MANORCARE AT PALOS HEIGHTS WEST
Facility I.D. Number 0041319
11860 Southwest Highway
Palos Heights, IL 60463
Date of Survey 11/02/00
The facility shall have written policies and procedures, governing all services provided by the facility, which are followed.
The facility shall notify the resident's physician of any accident, injury, or significant change in a resident's condition that threatens the health, safety or welfare of a resident.
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. 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.
Objective observations of changes in a resident's condition as a means of 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.
All medications shall be given as prescribed by the physician and at the designated time.
If for any reason a physician's medication order cannot be followed, the physician shall be notified.
Nurses' notes shall describe the nursing care provided, observations and assessment of symptoms, reactions to treatments and medications, progression toward or regression from each resident's established goals, and changes in the resident's physical or emotional condition.
A facility shall not neglect a resident.
These requirements are not met as evidenced by:
Based on family, staff and physician interviews, and record reviews, the facility failed to ensure that:
a) R1 received medications as ordered;
b) R1 received diet, fluids and supplements as ordered;
c) attending physician and significant family were notified of significant changes in condition, such as, refusal of significant heart medications, complaints of nausea and dark brown vomit on 9/29 and 9/30, and refusal to eat and drink;
d) R1 received assessment of neurological status to rule out concussion, 12/24 hours after the 9/29/00 4am fall, when nausea and vomiting started, and for 72 hours per facility policy/procedure; and
e) R1 received assessment of circulation, motion and skin (CMS) of left shoulder/arm and possible shoulder fracture after a fall and application of a sling in Emergency Room (ER).
R1 was admitted for a 4 day respite care from 1:30pm on Thursday, 9/28/00 to 7:30pm on Sunday, 10/01/00. R1 walked into the facility with Z8, a family member. They brought a plan of care and orders for a low salt diet. All R1's medications were counted and supplied by the family, per Z8. Ensure was ordered 3 times daily and 6 cans were supplied by the family. Applesauce was provided to assist R1 to swallow medications per family's care plan. R1 had an upper partial denture, documented as "good fit" by admission nurse. Denture cup was provided by family. This partial was unable to be found on 10/1/00 discharge.
R1's history and physical documented R1's diagnoses as "Moderate Aortic Insufficiency, Moderate Mitral Regurgitation, and Severe Left Ventricular Dysfunction" by her cardiologist, Z2. R1 was 86 years old. R1's orders were confirmed by Z1, R1's attending physician, on 9/28/00 admission.
"Social Work Assessment (short term), Informant/daughter...Needs assistance with all ADL's. Does not use a walker, able to ambulate with assistance..." "SSD to follow closely with resident/family to ensure continuity of care..." Z3 would be home during respite stay and was emergency contact. Family visited afternoon and evenings during stay. Pre-admission screening documented, "Does not know how to use a call light, continent for the most part..." On admission, facility was aware that R1 needed help with all activities of daily living, had family involvement and needed instruction and monitoring on calling for assistance.
Per incident report review, record review and E1 and family interviews, R1 was found on the floor, by a Certified Nurses Aid (CNA), at the end of the bed at 4:40AM on Friday, 9/29/00. R1 complained of pain to left shoulder and arm and stated, "Can't move. I was trying to go to the bathroom."
Z1 and daughter were notified and R1 was sent to the hospital at 5:50AM by ambulance. R1's daughter also went to the ER. Daughter stated she noted R1's face and left arm were bruised. X-ray of the left shoulder revealed, "Chronic rotator cuff tear with severe degenerative change and fragmentation of Left femoral head...with subchondral cyst formation. A small pathological fracture through this area cannot be excluded." A left sling was applied and referral to an orthopedic doctor was recommended for follow-up. CT scan of the head revealed, "...chronic small vessel ischemic disease...no intra cranial hemorrhage. No fracture." Blood tests revealed low sodium (130 with 136-145 normal); and low hemoglobin (10.2 with 11.4-15.6 normal). Z1 was notified when R1 returned to the facility with a left arm sling. Z1 changed the pain medication order to Tylenol #3, 2 tabs every 4 hours, orally as needed for pain and resume previous orders.
