HALSTED TERRACE NURSING CENTER
Facility I.D. Number: 0020842
10935 S. Halsted St.
Chicago, IL 60628
Survey Date: 10/12/00
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 needs of the resident.
Medications including oral, rectal, hypodermic, intravenous, and intramuscular shall be properly administered.
All medications, including cathartics, headache remedies, or vitamins, shall be given only upon the written order of a physician. All such orders shall have the handwritten signature of the physician. (Rubber stamp signatures are not acceptable.) These medications shall be given as prescribed by the physician and at the designated time.
The facility shall have medication records which shall be used and checked against the physician's orders to assure proper administration of medicine to each resident. Such records as computer generated medication sheets may be used. Medication records shall include or be accompanied by recent photographs or other means of easy identification such as resident identification wristbands.
Medication records shall contain the resident's name, diagnoses, known allergies, current medications, and, if possible, a history of prescription and non-prescription medications taken by the resident during the 30 days prior to admission to the facility.
AN OWNER, LICENSEE, ADMINISTRATOR, EMPLOYEE OR AGENT OF A FACILITY SHALL NOT NEGLECT A RESIDENT.
These regulations are not met as evidenced by:
Based on resident records reviewed and interviews of staff and physicians, the facility failed to always monitor and administer medications and report significant changes in Accucheck results to the physicians of all diabetic residents as evidenced in 6 of 12 2South diabetic residents reviewed with orders for Accucheck monitoring and/or Insulin in orders; R1, R2, R4, R5, R7 and R8 as evidenced by the following:
1) R4 was originally admitted to the facility 10-5-99 with diagnoses to include Diabetes Mellitus (DM), Peripheral Vascular Disease (PVD) and Left (Lt) Below the Knee Amputee (BKA).
R4's 8/00 Physicians (MD) Orders included: Accuchecks every Friday and Glybride 5mg daily (qd). Upon review of R4's Medication Administration Record (MAR), Nurses Notes (NN), and Accucheck sheet for 8/00 with E2, surveyor found that R4 only had Accuchecks done once during 8/00; 8/4/00 with result of 107.
R4 was hospitalized with recurrent CVA from 8/22/00 through 8/29/00. Upon readmission 8/29/00, Z2 ordered Accuchecks to be done twice daily (BID) and Glybride 5mg qd. R4 had no pressure sores 8/22/00 at time of discharge to hospital, per multiple staff interviews and Z1 and Z2 interviews and R4's chart record review. Upon 8/29/00 readmit to facility, R4 was noted with the following pressure sores; 1) Coccyx stage 2, 4x3cm. 2) Rt Heel Intact Blister, 5.5x5cm.
R4's MAR revealed that R4 did not receive the Glybride 5mg from 8/29/00 until 9/1/00 at approximately 9AM, at which time R4 was given the first dose since readmission. R4's Accuchecks revealed that blood sugars increased from 8/30 6AM result of 108 to 360 on 8/31/00 4PM. On 9/4/00 at 4:05PM, R4 started exhibiting uncontrollable right (Rt), arm twitching and had an Accucheck result of 500. R4 required hospitalization 9/4/00 through 9/12/00. Z2, per interview 10/5/00 stated; R4 was diagnosed with hyperglycemia and a bladder infection 9/4/00.
Z2 also stated that she was unaware that R4 had not received the Glybride 8/29-9/1/00 and that the hyperglycemic reaction on 9/4/00 could have been the result of those omissions.
R4 was readmitted 9/12/00 with MD orders for Accuchecks to be done every 6 hours (6-12-6-12), with Sliding Scale Regular Insulin coverage. R4's pressure sores were worsening;
1) Coccyx stage 4, 8x8cm with eschar. 2) Lt stump BKA stage 4, with soft eschar. 3) Rt great toe stage 2, 2x2cm red.
During R4's stay at facility from 9/12/00 at 6:30PM until 9/13/00 at 2:05PM discharge to hospital for a G-Tube insertion, (due to inability to swallow) the Accuchecks were only done at 12AM and 6AM.
R4 was again readmitted to the facility on 9/21/00 with worsening pressure sores:
1) Coccyx stage 4, was now 9x7.5x5cm with Black Eschar, yellow and red drainage with odors present. 2) Lt stump of BKA stage 4, 8x4cm with hard black eschar and red drainage and odor. 3) Rt Heel stage 4, 12.5x7.5cm with black eschar, yellow and red drainage with sloughing.
10/5/00 interview with Z2 revealed that R4's pressure sores progress/regression is affected by the blood sugar, therefore if the blood sugar is out of control the sores will not heal normally and could worsen.
On 9/21/00 Z1 ordered an increase in the Sliding Scale Insulin coverage dosage based on Accucheck results. Z2 ordered 70/30 insulin 15 Units to be administered every 6AM and 4PM. Z2's sliding scale and Accucheck order did not state frequency to be done. E2 was made aware of this by surveyor on 10/4/00. There was no documentation that Z1 was called to clarify the frequency as of 10/4/00. R4's 9/21-9/30/00 MAR and 10/00 MAR have a hand written entry for the frequency of the sliding scale coverage and Accuchecks to be done BID (6A and 4P).
