HEARTLAND MANOR NURSING CENTER
Facility I.D. Number 0002923
410 N.W. Third
Casey, IL 62420
Date of Survey:04/11/01
Notice of Violation:07/10/01
Incident Report Investigation
The facility shall have written policies and procedures, governing all services provided by the facility which shall be formulated by a Resident Care Policy Committee consisting of at least the administrator, the advisory physician or the medial advisory committee and representative of nursing and other services in the facility.
These policies shall be in compliance with the Act and all rules promulgated thereunder. These written policies shall be followed in operating the facility and shall be reviewed at least annually by this committee, as evidence by written, signed and dated minutes of such a meeting.
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 residents 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.
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 record review and interviews with facility staff it was determined that the facility failed to ensure that R1, with an advanced directive specifying "Do Not Resuscitate", was appropriately treated when an accident occurred on 4-2-01, resulting in the death of R1.
Specifically, the facility failed to initiate cardiopulmonary resuscitation (CPR) to R1 following cessation of vital signs, that resulted from a fall and subsequent severe head trauma. The facility failed to follow good First Aid practices by lifting R1 off the floor and into bed without the aid of a transfer board or cervical collar to prevent further possible injury to R1; and the facility failed to ensure the safe transfer of R1 with a mechanical lift that resulted in a fall and R1's death.
Review of an incident report transmitted to the Illinois Department of Public Health Regional Office on 4-2-01 at 10:32 a.m. revealed that R1 sustained a fall from an electric lift operated by facility staff at 5:40 a.m. the same day. Details of the incident report are documented as follows: "CNA (certified nurses aide) heard calling for nurse STAT (immediately), stated res. had fallen. Another CNA heard calling that (mechanical) lift had malfunctioned et (and) dropped res.(resident). Nurse entered rm et saw res. laying on floor of rm. on Rt. side, curled up into the fetal position. Res laying on floor between legs of (mechanical) lift parallel to bed. Lg. pool of blood spreading out from res. head. Resp. (respirations) irreg. et labored. Res. log rolled onto back, lg. ragged et deep X-shaped laceration present on Rt. forehead--edges gaping open et skull visible. Res. bleeding lg amts drk. red blood from mouth, mod. amt bright red blood from Rt. nare. Res. cradle lifted from floor et transferred onto bed per 3 staff. Res. turned onto Rt. side to help prevent aspirating blood. H.O.B. (head of bed) (elevated) approx. 20-30 degrees. Cold wet compress with ice packs applied to wound et pressure applied. (Physician Assistant) notified of incident per (LPN)--new orders received. Clark Co. Amb. phoned per (LPN) of STAT transfer of res. to emer. rm. Daughter (power of attorney) notified of incident per LPN. Resp. slow, gasping et irreg, fingers and hands becoming cyanotic. O2 (oxygen) at 5 liters per minute per mask started.
CNA's stated that during transfer of res. from bed to w/c (wheelchair) in the sling for the lift, the lower strap of sling came off of hook on lift while turning res. in preparation of transfer into w/c. Res. was leaning to the Lt. (left) in sling et when strap came off of hook, res. fell forward et down from sling et landed on Rt. side onto floor. Noted that res. had sustained a scrape on Rt. kneecap. Rt. eyelid very swollen with purple discoloration."
Review of R1's clinical record on 4-6-01 revealed the following documentation present in nurses notes:
4-2-01 5:40 to 5:45 a.m. (Verbatim documentation from above incident report)
4-2-01 5:50 a.m. "O2 at 5 L (liters) per mask cont. Only having resp. approx. q (every) 30 sec. Cont. to bleed mod amt. drk red blood from mouth. Bleeding only a sm. amt. from rt. nare. Unable to find radial pulse. Apical pulse slow, weak et very irregular."
4-2-01 5:55 a.m. "no resp for approx 90 sec. Pulse et B/P (blood pressure) absent. O2 at 5 L/min. D/Ced (discontinued)."
4-2-01 6:00 a.m. "(Physician Assistant) not. (notified) of res. expiring per LPN. Clark County
Amb. Crew here, advised of resident expiring."
