PEKIN LIVING & REHAB CENTER
Facility I.D. Number 0043471
2220 State St.
Pekin, IL 61554
Date of Survey: 01/10/01
Notice of Violation: 03/01/01
The facility shall provide a Resident Services Director who is assigned responsibility for the coordination and monitoring of the resident's overall plan of care. The director of nurses or an individual on the professional staff of the facility may fill this assignment to assure that residents' plans of care are individualized, written in terms of short and long-range goals, understandable and utilized; their needs are met through appropriate staff interventions and community resources; and residents are involved, whenever possible, in the preparation of their plan of care.
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.
General nursing care shall include at a minimum the following and shall be practiced on a 24-hour, seven-day-a-week basis:
Medications including oral, rectal, hypodermic, intravenous, and intramuscular shall be properly administered.
All treatments and procedures shall be administered as ordered by the physician.
The DON shall oversee the nursing services of the facility including:
Planning an up-to-date resident care plan for each resident based on the resident's comprehensive assessment, individual needs and goals to be accomplished, physician's orders, and personal care and nursing needs. Personnel representing other services such as nursing, activities, dietary, and such other modalities as are ordered by the physician shall be involved 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 resident's condition. The plan shall be reviewed at least every three months.
Development of Medication Policies:
Every facility shall adopt written policies and procedures which are consistent with the purpose of the Act and this Part and which shall be followed in the operation of the facility, for properly and promptly obtaining, dispensing, administering and disposing of drugs and medications. These policies and procedures shall be in compliance with all applicable Federal, State and local laws.
Review of Medication Orders:
The staff pharmacist or consultant pharmacist shall review the medical record, including physician orders and laboratory test results, at least monthly and based on their clinical experience and judgment, and Section 300.Appendix F, determine if there are irregularities which would cause potential adverse reactions, allergies, contraindications, or ineffectiveness. This review shall be done at the facility. Documentation of this review must be entered in the clinical record. Any irregularities noted shall be reported to the attending physician, the advisory physician, and the administrator.
If for any reason, a physician's medication order cannot be followed, the physician shall be notified as soon as is reasonable, depending upon the situation and a notation made on the resident's record.
AN OWNER, LICENSEE, ADMINISTRATOR, EMPLOYEE OR AGENT OF A FACILITY SHALL NOT ABUSE OR NEGLECT A RESIDENT.
These regulations are not met as evidenced by:
Based upon record review and interviews, the facility neglected to ensure prescribed medications to prevent kidney rejection were administered as ordered; neglected to ensure that lab tests for monitoring renal status were carried out as ordered; neglected to ensure follow-up consultations with the renal specialists occurred; neglected to have a written plan of care addressing kidney transplant needs; and neglected to catherize as ordered to check urinary retention for one resident (R1), who received a kidney transplant in 1995 and is currently experiencing rejection of the transplanted kidney. R1's decline and rejection cannot be deemed unavoidable based on the facility's negligence in providing the necessary care
The complete record of R1 was reviewed at the facility on 01/02/01. R1 is a seventy year old male who was admitted to this facility on 07/31/00 from another long term care facility. Diagnoses includes but is not limited to: Renal transplant (1995), history of urinary tract infection, insulin dependent diabetes mellitus, left and right leg amputee, and coronary artery disease.
Nurses note dated 12/20/00 and signed by E2 stated that R1 stayed in the facility from 07/31/00 until the early morning hours of 12/20/00. On this date, R1 was transferred to the local hospital at 5:20 AM. Documentation in this same nurses note by E2 (licensed nurse) states that R1 was found to be "unresponsive, eyes open dilated......slow response to light.....no response to sternal rub, eyes fixed.......res. was drinking glass of ice water when he dropped same over himself and went unresponsive."
Emergency room record dated 12/20/00 indicates that R1 was seen at the hospital at 0545. Laboratory tests indicative of kidney function done in the emergency room on 12/20/00 revealed BUN (blood urea nitrogen) to be 163 with normal range of 9-21. Creatinine level was 16.5 with normal range of 0.8-1.5. R1 stayed in the emergency room for only a short time and was then transferred to a larger medical center in the area.
