P.A. PETERSON HOME FOR THE AGED
I.D. 0010918
1311 PARKVIEW AVENUE
ROCKFORD, IL 61107
Survey Date: 8/26/99
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 shall obtain and record the physician’s plan of care for the care or treatment of such accident, injury or change in condition at the time of notification.
Adequate and properly supervised nursing and personal care shall be provided to each resident to meet the total nursing and personal care needs of the residents.
General nursing care shall include at a minimum the following and shall be practiced on a 24 hour, seven day a week basis.
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.
This REQUIREMENT is not met as evidenced by:
Based on interviews and record reviews, the facility failed to notify R-1 and R-2's orthopedic surgeon in a timely manner when changes in their status occurred.
Findings include:
R-1 is alert and oriented to person, place and time. He has a diagnosis not limited to Right Hip Arthroplasty done on 07/29/99. He was admitted to the facility on 08/02/99 at about 2p.m.
On 08/18/99 at 11:10 a.m. during interview with R-1, he stated, “I was admitted that day..., two aids came to put me to bed for the night; the one aide pulled so hard (removing the TED hose) it disrupted my hip; it (hip) was really hurting me after that. I had to ask the nurse for a pain pill”.
During interview with E-4 on 08/19/99, when asked about R-1's pain, she commented that about 7p.m. on 08/02/99, R-1 ranked his pain at a #10 on a scale of 1-10 (10 being the worse). He was uncomfortable. I didn’t call the doctor due to the fact that residents get so excited about their admission and sometimes wait too long to ask for a pain pill. I see R-1's reaction lots of times”.
During interviews and review of records, R-1 received Vicodin for his pain around 7:30p.m. on 08/02/99.
During interview with Z-1 on 08/18/99, he was asked if he had concerns about the facility’s staff performance related to R-1 right hip.
Z-1 stated, “I do have concerns. R-1's hip, prior to the incident, was stable..., I understand that R- 1 told staff that evening (of the incident) that he had increased pain. They said it should have been expected (or something like that). It wasn’t until the next day, about 10-11a.m., that staff called me. Nothing was told to me the night before. The nurse made me believe it just happened during a transfer. That hip had been out for almost 12 hours. I couldn’t put it right back in with closed reduction. I had to do surgery which increased risk for infection.”