Interview with E4, a CNA involved with the transfer of R1, on 4-6-01at 11:00 a.m. in the conference room, revealed that R1fell from the lift sling as she was suspended for the transfer. E4 stated that once R1 hit the floor, E4 became "stunned" as to what had happened. E4 stated that "it happened so fast. It (the impact) made the worst popping noise I ever heard. It was awful; blood was pouring out of a V shaped wound on her head." E4 further stated that "I tried to save her, but she was a Do Not Resuscitate". E4 stated that she attempted to help with clearing blood, and helped to get her on the bed. E4 stated that "blood was everywhere. Oxygen was put in place. I tried to keep the mask in place. (R1) was still breathing. I was rubbing her chest. Her pulse was becoming weak. 15 minutes later the nurse said she was gone". E4 confirmed in interview at this time that CPR was never initiated.
Interview with E5, the nurse responding to the incident, on 4-10-01 at 9 a.m. in the conference room, confirmed that the sequence of events went as she documented (above incident report documentation is also verbatim from E5's nurses notes). E5 stated that following the incident, it was immediately apparent that R1 had sustained a severe head trauma as evidenced by being able to see R1's skull through the large head wound and blood coming from the mouth and nose. E5 confirmed that she "log-rolled" R1 to assess the extent of the injuries and immediately initiated first aid measures. At this time E5 stated she made the decision to lift R1 to the bed by "cradling her" and to stabilize her head in the bend of her own (E5's) arm. The transfer was performed by E5, E4, and E3 according to E5. No transfer board or cervical collar was used for this transfer according to E5.
E5 stated that R1 was moved to the bed so R1 "wasn't lying on the cold floor and so it would be easier to take care of the resident in the bed".
Review of the facility's "Medical Emergency" procedures on 4-10-01 reflects specific procedures to be followed regarding movement of individuals with suspected "concussion and fracture of the skull". Among the "First Aid" initiatives to be taken by staff as outlined in the document is to "keep the patient lying down, with his head and shoulders slightly raised if his face is normal color or flushed. If his face is pale, keep the patient level or lower his head slightly. Move him only in the horizontal position, handling him carefully and avoiding unnecessary handling."
E5 stated at this time that she continued to monitor R1's heartbeat with a stethoscope and continued to maintain an open airway by turning R1's head to the right to prevent aspiration of blood. E5 stated that she waited for continued heartbeats and "when it was obvious that there were no more heartbeats", "I instructed the CNA to shut off the oxygen tank and I removed the mask". E5 stated at this time "I called it, I pronounced her death". Shortly after this E5 stated that the ambulance personnel arrived in the facility. E5 stated at this time that the ambulance personnel inquired as to what R1's code status was and E5 stated to them that "she was a DNR". E5 stated that the ambulance personnel acknowledged this fact and left the facility.
E5 stated in interview that initially she had considered administering CPR to R1 but that "she had a DNR order, so I didn't consider it further". E5 stated at this time that "some instances (accidents) would be appropriate to administer CPR, this was not one of them due to her code status and extent of injury". E5 confirmed that she had never been made aware of a DNR not applying in the event of an accidental situation.
Interview with E2, the director of nursing, on 4-10-01 at 1:45 p.m. in the conference room revealed that she was not sure what E5 could have done differently and that E2 "probably would have done the same thing" (not administer CPR based on R1's code status).
Interview with E2 and E8 revealed that they were unaware of a "Do Not Resuscitate" order not applying in the case of an accident.
Review of the facility policy entitled "Heartland Manor Nursing Center Policy Regarding Illinois Statement of Laws on Advanced Directives" yielded no evidence regarding how staff are to treat this type of event. A supplement attached to the policy entitled "A Personal Decision" provided by the Illinois State Medical Society refers to "Do-Not-Resuscitate Order" by stating "You may also ask your doctor about a do-not (resuscitate order (DNR order). A DNR order means that CPR will not be started if your heart stops. You and your doctor may decide together that your doctor should write a DNR order into your medical chart. If you have an accident, such as choking on food, the DNR order still allows health care workers to give you the Heimlich maneuver or take other appropriate action."
Interview with E1, the administrator, on 4-11-01 at 9 a.m. in his office revealed that he was unaware of a DNR order not applying in the event of an accident and up until this point was unaware of the need to develop a policy concerning it.
Interview with E14 on 4-11-01 at 10:30 a.m. in the chapel confirmed that 60 of the facility's 73 residents currently have DNR orders.
