LITTLE ANGELS NURSING HOME
I.D. Number: 0010918
1435 SUMMIT ST.
ELGIN, ILLINOIS 60120
Survey Date: 3/17/99
The facility shall notify the Department of any incident or accident which has, or is likely to have, a significant effect on the health, safety, or welfare of a resident or residents. Incidents and accidents requiring the services of a physician, hospital, police or fire department, coroner, or other service provider on an emergency basis shall be reported to the Department. Notification shall be made by a phone call to the Regional Office within 24 hours of each serious incident or accident. If the facility is unable to contact the Regional Office, notification shall be made by a phone call to the Department’s toll-free complaint registry number. A narrative summary of each serious accident or incident occurrence shall be sent to the Department within seven days of the occurrence.
A descriptive summary of each incident or accident shall be recorded in the progress notes or nurse’s notes for each resident involved.
The facility shall have a written program of Nursing Services, providing for a planned medical program, encompassing nursing treatments, rehabilitation and habilitation nursing, skilled observations, and ongoing evaluation and coordination of the resident’s individual habilitation plan.
There shall be a sufficient number of nursing and auxiliary personnel on duty 24 hours each day to provide adequate and properly supervised nursing services to meet the nursing needs of the residents. There shall be at least one registered nurse seven days a week, for 8 consecutive hours. There shall be at least one registered nurse or licensed practical nurse on duty at all times and on each floor housing residents. Nursing staff personnel shall include registered professional nurses, licensed practical nurses, and auxiliary personnel as defined in Section 390.330 of this Part.
The responsibilities of the director of nursing shall include, at a minimum, the following:
Planning an up-to-date resident care plan for each resident in cooperation with the interdisciplinary team based on individual needs and goals to be accomplished, physician’s orders, and personal care and nursing needs. Services such as nursing, developmental, activities, dietary, and such other modalities as are ordered by the physician, shall be reflected in the preparation of the resident care plan. The plan shall be in writing and shall be reviewed and modified in keeping with the care needed as indicated by the residents condition. The plan shall be reviewed every three months.
Nursing care shall include at a minimum the following:
All medications including oral, rectal, hypodermic, and intra-muscular shall be properly administered.
All 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, nursing or psychosocial evaluation and treatment shall be provided.
The facility shall also immediately notify the resident’s family, guardian representative, conservator and any private or public agency financially responsible for the resident’s care whenever unusual circumstances such as accidents, sudden illness, disease, unexplained absences, extraordinary resident charges, billings, or related administrative matters arise.
An owner, licensee, administrator, employee or agent of a facility shall not abuse or neglect a resident.
1) Based on observation, interview and file verification, the facility failed to ensure that a client was provided nursing services in accordance with his needs for 2 of 2 clients who had their tracheotomies decanulated in 1999.
2) R1 was a 6 year old profoundly mentally retarded, non-verbal male with a tracheotomy and gastrostomy tube. R1 was diagnosed as having a seizure disorder and spastic quadriplegia.
Z6 stated R1 was “...on Amoxicillin for pneumonia” and had been started”...on a course of Prednisone for bronchial spasms related to the pneumonia.”
The facility’s Occurrence Report and Investigation Report revealed that R1 “was found (in his room, in his bed) unresponsive with his tracheotomy tube out” at 10:40 a.m. on 01/30/99. Per interview
with E1 2/25/99, the tracheotomy (trach) “ties were untied.” E10 acknowledged being aware of this during an interview on 2/25/99.
R1 was pronounced dead at Sherman Hospital emergency Room in Elgin on 1/30/99. According to the Death Certificate the cause of death was: “acute airway obstruction due to or as a consequence of pneumonia and asthma due to or as a consequence of cerebral palsy.”
Per file verification (2/2/98 and 6/27/98 and 12/11/98 Nurses’s Notes) and interviews with E12 on (3/3/99) and E2 on (3/1/99), R1 had a history of paramedics called and the tracheotomy (trach) coming out. Examples follow:
Per a 2/2/98 Nurses’s Note written by E12, the “school RN phoned” at 12:30 p.m. to report R1's trach had come out of the stoma. According to the note, the trach was “reinserted (without) difficulty (after) expulsion” and the child ?pinked’ up. Z5 stated per interview of 3/2/99 that R1 “was down on a floor mat” when she heard him having difficulty breathing and discovered his “trach out of the stoma.” A 2/2/98 Nurse’s Note at 1900 (7 p.m.) reads: “Labored breathing...coughed up mucous plug. Trach Changed (with) great difficulty. Resident cyanotic.” When E12 was interviewed on 3/3/99, indicated that “usually the school will make out the incident report–probably the DON or case manager should have made sure there was an incident report from the school.” Regarding notifications, E12 stated she would “think I would have” notified the Director of Nursing (DON) and “probably” the case manager. The parent/guardian was not notified.
