MANORCARE AT LIBERTYVILLE
Facility I.D. Number 0032904
1500 S. Milwaukee Ave.
Libertyville, IL 60048
Date of Survey March 13, 2001
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 shall be provided to each resident to meet the total nursing and personal care needs of the resident.
All medical treatment and procedures shall be administered as ordered by the physician.
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:
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.
All medical treatment and procedures shall be administered as ordered by the physician.
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.
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 medical record review, observation and resident interview, staff and physician interviews, the facility failed to provide treatment and care for R7, one of two residents with tracheostomies. Nursing staff did not follow physician orders for PRN suctioning for R7. The 7-3 shift nurses did not suction R7 the entire shift and did not follow standards of nursing practice to assess if R7 needed suctioning. This resulted in R7 being sent to the emergency room for treatment and hospitalization.
The findings include:
Review of the facility's admitting record revealed that R7 was a 50 year old admitted to the facility 1/19/01 with diagnoses including Pneumonia, Muscular Dystrophy, Hypertension, and Methicillin Resistant Staph Aureus (MRSA) infection. Hospital M.D. consultation records and discharge summary record which were included in the medical record reveal R7 was hospitalized on 1/01/01 for pneumonia and underwent a tracheostomy on 1/04/01. These hospital records indicated the tracheostomy as the best option to manage further episodes of pneumonia and to provide for deep suctioning. Per physician orders R7's pneumonia and MRSA was treated with Vancomycin 1.5 grams every 24 hours intravenously during his stay at the facility. R7's Minimum Data Set assessment dated 1/29/01 indicates that R7 was being monitored for an acute medical condition. R7's physician orders and care plan indicated to suction trach as necessary. R7 required total care for all activities of daily living.
Nursing notes for R7's suctioning needs were as follows:
On arrival to the facility on 1/19/01 R7 was suctioned through the trach for
clear white secretions and a 10:00p.m. note indicates suctioned secretions
every one hour.
1/20/01 at 4:00p.m. large amount of thick yellowish to greenish secretions--suctioning done every hour and as needed.
1/20/01 8:00p.m. alert, able to express self by mouth wording, suctioned thick yellowish-green secretions, moderate in amount.
1/21/01 6:00a.m. alert and oriented times 3, suctioned trach every hour sputum thick and tenacious.
1/21/01 9:00a.m. suctioned thru trach almost every 30 minutes. Resident calls the nurse when he needs to be suctioned.
1/21/01 (no time indicated ) uses call light for help, suctioned moderate
amount of thick secretions every 45 minutes.
1/22/01 10:40p.m. calls frequently for suctioning of trach thick whitish
secretions noted.
1/23/01 1:10a.m. secretions thick per trach and whitish and needs frequent
suctioning.
1/22/01 late entry 5:00 resident had call bell on almost every 10-15 minutes to
be suctioned, obtained thick white sputum from deep suctioning.
1/24/01 12MN suctioned as often as necessary.
1/23/01 late entry 2:00p.m. total number of suction are in excess of 10 times
this shift.
1/24/01 10:00p.m. suctioned every 30-45 minutes.
1/26/01 2:00p.m. not in acute respiratory distress, suctioned frequently,
obtained moderate amount of thick yellow white phlegm.
1/27/01 6:00a.m. suctioned trach as necessary noted with thick whitish
secretion coming out from his trach.
1/27/01 8:00p.m. suctioned per his request 2 to 3 times per hour or more.
Mostly thin secretions and clear
1/28/01 1500 family complaining of general lack of care for patient. Patient
having difficulty breathing, oxygen saturation at 89%, blood pressure 160/72,
pulse 92, temperature 101.8. Suctioned with thick tenacious secretions. Breath
sounds coarse, filled with fluid, wheezing in upper and lower lobes bilateral.
Patient very anxious. Received order to transfer to hospital and 911 called.
1/28/01 1615 patient transferred via cart to ambulance.
Interview on 2/07/01 at approximately 3:15p.m. in the conference room/work area with E7 revealed that during the shift change for the 7-3 and 3-11 on 1/28/01, R7's family came to the nursing station complaining to E7 that R7 had trouble with breathing. While the family and E7 were at the nursing station another visitor ran out of R7's room saying that R7 had trouble breathing and needed assistance. E7 went to R7's room, assessed R7 lungs, and heard generalized wheezing and diminished air movement both lungs. R7 was anxious, mouthed "trouble breathing" and wanted to be suctioned. E7 suctioned R7 and checked the oxygen saturation which was 89%. The secretions were thick and tenacious--he felt better after suctioning. E7 determined R7 needed to be sent out. E10 who was also in R7's room indicated R7 was becoming worse and called 911. Additional interview on 2/28/01 at 3:05p.m. in the conference room revealed that when E7 suctioned R7 there was approximately 20 cubic centimeters (cc's) of thick tenacious secretions. E7 stated "did not have saline to instill into trach tube to breakup the secretions." E7 stated R7 was "frantic."
Telephone interview with E10 on 2/07/01 at 4:30p.m. revealed that on 1/28/01 after doing the narcotic count for the 3-11 shift, E10 went into R7's room with the family. E10 observed that R7 was in respiratory distress, was being suctioned by E7 and needed continuous suctioning at that time. E10 indicated R7 had bilateral rales and had so much in his throat. Per telephone interview with E10 on 2/28/01 at 4:05p.m., E10 took over the suctioning for E7. E10 suctioned approximately 1/4 of a canister/300-400 cc's of thick secretions until the paramedics arrived. E10 stated that when caring for R7 prior to this shift (1/28/01 3-11p.m.), R7 required suctioning often but that not much was obtained with suctioning. E10 stated that "when the 1/4 canister was obtained, this was a change." E10 stated "R7 was very anxious that day." E10 thought a pulse oximetry was done during the suctioning but was not sure of this.