Interview with Z1 (kidney specialist and previous physician of R1) was done by telephone on 12/28/00 at 12:15 PM. The interview revealed the following: 1) R1 was seen at the larger medical facility by Z1 on 12/20/00. 2) Z1 stated that R1 is now experiencing "moderate to critical rejection of his transplanted kidney which may or may not be reversible." 3) Z1 stated if R1 "loses the transplanted kidney he may die" because no good access areas are left to be used for dialysis. 4) Z1 confirmed that only 1 of 3 needed immunosuppressant medications was administered while R1 was at the facility. 5) Z1 stated that R1's condition "is due to lack of care and a lack of assessment by the facility." 6) It is Z1's medical opinion that R1's "present condition would not be as it is if monitoring of laboratory tests had been done."
Per the complete record review, R1 was admitted to the facility on 07/31/00 from another long term care facility. A copy of the physician's order sheet was sent with the resident. The order sheet observed in the record at the facility stated laboratory tests to be done as follows: "BMP: Jan, Mar, Apr, June, July, Sept, Dec.-CBC every month-CMP: Feb, May, Aug, Nov-phosphorus and Mag: May, Aug< Nov- Uric Acid, lipid prof. fasting, a1c: Feb and Aug." The immunosuppressant medication listed was imuran 50 milligrams every morning. The physician's name in the lower bottom corner was that of Z1.
E1 (licensed nurse), per signature, on physician's orders dated 07/31/00 called Z3 (attending physician/general practitioner) for admission orders. These orders dated 07/31/00 stated "(Z1) to follow re: renal.... (Z1) to decide labs."
There is no evidence in the entire record that indicates these orders were followed or that Z1 was called to discontinue them or revise them.
The facility was ordered by Z3 (attending physician/general practitioner) on 7/31/00 to contact Z1 regarding the renal care of R1. Z1 was to be involved in the care planning for R1. Z3 also stated that Z1 was to determine any needed laboratory testing to be done. R1 was to be followed in the facility by Z1. This was verified by interviews with Z1 on 12/28/00, with Z2 on 12/27/00, and with Z3 on 01/09/01. The same interviews with Z1 and Z2 also verified that Z1 was never contacted by the facility.
Z1 and Z2 stated that R1 was to receive three immunosuppressant medications to prevent kidney transplant rejection. Only 1 of the 3 was administered to R1 during the period of time he resided in this facility (7/31/00-12/20/00). This is verified by facility medication administration records (dated from 07/31/00 through 12/19/00) and interviews with Z1, Z2, and facility staff. Both Z1 and Z2 stated that facility staff were told the importance of these medications. E1, E4, E5, and E9 stated when interviewed that they were not aware of the need for prednisone and neoral to be administered.
E1 was interviewed by telephone on 01/09/01 at 1:35 PM. E1 stated that if R1 was admitted early enough in the day the specializing physician would have been called. R1, per nurses note dated 07/31/00, was admitted at 9:20 AM. E1 feels that she "probably called" Z1. If she did not, per E1, the next nurse coming on duty should have called Z1. E1 could not explain the orders of Z1 and Z3 not being followed or verified.
E4 (Director of Nursing) was interviewed on 01/02/01 at 11:10 AM in the administrator's office. E4 confirmed that the orders were not followed.
The record of R1 contained laboratory testing dated 11/22/00 only. This laboratory testing was done after a contracted laboratory working for the facility did a chart audit. This was confirmed by E5 on 01/05/01. An order dated 11/17/00 from Z3 allowed for this testing. One of the tests indicates a urea nitrogen level of 21.4 (normal 6-20). Creatinine level 1.1 (normal 0.5-1.2). With no prior laboratory results in the record, there is no way for the facility staff and/or the new attending physician (Z3) to know if these results are normal for this resident or causes for concern. There would be no way for the facility to know if laboratory results were going up and/or down.