Per a 6/27/98 Nurses’s Note written by E2 at 12 midnight, R1's “trach was found out of (R1's) stoma. (R1) was in distress –struggling for (oxygen). Trach was placed back into stoma and (R1) recovered.” Per interview with E2 on 3/1/99, she did not believe she had completed an Occurrence Report and “did not notify anyone” she described the child as “upset, agitated, very panicky” when found 6/27/98.
On 12/11/98 a Nurses’s Note stated the school nurse had called to report that R1 had become
“cyanotic”–that the trach was obstructed and the paramedics had been called. Per interview with Z3 on 3/2/99 the child was in “respiratory distress” (12/11/98). “Saline drops were used and worked” for the “mucous plug.” File verification revealed no Occurrence Report or notification to guardian. Per interview 3/8/99, Z6 stated he “does not recall” the incident of 12/11/98. E10 (2/25/99) acknowledge she knew f the incident; “that’s why he (R1) went for the consultation” (12/17/98) with a pulmonologist. when interviewed on 3/11/99, Z2, the mother, stated that she was “never notified of it (the trach) coming out” before the day R1 died (4/30/99). She also denied ever being notified of any emergency situation when the paramedics or other emergency help had to be called. According to the “Notification of Occurrence” form in R1's file, Z2 requested to be notified”...of all occurrences, including all minor changes in conditions...” The facility failed to notify R1's parent/guardian of significant incidents on at least three occasions.
The following describe R1's medical condition in January 1999. Per a 1/5/99 Nurse’s Note: R1's “lips blue, Resp. labored and (increased).... Breathaide filled (with) mucous.”
On 1/25/99, Z6 wrote in his progress Note that “if he (R1) should deteriorate any further we will need to send him to the hospital.”
A 1/27/99 (3:23 p.m.) Nurses’s Note reads: “Old trach plugged...”
Per a 1/28/99 Nurses’s Note: “trach change d/t..mucus (mucous) in trach...”
Per Nurses’s Note on 1/30/99 at 1 a.m., R1 had “scattered rhonchi present bilaterally...Resident began brief coughing episode and produced moderate amount of blood-tinged trach secretions...Will monitor.”
The next Nurse’s Note on 1/30/99 was at 10:50 a.m. which reads “found resident at approximately 10:40 a.m. (with) trach out. (No) pulse palpable (No) spontaneous resp.”
E16 reported that on 1/30/99 (R1) has been noted to pull at his corrugated tubing and tracheotomy collar used to administer humidification to his tracheotomy and had observed (R1) pulling on them the morning of his death.”
The following are interviews that confirm R1's continued problems:
E8, 2/24/99, “COUGHED trach out before-maybe 1-2 times in past.”
E3, 2/24/99, he “did keep trying to take off the mask and did; pulled at everything.”
E4, 2/25/99, “would grab at the mist collar.”
E7, 2/25/99,” often used to pull, saw him, at trach cuff or tubing during treatment. Tube would
disconnect or cuff come off trach-usually when he was sick.”
E8, 2/25/99, “grabbed at humidity mist, trach-mostly at tubing.”
E4, 2/25/99, would grab at the mist collar.”
E9, 2/25/99, “would take collar off during treatment–all the time, constantly.”
E12, 2/25/99, “used to pull at tubing, pull tubing off sometime, during treatment.”
E6, 2/25/99, “Heard of (R1) COUGHING out his trach- through report from previous shifts-1 or 2, a few times.”
E9, 2/25/99, “...coughing more than usual” evenings of 1/28 and 1/29/99.
E12, 2/25/99, “Had a forcible cough during the day.”
E2, 3/1/99, R1 “had a pretty forcible cough: whole body would shake. Arms and legs would come up-definitely when sick; more forceful when he was sick.”
Z3, 3/1/99, R1 did “forcible, hard coughing.”
E2, 3/1/99, R1 during treatments, “would pull on tubing until elastic would snap on tubing or ball mechanism came right out of the machine--was on-going.”
E13, 3/2/99, regarding night of 6/27/98, “(R1) COUGHED it (trach) out. A good cougher.”
Z6, 3/8/99, stated he “saw him cough; very forcible. Suptum would fly out 1-2 feet.”
Per interview with Z6 on 3/8/99, he stated that had he known of R1's history of the “trach coming out,” he “would expect more frequent monitoring.” Z6 confirmed that R1 “was trach dependent” and needed the trach to breathe.
Per interview with Z1 on 3/1/99 when asked how often would be reasonable to expect a child with this child’s history to be monitored while ill with pneumonia and having asthma? Z1 replied that she would expect “any 6 year old child, not just one with a trach, to be checked on at least two times in an hour.”