Per staff and family interviews, E1's investigation report after family's 10/07/00 complaint, and record reviews, R1's record had no nurse's notes from 11:30am on Friday 9/29/00 until 4am on Saturday 9/30/00. The 4am 9/30/00 note documented that R1 "rested in bed all night quietly...". 10/01/00 note by E7 was the only other note and stated, "Resident discharge to care of daughter. Stated resident is missing upper partial consist of two teeth. Left per wheelchair."
Z3 and Z8's interviews revealed that at the time of discharge, R1 was unable to stand or walk and had to be taken out by a wheelchair. Medications were taken home and indicated that meds were not given as ordered. The 6 cans of Ensure that were brought in and were ordered 3 times a day were still left. Clothing, gown, blouse and dress, had dark black stains that looked like blood and were found to be vomit, per staff, visitors and investigation report by E1.
Medication Administration Record (MAR) review, investigation report and family interviews revealed approximately 20 medications that were ordered were not given. Some of these medications were significant heart medications, per physician interviews with Z1 and Z2. No medications were given at 8am on 9/29 or 9/30. 4pm meds on 10/1/00 were circled as not given by E7. Bedtime/8pm medications were not documented as given for 9/28, 9/29 and 9/30. There was evidence of vomiting after 4pm meds on 9/29/00 and there was no follow-up.
Medications ordered included:
Aspirin 325 mg. daily at 8am;
Co-Enzyme Q-10 100mg. bid 8am & 4pm, for heart oxygenation per Z-1;
Colace 100mg. every other day, to prevent constipation and straining, due 9/30/00;
Isosorbide 60 mg. ½ tab at 8am & 4pm, for vaso-dilation/circulation;
Lisinopril 20 mg. 2 times daily 8am & 4pm;
Serzone 100mg. at 8am and 4pm, an anti-depressant;
Synthroid 0.025mg. po daily at 8am, thyroid medication needed daily to maintain level;
Zantac 75 mg. at 8pm bedtime; and Zyrtec 10mg at 8pm bedtime, an antihistamine.
Lisinopril is "An ACE inhibitor, and for her, a significant cardiac drug. She was being kept alive by meds and her daughter's TLC (Tender Loving Care.)", per 11/01/00 interview with Z-2.
Zantac was given by E8 on Saturday morning. "Given Zantac to calm her", per written statement to E1. There was no call to the doctor.
Staff interviews of E4 revealed R1 was not eating Saturday morning 9/30 or at lunch or at supper on Sunday. E5 stated R1 was not eating Saturday on the 3pm to 11 shift.
There was no notification to Z1 regarding nausea, vomiting, and refusal of medications. There was no report to Z1 of daily and 2 times daily "significant heart medications" missed on 9/29/00 at 8am and no plan to give them. There was no call to Z1 when R1 was noted to vomit "black" on Friday evening, per family and E10. There were no neuro checks done post unwitnessed incident policy. There was no documentation by nurse E8 when E4 saw R1 vomit "brown" before and after breakfast on Saturday 9/30/00. There were no neuro checks done, no 8am meds given, no breakfast taken and R1 complained of nausea. Interview with Z1 revealed she should have been called and R1 needed to be examined and/or sent to the ER.
On Saturday evening, Z5 observed E7 trying to give medications to R1 without the applesauce provided by the family. E7 stated she did not know about the care plan provided by the family. When Z-5 showed it to E7 she said she didn't look at it as E7 thought it was private, the list/care plan for "continuation of care."
Z7 visited on Sunday afternoon 10/1/00 and R1 was in bed with her lunch tray at bedside and not set up. R1 had a sling on the left arm. There was no call to family or Z1.
R1 was taken home by Z3 and Z8 about 7:30pm. The discharge summary presented by E7 indicated that R1 was the "same". E7 refused to change it after the family pointed out that R1 was unable to stand without help, much less walk. When family signed the discharge, she documented that R1 needed a wheelchair because she was so weak.
R1 expired at home during the night about 6 hours later. No autopsy was done and family stated the death certificate listed cause as Congestive Heart Failure.
On 11/2/00 at 1030am to 1045am, requests for policies and procedures for resident refusal of meds or staff's inability to follow doctor's orders were made to E1, then also to E11. These policies were received at 12:48pm and documented need to notify the Medical Director. Staff had failed to follow these policies and procedures. Policy and procedure for follow-up assessment for head injuries and possible fractures/injuries and unwitnessed falls were also sent. These facility policies and procedures were not followed for assessment every four hours, for 72 hours, after an incident.