There is no evidence that Z1 was notified of these laboratory results. Interview of 12/28/00 at 12:15 PM revealed that he was not.
The record of R1 contained 5 monthly reviews having been done by the facility contracted pharmacy. These reviews were done in 8/00, 9/00, 10/00, 11/00, and 12/00. The review dated 12/00 referred only to the laboratory testing done on 11/22/00. Reviews prior to this did not make need for the need for or lack of laboratory testing. The reviews did not comment on lack of follow-up on laboratory tests noted on transfer sheet sent to facility on the date of admission.
Interview with Z3 by telephone on 01/09/01 at 2:00 PM revealed that Z3 gave the facility an order to verify the laboratory tests written on the transfer sheet on the date of admission.
The physician's order sheet sent from the transferring facility was reviewed in the record of R1 on 01/02/01 and during the extended survey of 1/05/01. One page of typed orders was present. On 01/05/01 in the administrator's office, E5 (administrator) and E9 (corporate nurse) stated that this page of orders was the only order sheet that the facility had received from the transferring facility. One medication to prevent kidney rejection was listed on this sheet. It was imuran 50 milligrams every morning.
At the bottom of this page of orders, it is typed in all capitalized letters "CONTINUED NEXT PAGE." There is no evidence in the record or through interviews with E4 on 01/02/01 and E5 and E9 on 01/05/01 that anyone made an attempt to find out what was on the next page. All three stated no knowledge of having seen this statement before being brought to their attention by the surveyor. E1, when interviewed on 01/09/01, denied having seen this statement.
Z4 and Z5 were contacted at their place of employment on the afternoon of 01/02/01. When asked to see the information sent to R1's new facility, they provided two pages of physician's orders, a transfer sheet, and two pages of interdisciplinary summary. The other two medications to prevent kidney rejection were typed clearly on the second page of the orders. The needed medications were prednisone 5 milligrams every morning and neoral 25 milligrams 3 capsules PO (by mouth) twice daily.
Medication administration records were reviewed from 07/31/00 until 12/19/00. They were found in the record of R1. The only immunosuppressant medication documented as having been given was imuran. There was no evidence of neoral or prednisone being given.
When interviewed on 12/27/00 at 12:45 PM by telephone, Z2 stated that during the admission process of R1 to this facility he (Z2) told the admitting nurse that a complete listing of R1's medications could be found in R1's wallet which R1 kept with him. Z2 stated that Z4 went over a computer print out with the admitting nurse at the time of admission (7/31/00). Z2 stated that all three immunosuppressant medications are on this print out.
Record review revealed a group of papers, dated 08/24/00, stapled together with a transfer sheet attached to them. This transfer sheet indicated that R1 was transferring to see Z1. Facility calendar indicated that R1 had an appointment with Z1. This calendar was seen with E4 present on 01/02/01. No one at the facility interviewed knew who made the appointment. The record contained no documentation that an appointment had been made. Since the papers were still in the record, E4 and E5 were asked to find out if R1 went to the appointment or not, as neither readily knew. E4 stated on 01/02/01 that it appeared that R1 did not make the appointment. E5 stated on 01/05/01 that she had contacted the transportation company for the facility to clarify this matter. She stated they told her that they had been scheduled to take R1 to see Z1 on 08/24/00. The transportation company told E5 that they were later called and told that the appointment had been canceled. No one interviewed could explain why the appointment was not kept.
Z1 verified in interview of 12/28/00 that R1 never came to his office from this facility. The physician's order sheet readied for this appointment listed imuran only and no mention of laboratory testing.
Interview with Z1 on 12/28/00 revealed that Z1 was to follow the renal condition of R1 while in the facility. Z1 stated that his employee called the facility in 08/00 and stated that Z1 would be following-up on R1's care. Z1 stated that it was stressed to facility personnel that R1 be seen routinely by him, receive all ordered medications, and that laboratory testing be done as ordered. Z1 stated he was never contacted by this facility during any of the dates that R1 resided there.