Per file verification and confirmed by interview with E10 on 3/2/99 R1 was on no specific monitoring system to address his needs. R1 was under treatment for pneumonia and asthma. He had a history of the trach coming out, forcible coughing, mucous plugs, and grabbing/pulling. R1's medical care plan did not address his history of the trach decannulation, forcible coughing, mucous
plugs, or grabbing/pulling; he was in need of 24 hours nursing services. R1 was not checked for one hour and forty minutes on 1/30/99 to see if any of these conditions were problematic. Per file documentation, E1 and interviews, E1 last saw R1 “sleeping” at 9 a.m. Per interviews with E1and E5 (2/25/99) and E14 (2/24/99), the staff to whom R1 was assigned the morning of 1/30/99, none of them saw him again until 10:40 a.m.
Per file verification, R1's IPP (Annual 8/4/98 and Quarterly Review 11/17/98) do not address R1's history of trach decannulation, mucous plugs, forcible coughing or grabbing/pulling. When interviewed 3/8/99, E7 stated I “can’t give you a good answer” as to why these issues were not addressed in the IPP.
The facility failed to ensure nursing services included the development, review and update as needed for R1's IPP.
Based on interview and file verification, the facility failed to ensure that nursing services include the development, with a physician, of a medical care plan of treatment for a client when the physician has determined that an individual client requires such a plan. Per interview on 3/4/99 with E15, “nurses have the responsibility to update the medical care plan.” “ The nursing assessments, observation and input they may get from others” are part of the process to develop the medical care plan. Per file verification, R1's medical care plan does not include any “problem, goal and/orintervention” for trach decannulation, mucous plugs, forcible coughing, or grabbing/pulling.
The facility neglected to follow its own policy regarding completing Resident Occurrence Reports and notifications (to include the Medical Director) on at least three occasions (2/2/98, 6/27/98 and 12/11/98). Per review of the facility’s Policy on Resident Occurrences, an investigation shall include:
“Identifying and interviewing all staff, family or personnel who had direct contact with the resident in the last 24 hours when the cause of the incident is unknown.” The Investigation Report of R1's death of 1/30/99 contains no identification or interviews of the night (1/30/99) or evening (1/29/99) of staff. Per a 1/29/99 Nurses’s Note, it was the evening shift nurse who last changed the trach. The Investigation Report neglects to mention the trach ties were not tied. The “two ties were untied” was stated on interview with E1 2/25/99.
R2 is a 27 year old profoundly mentally retarded female with a tracheotomy (trach). Per the facility’s Incident Investigation Summary on 2/19/99 6:30 p.m., R2 was found”...with tracheotomy out of the stoma with trach strings untied.” According to the Investigation Summary “Both the resident’s shirt and trach strings were saturated with secretions.” The summary does not indicate when R2 was seen by staff prior to 6:30 p.m. E10 confirmed in interview that R2 is not on any specific monitoring system.
The facility neglected to provide two clients with tracheotomies with nursing services in accordance with their needs.
2) Based on interview and file verification, the facility failed to administer all drugs without error for 2 of 2 clients reviewed for medication errors.
R3 is a 2 year old mentally retarded male with a nasogastric (NG) tube. R3 receives peritoneal dialysis.
Per the facility’s Report, on 11/25/98, 11:15 a.m., R3 was administered Metoprolol 10ml. (10mg/ml)
instead of the ordered 1m. per his NG tube Metoprolol is a gastrointestinal stimulant). This was ten times the ordered dosage of medication given per NG tube to a then 1 year old. R3's stomach contents were aspirated at the facility.
Per interview with E10 on 3/2/99, R3 was transported to Lutheran General Hospital Emergency Room (11/25/98) due to peritoneal dialysis problems.
3) R4 is a 1 year old profoundly mentally retarded female with a gastrostomy tube.
Per documentation received from the facility, R4 returned from the hospital on 2/13/99 with differing information regarding the amount of the medication, Robinol, R4 was to receive (discharge planning summary information differed from the outpatient prescription). E2 transcribed the Robinol order to the physician order sheet, telephone order slip and medication administration record with another differing dosage. Robinol is a cholinergic blocking agent. It reduces smooth muscle spasms, bladder, bronchial and intestinal muscle. It increases rate and speed of heart muscle conduction. It decreases gastric secretions.
The correct dose per the hospital discharging physician was Robinol 500 mcg. qid (4 times a day).
Three incorrect dosages (125mcg., 250 mcg., and 125mcg.) were administered before E8 identified the problem and verified the correct dosage with the attending physician.
E10 confirmed on interview 2/16/99 that 3 times “nurses gave less dose than required.”
The facility failed to administer drugs without error to 2 clients.