Review of the most recent facility assessment documentation dated 2-20-01 reflect that R1 required total assistance for all activities of daily living except for eating, including total dependence on 2 staff persons for bed mobility and all transfers. "Activity of Daily Living (ADL) assessment" documentation in R1's record reflects that a mechanical lift was required for transfers for each of the (previous three quarters (9-1-00, 6-13-00, and 3-21-00). Interview with E10, the assessment coordinator, on 4-6-01 at 2:15 p.m. in the conference room, reflected that she was responsible for completing these assessments. E10 confirmed that R1 has used the lift for years but had "no idea why the (lift) was always used".
Review of R1's established, written Care Plan dated 2-28-01 reflects that R1 is "dependent of ADL's as evidenced by: decision making poor, not able to balance while sitting or standing without physical support, limitation of right side arm & hand with full loss, limitation of legs & feet with partial loss. Contributing factor: amputation right arm & dementia." A related approach to R1's problem of bed mobility and transfers reads "Be careful with all transfers". There is no documentation in R1's Care Plan related to the use of a lift of any kind.
Interview with E5, the nurse who responded to the incident, on 4-10-01 at 9 a.m., revealed that R1 "has used the lift for a long time". E5 stated at this time that "quite frankly I don't see why 2 people couldn't transfer her by cradling her". E5 confirmed that R1 was a small person, weighing approximately 90 pounds.
Further interview with E5, who is responsible for supervision of CNA's on her shift, confirmed at this time, that while she never operates the lifts independently, she has never received any training on how to operate the lifts. E5 confirmed that she relies on the CNA's to take the lead role in operating the lifts and has assisted when called upon to do so. E5 stated that "I've never liked the lifts, period. There's too much potential for someone getting hurt."
Interview with E3, the CNA who was operating the controls and maneuvering the lift during the transfer of R1, on 4-6-01 at 10:30 a.m. in the conference room, confirmed that R1 had been placed in the sling while on the bed, R1 was lifted slightly off the bed to use the bedpan, remained suspended off the bed while she was cleaned up, then pivoted the wheeled lift away from the bed toward R1's wheelchair. E3 confirmed that R1 was leaning to the left in the sling when the "left strap came loose and (R1) went out onto the floor head first, hitting her right frontal area of her forehead on the floor". E3 stated that "I thought the other CNA had ahold of her (R1)".
Further interview with E3 at this time confirmed that she recalls no formal inservice training on how to operate the lifts but does recall on the job training by another CNA at some point. E3stated that she was aware that R1 "did not like the lifts" and would sometimes get upset when in the lift sling.
Interview with E4, the CNA who was preparing to receive R1 to her wheelchair during the transfer, on 4-6-01 at 11 a.m. in the conference room, confirmed that neither CNA held onto the resident or the sling during the transfer and that it was not a usual practice to do so. E4 confirmed at this time that she was standing in back of R1's wheelchair preparing to seat her as R1 was being pivoted in the lift away from the bed when "she flew right out before I could catch her. The left front strap (of the sling) came out of the hook".
Further interview with E4 at this time revealed that "I've always been scared of these lifts since I've been here". She stated that she "has never felt comfortable using the lifts", the lifts "make me feel uneasy", "lives are in my hands". E4 confirmed in interview at this time that she had never attended any inservice meetings regarding the operation of the lifts but that she does recall a CNA co-worker showing her how to use the device.
Interview with E2, the director of nursing and E8, the assistant administrator, on 4-6-01 at 9:45 a.m. revealed that electric lift devices had been in use in the facility since mid December 2000. Since then a total of 3 electric lift devices have been acquired and have been in use for the 11 residents in the facility requiring such lifts.
Interview with E6, the designated in-house trainer for the lift devices, on 4-6-01 at 3 p.m. confirmed that she has never received any specific training by anyone regarding the lift devices, "we just learned it on our own".
E6 confirmed at this time that she provided hands-on training regarding the electric lift to 17 CNA's in December 2000. E6 stated that she maintained no record of what the training consisted of but specifically recalls key points such as "how to attach the slings to the hooks, proper lift leg alignment, holding onto or guiding the resident during the transfer, and actually practicing such lifts". E6 stated that she would expect that the CNA's to keep their hands on the resident while being suspended during the transfer.