Nurses note dated 08/21/00 by E1 was reviewed. This note states "(Z1) called et will cont to follow res." During the interview of 01/09/01, E1 could not recall if she called Z1 or if Z1 called the facility. There was no further mention of Z1 in R1's record after this entry. When interviewed on 01/02/01, E4 could provide no explanation.
Z2 stated in interview of 12/27/00 that he stressed to the admitting nurse of the facility how important it was for the facility to keep in frequent contact with Z1. Z2 stated that he explained the importance of Z1 being R1's primary physician to facility nursing staff.
There was no evidence in the record that anyone from the facility involved Z1 in the care of R1 regarding his renal condition. No one from the facility ever verified the needed medications or laboratory testing.
Nurses notes of 9:30 PM on 12/19/00 indicate E3 (Registered Nurse) called Z3 to inform him that R1 had not urinated on her shift. An order was received to catherize R1 to check for retention of urine in the bladder after he urinates. R1 did not urinate on E3's shift per interview with E3, in the administrator's office on 01/02/01 at 1:30 PM. E3 stated that she passed this information on to E2 (Registered Nurse) when she(E2) came on duty. Interview with E2 was done per telephone on 01/05/01 at 1:25 PM. Documentation indicates that R1 urinated on E2's shift. E2 stated that she was aware of the need to catherize R1 after he urinated at 11:00 PM on 12//19/00. When told that documentation did not indicate this was done, E2 stated that she did not do it. When questioned why this procedure was not done, E2 replied, "because I probably didn't have time because I was working the whole C Wing alone." Order by physician was not followed.
R1 went to the hospital the following morning at 5:20 AM. No documentation was made on the night shift of 12/19/00 after the 11:00 PM entry until 5:00 AM. At 5:00 AM, E2 documented being called to the room of R1 because "res. found to be unresponsive, eyes open dilated approx 3 mm with slow response to light, no response from sternal rub, eyes fixed, .........res. was drinking glass of ice water when he dropped same over himself and went unresponsive, per CNA."
Failure to develop appropriate care plan-Care plan of R1 was reviewed on 01/02/01 and 01/05/01. The care plan does not indicate any involvement by Z1. The care plan does not identify precautions and approaches that staff should be made aware of in order to provide proper care to R1 in regards to his kidney transplant. The care plan does not address any signs and/or symptoms for staff to watch for that would indicate kidney transplant rejection.
Lack of assessment and monitoring-Nurses notes were reviewed from 07/31/00 through 12/20/00. No ongoing assessment was observed of R1's renal condition. The entire record contained no information that would assist the staff in monitoring the renal condition of R1.
Z3 was interviewed by telephone on 01/09/01 at 2:00 PM. Z3 stated it is the responsibility of the facility to contact another physician who is needed along with himself to provide care to a resident. Z3 ordered the facility to contact Z1 regarding R1's renal condition. Why this was not done, Z3 cannot say.
E1 was interviewed by telephone on 01/09/01 at 1:35 PM. E1 stated that if R1 was admitted early enough in the day the specializing physician would be called. R1 was admitted at 9:20 AM per record review. E1 feels that she probably called Z1. If she did not, per E1, the next nurse coming on duty should have called Z1. E1 could not explain the orders by Z1 and/or Z3 not being followed or verified. E1 stated she could not identify what the problem was regarding the lack of renal care for R1.
None of the facility staff interviewed could provide an explanation for why R1 did not receive appropriate care and medication administration while at their facility. None could explain why Z1 was never contacted and/or involved in R1's care.
Staff interviewed were: E1 (Licensed Practical Nurse) by telephone on 01/09/01. E2 (Registered Nurse) by telephone on 01/05/01. E3 (Registered Nurse) and E4 (Director of Nursing) on 01/02/01 at the facility. E5 (Administrator) and E9 (Corporate Nurse) on 01/05/01.