GLEN BRIDGE NURSING AND REHAB CENTRE
Facility I.D. Number 0035014
8333 West Golf Road
Niles, IL 60174
Date of Survey: 06/25/01
Notice of Violation: 08/27/01
Complaint Investigation
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, including, but not limited to, the presence of incipient or manifest decubitus ulcers or weight loss or gain of five percent or more within a period of 30 days. The facility shall obtain and record the physician’s plan of care for the care or treatment of such accident injury or change in condition at the time of notification.
The advisory physician or medical advisory committee shall develop policies and procedures to be followed during the various medical emergencies that may occur from time to time in long-term care facilities. These medical emergencies include, but are not limited to, such things as: Traumatic injuries (for example, fractures, burns and lacerations).
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.
These REQUIREMENTS are not met as evidenced by:
Based on record reviews as well as interviews with staff and others, the facility 1]failed to seek timely emergency care for 1 resident, R#1, with a head injury and changes in her condition; 2] failed to assess, identify and document mental status changes for R#1; 3] failed to contact R#1's attending physician in a timely manner and 4]failed to call 911 initially and failed to quickly assess a deteriorating medical status post head trauma on R#1 while they continued to wait for the regular ambulance to arrive.
On 2/28/01 surveyors reviewed facility's incident report regarding R#1 dated 2/26/01, 8:15a.m. This report states: "(R#1) was coming out of her room with blood noted on the back of her head."
Review of 2 page ambulance report for R#1 dated 2/26/01 reflects time of call=9:06a.m. arrival time=10:09a.m., departure time 10:47a.m., and arrived at the hospital 2 minutes later at 10:49a.m. 2 hours and 34 minutes lapsed from the time R#1 was found with the head injury [ per incident report ] until she arrived at the hospital for treatment. The ambulance driver, Z#8, was interviewed by phone on 5/3/01. He stated he questioned the dispatcher why they were being sent "lights and sirens for a fall?" He was told due to the facility report of R#1 being lethargic. Facility took no steps to arrange for 911 or paramedics when they became aware of the delay in transportation and the change in the resident's condition.
Per review R#1's hospital record ( received on 4/2/01) reveals she was admitted 2/26/01, became comatose, and was placed on life support at 1:12p.m.. She remained comatose and on life support after an emergency Craniotomy was done. The CAT Scan before surgery showed a large acute Sub Dural Hematoma over the right cerebral hemisphere with a marked midline shift from the right to the left. A second CAT Scan was done as well as a neurological examination. Based on these results the family wished to withdraw life support. R#1 expired on 2/27/01. These medical results show a serious brain injury had occurred to this resident at the nursing home rather than a documented laceration as per nurse's notes.
Per review of R#1's medical record and incident report at the facility, there is no documentation of R#1's lethargy, the amount of bleeding, or droopy eyes as described by E#5 and E#9 to the Surveyors. No documentation of this observation was in the nurse's notes.
Per review of police report received on 6/18/01, this stated that blood was found in R#1's room per observation and the use of Luminal.
Per review of the coroner's report, received on 6/4/01, Z#10 (the coroner) states that R#1 died as a result of a subdural hematoma due to blunt head trauma and the manner was homicide.
E#5 was interviewed on 2/28/01 on the 5th floor at approximately 9:30a.m. E#5 stated that on 2/26/01 E#6 said she(E#5) should come and see R#1. R#1 was observed coming out of the room next door to her assigned room with blood dripping from the back of her head down onto the floor. E#5 observed R#2 in the room that was assigned to R#1. "We used towels to stop the bleeding. We looked into (R#1's) room and saw (R#2) walking around (R#1's) bed and there were drips of blood on the floor going toward the foot of the bed." Per nurse's note this was approximately 8:35a.m. [Per final incident report this was 8:15a.m.] E#5 continued, "I left a message with (Z#1's) [R#1's attending] secretary because (Z#1) was not there. I told the secretary we might have to send (R#1) to the hospital. I called (ambulance). I asked for one ASAP because (R#1) complained of a headache and became increasingly sleepy and lethargic, which was not usual for her. (R#1's) eyelids were drooping. I shook her and kept saying, (R#1, R#1), please wake up. (Ambulance) told me they couldn't be there quickly. I suggested 30 minutes." This is evidence that R#1 was showing signs of head injury that was needing emergency treatment. Surveyors received conflicting information on R#1's assessment during this wait for the ambulance.
Interview with Z#1 on 3/1/01, per phone, at 3:10p.m., revealed, "I was not paged about (R#1). They called my office and left a message that (R#1) had trauma and was being sent to the hospital. I was on rounds at the hospital. I should have been paged and 911 called. The normal procedure is to call 911. There is a major issue as to the amount of time it took (R#1) to get to the hospital. They should have called 911."
E#9 was interviewed on 3/2/01 per phone. She stated, "They should have called 911 due to the amount of bleeding (R#1) had. There were tons and tons of towels full of blood. There was a trail of blood out of (R#1's) room and in the doorway of the room next to hers. Blood was all in her clothes."
None of this information is in the chart or nursing notes.
Z#5 was interviewed per phone on 3/8/01. He stated he performed a Craniotomy on R#1."(R#1) had a large Sub Dural Hematoma in the frontal , parietal and temporal area 2 cm thick...yes it was affecting her brain stem, no doubt about it." Z#5 stated "(R#1) came to the E.R. lethargic and became progressively more lethargic to comatose...The hematoma was progressively growing... Yes it probably would have been better if she had been brought in earlier."