Telephone interview with E9 on 2/07/01 at 4:00p.m. revealed that E9 worked the day shift on 1/28/01. E9 works part time at the facility and on 1/28/01 E9 was pulled from the Arcadia Unit (dementia care) to work on the Medicare floor. E9 indicated that she had not worked this floor before and that it was a busy day. E9 said that R7's call light was on and off every 10-15 minutes. E9 indicated that when R7's family came to visit they turned on the call light and wanted his trach suctioned. R7's family came in during the change of shifts for 7-3 and 3-11. When E9 went into the room, E9 was told by the family that R7 did not need suctioning. E9 listened to R7's lungs and did not hear gurgling. E9 stated R7's trach was not suctioned at this time and that R7's trach was not suctioned on the day shift.
"Basic Assessment Series: The Adult Pulmonary System", American
Journal of Nursing, February 1998/Vol. 98, No. 2 contains the following steps
in pulmonary assessment:
1. Begin by taking vital signs and pulse oximetry if available.
2. Is there evidence of drowsiness, restlessness, or irritability, which may
indicate cerebral hypoxia.
3. History and inspection to be followed by palpation, percussion, and
auscultation.
At no time during the interview or through documentation did E9 indicate that these basic assessment techniques were performed for R7 on 1/28/01.
E9 indicated R7 calmed down with his family there. Nursing notes for 1/28/01 written at 3:00p.m. state "vanco peak and trough results relayed. M.D. also notified regarding the frequent request of suctioning. New orders made." Additional interview with E9 on 2/28/01 at 2:00p.m. in the conference room revealed E9 came late (8:00a.m.) to work on 1/28/01. E9 stated that the morning medications on the Medicare unit are heavy and that the morning pass was completed around 11:30a.m. E9 went to lunch approximately from 11:45a.m.-12:15p.m. and returned to the unit to start the 1:00p.m. medications which was completed around 1:30p.m. E9 stated there were 5-6 pressure ulcer dressings to do that day and indicated that days are interrupted by the families especially on the weekend. E9 stated R7's family came in around 1:00p.m. and requested for E9 to call the doctor for Ativan and a sleeping pill. E9 stated "it is more anxiety--every time he woke up his call light would go on."
Interview on 2/07/01 in the conference room at approximately 3:30p.m. with E8 revealed that E8 worked the desk on the Medicare floor on 1/28/01. E8 said she did not go into R7's room but that she did call the physician for E9 to obtain an order for Ativan because the family noted that R7 was anxious. E8 stated E9 did not indicate that R7 was in any respiratory distress.
Telephone interview on 2/15/01 at 9:30 a.m. with the paramedics who responded to the 911 call at 16:16 from the facility on 1/28/01 revealed they were to respond to a patient with difficulty breathing and a trach tube which was clogged with mucus. Upon arrival to the facility the 3-11 staff stated "they were suctioning R7 every 10-15 minutes and that R7's saturated pulse oximetry (SPO2) was 86 fifteen minutes prior to their arrival." Between the facility nurse and the paramedics, R7 was suctioned six times. We placed a nonrebreather over R7's trach tube at 15 liters of oxygen per minute. The SPO was 90 then 96. During a reinterview by telephone on 3/5/01 at 7:10a.m., the paramedics stated that the amount of mucous suctioned from R7 by the paramedics and the facility nurse filled the suction canister to within 1-2 inches from the top or approximately 800 cubic centimeters. The paramedics stated the reason they remember the amount was because they had never seen so much suctioned from a patient and that they knew it would be important information for the emergency room physician. The amount suctioned was observed by the 3 paramedics who responded to the call.
On 2/28/01 surveyor requested to see the suction canister used by the facility. The suction canister provided has a capacity of 1200 cubic centimeters.
Telephone interview on 2/15/01 at 3:15p.m. with Z1 revealed that "the facility staff had called regarding the frequent suctioning and they (staff) did not want to do it. They never said they could not handle the suctioning, otherwise I would have had (R7) out of there." "The nurses implied that the family wanted frequent suctioning." "They (staff) were tired of it and felt (R7) didn't need it. "He was drowning in fluid." "800 cc does not accumulate in 5 minutes." "Had he not been tended to in another 20-30 minutes he would have been killed." "Mental dysfunction begins when an SPO2 is around 85%--he would have died."
Interview with E11 (CNA) on 2/28/01 in the conference room at 2:45p.m. revealed that E11 cared for R7 on 1/28/01. E11 stated "R7 put the call light on quite a bit and most of the times it was for suctioning." E11 stated "the work assignment was heavy that day--10 to 12 residents to care for on the medicare unit." E11 thought R7 might have turned the light on 5 times on 1/28/01 for suctioning.
R7 was interviewed on 2/15/01 by another surveyor in another facility. R7's interview was done at 10:00a.m. in room 309. R7 was asked about the incident from the previous nursing home. R7 remembered the date 1/28/01. R7 indicated and motioned to trach, "I was never suctioned every 1-2 hours that day and I could not breathe." R7 was alert. R7 was interviewed on 3/1/01 at 7:45a.m. in room 304 at another facility. R7 plugged his trach to talk. R7 remembered the day he went to the hospital from the other nursing home. R7 stated "I turned on my light and asked to be changed (R7 pointed to his diaper)." "They became angry, turned off my light and left the room--they did not change me." "About 1/2 hour later I put the light on to be changed and suctioned--they turned off the light and did not come back." R7 could not answer how many times he turned the light on that day. "I have a good memory, but I did not have a clock there." "They let me lay." "When you move me stuff comes out (from the trach)--but they just let me lay there."