Accuchecks averaged in the 300's and went as high as 425. On 9/23/00 Z1 increased the 6AM dose of the 70/30 Insulin from 15 Units to 18 Units daily.
Surveyor also noted that R4's BID (6A and 4P), Accucheck and Sliding Scale coverage was not always followed and that Z1 was not always notified when R4's Accucheck results exceeded the highest sliding scale range, as follows;
9/21 sliding scale : 150-200=4U, 201-250=8U and 251-300=12U.
- On 9/22/00 4PM Accucheck not done.
- 9/23/00 only one Accucheck was done, the time unknown, but the results were
354 and only 8 Units noted as given. There is no documentation that Z1 was
called and notified of the result is greater than (>) 300.
- 9/26/00 4PM no Accucheck was done.
- 9/29/00 6AM result was 357 and PM was 300. The MAR only reflects coverage
given once on 9/29/00, but time unknown. No notation that Z1 made aware of
Accucheck results >300.
- 9/30/00 6AM results were 231 but no coverage given.
As of 10AM on 10/05/00, E2 had still not called Z1 to clarify R4's Accucheck and Sliding Scale coverage frequency.
E2 called surveyor 10/5/00 at 11:30AM stating that Z1 "just called and ordered (R4's) Accucheck and Slding Scale frequency was supposed to be every 6 hours, more frequent than BID."
2) R2 has MD orders for Sliding Scale Regular Insulin Coverage BID: 200-250=3U, 251-300=5U, 301-350=8Units, 351-400=10U and 401=12U and call MD.
Accucheck sheet and MAR noted the following dates Accuchecks with no coverage given;
9/20 6AM=331, 9/21 6AM=335 and 4PM=334, 9/22 6AM=379 and 4PM=242, 9/23 6AM=409 and 4PM=338, 9/24 6AM=349 and 4PM=353, 9/25 4PM=338
3.) R1 has MD orders for 70/30 Insulin 20U every AM and 10U every PM and Accuchecks BID (6A-4P), with Sliding Scale Coverage of Regular Insulin as follows;
200-250=4U, 251-300=6U, 301-350=8U and 351->=10U.
- On 9/13/00 4PM no Accucheck done,
- 9/14/00 6AM result=196, yet 8U of Regular Insulin given,
- 9/14 4PM result=294 and only 6U Regular Insulin given,
- 9/15 4PM result=328 and only 6U Regular Insulin given,
- 9/16 6AM result=196 and only 8U Regular Insulin given,
- 9/18 6AM result=321 and no coverage provided.
4.) R5 has MD orders for 70/30 Insulin 22U every AM, but hold if less than (<) 150 and Accuchecks BID (6A-6P), with Sliding Scale Regular Insulin coverage as follows;
200-300=10U and 301-400=20U.
On 9/12 6AM Accucheck result was 60 and on 9/24/00 at 6AM result was 142, yet R5's MAR notes R5 was administered the 22 Units of 70/30 Insulin on both of these days.
R5's 9/00 MAR has no documentation section for the 6AM Sliding Scale coverage.
On 9/15/00 6PM Accucheck result was 148 yet the MAR notes 20 Units of Regular Insulin was given.
R5's 10/00 MAR Sliding Scale coverage section was "ERROR" from 10/3/00 and on, yet E2 was not sure why it was "ERROR" since there was no discontinuation order or change noted.
- 10/1/00 6PM Accucheck result=299 but no coverage given.
- 10/2/00 6PM no Accucheck done.
- 10/3/00 6PM Accucheck result=355 yet no coverage given.
5.) R7 has MD orders for Accucheck to be done every 12 Hours (6A-6P), with Sliding Scale Regular Insulin coverage as follows; 201-250=3U, 251-300=6U, 301-350=9U and 351-400=12U and call MD if <85 or >400.
- 9/6 6AM and 6PM no Accucheck done.
- 9/21 6AM no Accucheck done.
- 9/22, 9/23 and 9/24/00 no 6PM Accuchecks done.
- 9/25/00 6AM no Accucheck done.
6.) R8 was admitted to facility 8/15/00 with MD orders for Accuchecks BID (6A-6P), with Sliding Scale coverage of Regular Insulin as follows;
200-250=3U, 251-300=6U, 301-350=9U and 351-400=12U, call MD if >400.
R8 was then hospitalized 8/22/00 through 8/29/00. 8/29/00 was readmitted but no orders were received for Accucheck and Sliding Scale coverage to be continued. There was no documentation by nursing of MD being called to clarify that no Accuchecks and Insulin coverage was to be restarted, yet upon review of R8's 9/00 MAR the BID Accuchecks and Sliding Scale coverage was hand written in on 9/12/00 at 4PM. On further review, surveyor noted that on the following dates the Accuchecks and Sliding Scale coverage was not followed as written in on the 9/00 MAR.
- On 9/22, 9/23 and 9/26 the 4PM Accuchecks were not done.