JEFFERSONIAN CARE CENTER
Facility I.D. Number 0039818
1700 White Street
Mount Vernon, IL 62864
Date of Survey: 08/17/01
Incident Investigation of 08/04/01
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.
All necessary precautions shall be taken to assure that the residents environment remains as free of accident hazards as possible. All nursing personnel shall evaluate residents to see that each resident receives adequate supervision and assistance to prevent accidents.
These regulations are not met as evidenced by:
Based on staff interviews, observations, record reviews and review of incident reports the facility failed to initiate interventions to prevent reoccurrence of incidents involving the chest and neck being wedged between the side rail and bed on two different occasions for 1 resident (R1).
According to review of R1's clinical record, R1 was a 92 year old female , originally admitted on 2-27-01, with readmission dates of 3-16-01, and 3-30-01. R1's diagnoses include Transischemic Attacks, Alzheimer's Disease, Coronary Artery Disease, and Dementia.
R1's quarterly assessment of 6-12-01 has assessed R1's bed mobility as needing limited assistance of 1 person. Her bed mobility was also assessed as using half bed rails for bed mobility or transfer. The assessment also identified R1 as having short-term memory problems and is moderately impaired cognitively for skills for daily decision making. R1's care plan, dated 6-13-01, identifies resident as a potential risk for injury related to Cerebrovascular Accident, Arthritis, Dementia, etc. One of the approaches for this problem was to "provide ½ side rails times two to assist with bed mobility."
Review of the incident reports revealed that R1, on 4-9-01 at 3:30 a.m., was "found during bed check with her chest caught between upper half side rails and bed, right chest wall red and scraped, right knee scraped." R1 was transported to a local emergency room for evaluation. At the time of the incident on 4-9-01, the facility did not re-evaluate R1's use of the side rails. This information was verified with E18 on 8-15-01. Side rails were continued and were raised at all times while R1 was in bed, as verified per R1's nurses notes and interviews with E5 and E15. R1's use of side rails were evaluated during quarterly reassessments on 5-27-01 and 6-13-01 without any changes being implemented.
Per nurse's notes in R1's clinical record, on 8-4-01, at approximately 6:10 a.m., "Res was found with trunk and legs on the floor, head and neck between ½ side rail and mattress. Resident removed from the side rail and placed on floor on her back. Skin cool and dry, color ashen. No respirations , no pulses palpable. Pupils fixed and dilated." The physician, coroner, family, and funeral home were notified.
Per interview with E5 on 8-8-01 regarding R1's demise on 8-4-01, E5 stated, "I saw her head. All I could see was the top of her head and a hand. I bolted over to her and tried to hold her up, thinking we would save her. I got up on the bed and held her under the arms."
Per interview with E4 on 8-7-01 regarding R1's demise on 8-4-01, E4 stated , "I was one of the ones that found her. (E5) and I went into the room and I didn't see her in the bed. I looked a second time and saw her head. Her head was between the rail and the bed. It took (E12, E5, E15) and another staff person to get her out of the position she was in."
Per interview with E12 on 8-7-01 regarding R1's demise on 8-4-01, E12 stated, "Her trunk and legs were out of bed, almost hanging. Her neck and head was wedged, tightly fixed in the side rail, more or less hanging. In order to extricate her, we pulled the side rail out and up. One of the other nurses slid her sideways and got her out and eased her to the floor. She had a few superficial indentations on the front, middle of her neck."
Per interview with E15 on 8-8-01 regarding R1's demise on 8-4-01, E15 stated, "I walked into the room. (E5) was standing in the middle of the bed, trying to hold her up. (R1's) head was between the rail and the mattress, her neck was twisted a little. The rail was under her neck. Her head was tilted to the left, but her face was looking to the right. (E12) pulled the rail up so they could slide her out."
The Medical Certificate of Death dated 8-4-01 lists the immediate cause of death as Acute Cardiopulmonary Pulmonary Event due to, or as a consequence of Coronary Artery Disease, Chronic Obstructive Pulmonary Disease, Status/Post Cerebrovascular Accident.
Per staff interview with E16, R1 had been previously observed with her arms through the side rails. E15 stated she had found R1 close to the rail and moved her over to the middle of the bed. E15 and E16 could not recall exact times and dates.
Per staff interview with E4, E6, E15, E17, and E11, R1 could use the side rail while being changed. E14, Care Plan Coordinator, stated R1 could use the side rails with verbal cues only and hands on assist.
Per review of the Side Rail Assessments, dated 2-27-01, 5-27-01, and 6-13-01, R1 used ½ side rails to assist with bed mobility, requires verbal cues and hands on assist. The assessment indicated that lesser restrictive alternatives had not been attempted.