/31/01 at 2:00 p.m. notes state that "{Z2} aware" of a fall by R2 on 5/30/01.
Review of the decubitus/pressure ulcer report initially describes the burned areas as follows:
No further measurements were documented. Entry on 4/28/01 states "Scabbing over. Pink edges". All other entries through 5/27/01 state that areas were healing or showing improvement, with no further description or measurements.
Also documented in nurses notes from 4/13/01 to 5/31/01 was consistent poor appetite and frequent refusal of meals. Review of dietary notes from 10/11/00, 11/8/00, 12/15/00 and 3/9/01, R2 had history of weight loss, poor appetite with intakes of 25-50%. The last serum protein and albumin dated 7/11/00 were low at 5.9 and 2.8mg/dL respectively (Normals 6.4-8.2mg/dL; 3.4-5mg/dL.) R2 also had a history of pressure sores. According to the notes of 11/8/00, the registered dietician (RD) recommended Orazinc and Vitamin C to promote wound healing. Review of nurses notes, physician's orders and faxes reveal that this recommendation had not been carried out or called to the physician. The last dietary note was dated 3/9/01. No further dietary consults or recommendations were made following the burns for nutritional support to promote healing.
According to the nurses notes and transfer sheet, R2 was sent to the hospital on 5/31/01, R2 was sent to the hospital with sudden onset of temp of 103, elevated pulse and low oxygen saturation. According to the emergency room report (ER), history and physical and consultant's reports of 5/31/01, 6/1/01and 6/5/01 respectively, R2 was admitted to the hospital with bilateral infected leg. The ER nursing assessment describes "open wounds. . . grayish drainage. . . " Wound cultured dated 6/2/01 revealed moderate growth of Methicillin Resistant Staphylococcus Aureus. The history and physical by Z5 dated 6/1/01 states that R2 had "burns that have degenerated into large decubiti on the abdominal wall and both thighs. . . " Z5 also describes an elevated white count with left shift and band forms. Z5's impression is stated as "status post burn, second degree with stage 3 decubiti, abdominal wall, both thighs." The nursing assessment data base and wound assessment sheet documents the wound measurements as follows:
History and physical estimated burns to involve approximately 10% body surface area.
According to review of the hospital records, R2's course of treatment included debridement and consultation with Z3 for antibiotic therapy. Also, according to progress note of 6/5/01, R2 also agreed to temporary tube feeding due to compromised nutritional state. R2's serum albumin was noted to be 1.8, and R2 was not eating. This note also states "Pt may very well not survive. . ." Also, according to x-ray reports, R2 developed bilateral lower lobe infiltrates on 6/4/01, different from the initial x-ray of 5/31/01 with showed no acute infiltrates. According to progress notes of 6/11/01, R2 went into respiratory failure and expired at 9:30 a.m.
The discharge summary dated 6/11/01by Z5 lists the principal diagnosis as "Stage II burn with large eschar approximately 10% body surface area. Secondary diagnoses are listed as follows:
Methicillin Resistant Staph infection
Bilateral pneumonia with effusion
Severe protein calorie malnourishment
Possible sepsis
Respiratory failure
Congestive heart failure.
Telephone interviews with Z3 and Z5 on 6/14/01 at 1:15 p.m. and 3:00 p.m. respectively confirmed the above hospital information. Z3 stated that 10% body surface involvement would be enough to cause respiratory complications over time, especially with the low albumin, which leads to fluid leakage. Z5 stated that the wounds on admission did not appear grossly infected as in foul-smelling purulence or cellulitis, but did have the eschar that needed to be debrided. Z5 also stated that a percentage of patients do succumb to these types of burns, especially given the age and compromised nutritional status.