LAGRANGE REHAB HEALTHCARE CENTER
Facility I.D. Number 0044982
339 S. Ninth Ave.
LaGrange, IL 60525
Date of Survey 11/21/00
Incident Investigation of 11-07-00
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.
There shall be at least one staff person on duty at all times who has been properly trained to handle the medical emergencies listed in subsection (a) of this Section. This staff person may also be counted in fulfilling the requirement of subsection (d) of this Section, if the staff person meets the specified certification requirements.
When two or more staff are on duty in the facility, at least two staff people on duty in the facility shall have current certification in the provision of basic life support by an American Heart Association or American Red Cross certified training program. When there is only one person on duty in the facility, that person needs to be certified. Any facility employee who is on duty in the facility may be utilized to meet this requirement.
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.
AN OWNER, LICENSEE, ADMINISTRATOR, EMPLOYEE OR AGENT OF A FACILITY SHALL NOT NEGLECT A RESIDENT.
These REQUIREMENTS are not met as evidenced by
Based on record review and staff interview, and medical record review, the facility failed to assure that emergency services were given to R3. Facility failed to properly assess one resident after a strangulation accident, failed to institute CPR, and failed to call for emergency services in a timely manner. Further, staff on the unit at the time of the accident did not have CPR/emergency certification.
Findings include:
Based on record review, R3 had a diagnoses that included Alzheimer's Disease, s/p Coronary Bypass and Dementia with agitation. R3 was a known pacer and wanderer. The night of his death on 11/7/00, nurses notes state that he was pacing earlier in the evening and nurses notes state that they found this resident R3 awake and in bed for many of the bed checks.
Per nursing note documentation, on 11/7/00 at 5:20 a.m., E3 found R3 unresponsive, in a sitting position on the floor near the lower part of his bed. On interview and documentation, E3 stated that part of the privacy curtain was entangled and twisted together with his gown. E3 stated that the gown made a very tight twisting around R3's neck and she could not release the knot and the entanglement. She then called for help. Per recorded document and interview, E4 responded right away and also attempted to untie and release the entangled gown around R3's neck but could not. E5 came in after and was able to release the entanglement. These three staff were the only employees on duty on the night shift of Unit 3 which is a locked Alzheimers unit.
E4 documented on the nurse's note dated 11/7/00 5:20 a.m., "Resident soaking wet, cold Gown tied around neck and courtesy curtain, unable to appreciate vital. Supervisor was notified and came up the unit right away." There were no further notations by E4 regarding any emergency measures done by staff and any assessment done to check the resident and his breathing after the gown was removed. The next notation on the nurse's note is from E6 who was the Supervisor notified to come from another floor Unit 2 to assess the situation.E6 charted "11/7/00 5/30 a.,called by third floor nurse stating that she need help due to death. Upon arrival on the vicinity the resident was seen in bed already lying flat. Marks on the neck area noted..."
There again was no documentation from the staff on site during this incident of what they did to help R3 while they waited for E6 to arrive. E6 was the only staff involved that had a CPR certification card.
On interview of E4 on 11/10/00 at 7:30 to 8:00 a.m., E4 was asked about the charting as to what occurred between her charting and E6's charting which is from 5:20a.m. to 5:30a.m. E4 stated after they released all the stuff around R3's neck, she did check for pulse. E4 stated that she thought she felt a faint pulse but was not sure if it were hers or the resident's.
E4 failed to confirm with other staff and failed to follow facility policy at this point to confirm whether or not R3 had actually expired.E4 then told the CNAs (E3 and E5) to put R3 in bed and clean him up as the resident was sitting on a puddle of urine. E4 stated that she then went out of the room to call the supervisor.E4 told the Surveyor in interview that she did not attempt CPR because R3 was a DNR.
Surveyor asked if E4 took any vitals after putting the person in bed. E4 stated that she did but she did not appreciate a pulse. No other vital sign assessment was done. Per interview, E4 did not attempt to check other vital signs or neuro signs. Surveyor asked about R3's temperature when she was checking for pulse, E4 responded that the body and the neck area were still warm but the extremities were cold to touch. This was consistent with E3's description of R3 on interview of 11/9/00 at 3:00 p.m. E3 stated that when she first checked R3, she described "R3's body was still warm but extremities were cold". Both stated that extremities were not rigid at the time they discovered R3 with gown around his neck.E4 was asked if any emergency services were given, E4 responded that no services were provided and stated that R3 has a DNR order. (Do Not Resuscitate).
Review of policy for Accidents/Emergency care reflect instruction not to move resident. This was not followed. In this case, initial assessment only consisted of E4's attempt to obtain a pulse in which she was not sure if there was a pulse or not. The resident was moved to his bed so he could be cleaned. The facility's emergency procedures calls for checking for airway, breathing and circulation. This was not done. The facility only documented attempt at vital signs consisting of attempt at checking the pulse. No other procedure attempted. E2 and E4 both stated that the resident has a DNR order, no CPR initiated even though the incident was accidental with obvious sign of strangulation. DNR does not apply to unnatural accidental incidents where the resident may have been viable should these emergency services be initiated. The Facility doesn't have a policy of who can certify the death of resident, but per E2, the facility has the practice that two licensed nurses can pronounce death. Review of record in fact shows that E4 was already notifying the supervisor of R3's death before E6 went up to check the resident. E4 on her interview stated that the Supervisor arrived on unit 3, thirty minutes after they found R3 strangled with marks around his neck and the gown tightly twisted around his neck. Police were notified at 7:40 a.m. about the incident which is 2 hours after staff found R3.
The facility staff are not properly trained to handle emergencies such as above and perform emergency services according to their procedure. The facility has not trained its staff regarding when and what to do in emergency situations such as the incident of R3.