Facility I.D. Number0040295
1675 E. Ash St.
Canton, IL 61520
Date of Survey 04/12/01
Complaint Investigation
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 resident’s 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 advisory physician or medical advisory committee shall develop policies and procedures to be followed during the various medical emergencies that may occur from time to time in long- term care facilities. These medical emergencies include, but are not limited to, such things as:
1) Pulmonary emergencies (for example, airway obstruction, foreign body aspiration, and acute respiratory distress, failure, or arrest).
2) Cardiac emergencies (for example, ischemic pain, cardiac failure, or cardiac arrest).
The facility shall maintain in a suitable location the equipment to be used during these emergencies. This equipment shall include at a minimum the following: a portable oxygen kit, including a face mask and/or cannula, an airway; and bag-valve mask manual ventilating device.
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.
The DON shall oversee the nursing services of the facility including:
Overseeing the comprehensive assessment of the residents’ needs, which include medically defined conditions and medical functional status, sensory and physical impairments, nutritional status and requirements, psychosocial status, discharge potential, dental condition, activities potential, rehabilitation potential, cognitive status, and drug therapy.
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.
Developing and maintaining nursing service objectives, standards of nursing practice, written policies and procedures, and written job descriptions for each level of nursing personnel.
Planning in-service education, embracing orientation, skill training, and on-going education for all personnel and covering all aspects of resident care and programming. The educational program shall include training and practice in activities and restorative/rehabilitative nursing techniques through out-of-facility or in-facility training programs. This person may conduct these programs personally or see that they are carried out.
Participating in the development and implementation of resident care policies and bringing resident care problems, requiring changes in policy, to the attention of the facility’s policy development group.
These Regulations are not met.
Findings include:
R1, a fifty-seven year old resident, was originally admitted to the facility on 4/19/99. R1 was
readmitted to the facility on 6/07/00 after a hospital stay due to respiratory failure. R1 had a permanent tracheostomy at the time of readmission. Diagnosis include but are not limited to: Cerebral Palsy, Moderate Mental Retardation, Depression, Seizure Disorder and Tracheostomy with artificial tube placement.
Telephone order 6/16/00 documents physician order for; “May use right hand mitting”. Interview with E2 on 3/30/01 at 2:10PM verifies that “Yes, the hand mitts were used as a preventive measure so R1 could not pull her trach out”.
Nurses Notes from 7/18/00 to 2/14/00 reveal that R1 had 7 documented instances of where she either pulled her trach out, pulled at her trach, pulled off her mitts, or a combination of all three. All 7 of these occasions occurred prior to the incident of 3/24/01:
1). On 7/18/00 the nurses note states; “3 AM Nurse heard resident gasping for air-Resident had pulled out trach:, and “resident was cyanotic of lips and extremities.”
2). On 9/12/00 the nurses notes read “4 AM trach pulled out”, “Resident pulling at trach and O2 tubing:, “hands covered, with good results for now”.
3). On 2/06/01, the nurses notes read; “Res. very restless, pulling at trach and O2 tubing-Res. Pulled trach out. Res. continued to pull at O2 tubing and trach”.
4). On 2/08/01 nurses notes read; “Res. was found in bed with her trach out, skin cool/purple.
5). On 2/09/01 the nurses notes read; “Res. had been pulling at trach and O2 tubing all this shift”, “Res. has removed mitts x 2 and pulled at trach”.
6). On 2/10/01 the nurses notes read; “Res. pulled trach out”, “Mitts were found on floor. Res. removed herself”.
7). On 2/14/01, Per nurses notes “Resident has released mitts with teeth several times and pulled at trach”.
Recent physician progress notes verify that R1 had a history of dislodging her trach. Physician’s progress note dated 2/08/01 reads “Pt more agitated lately and has pulled out trach x 2. Pt immediately cyanotic when she does this”. Physicians note, dated 3/08/01, states “Pt. has been pulling on trach like she was”.
Accident/Incident Report dated 3/24/01 at 6:50 PM. reads; at approximately 6:15PM.; “C.N.A. yelled from residents (R1) room to come quick, Immediate response to residents room. Noted resident laying on R. side, skin light blue, color pale, warm to touch, trach out, Attempted to re- insert trach.”
Interview with E5 on 3/30/01 at 11:20 AM. verified that; “We tried to re-insert the trach, but there was no obturator or extra trach at the bedside ...we needed to go back to 300 wing to get a new trach kit....paramedics took over care of R1 and ended up calling time of death 6:45PM.”
Current care plan does not address the Problem: behavior of R1 pulling out her trach. There are no interventions on this care plan to direct facility staff with regard to R1's dislodging of her trach. The care plan also does not address what emergency equipment was needed at the bedside of this resident.
On 4/04/01 at 2:20 PM, E2 stated “ No we do not have a policy regarding what emergency equipment to have at the bedside for trach patients.”
When reviewing the written statements made by the staff involved in the incident on 3/24/01, it was noted that E5 states that “went back to 300 wing to get a new trach set because we could not find any obturator or an extra trach at the bedside.” At the time of the incident R1's bed was the third bed in from the door of a 4 bed ward. The room itself is located at the very end of 200 wing, which is approximately 75 feet from the 200 wing nurses station and another 85 feet from the 300 wing nurses station.
During interview with E4 on 3/30/01 at 11:10AM., E4 stated; “ It was very common for R1 to use her mouth to remove her mitts and pull at her trach.” E8, during interview on 3/30/01 at 2:00 PM., stated that; “I think I started back to work around October 2000 and R1 has been getting her mitts off since then.” When asked if other interventions were used since using the hand mitts did not seem to work, E8 stated “No”. During interview on 4/4/01 at 2:10PM. with E11, E11 stated “The mitts were the only intervention when R1 was unobserved...R1 was know for getting her mitts off”. E11 also states that “R1 would become very cyanotic and short of breath when she would pull out her trach...There should have been an extra trach at the bedside”.
During interview with E2 on 4/04/01, E2 acknowledged that R1's care plan failed to address R1 pulling out her trach as a “problem”. E2 also acknowledged that the facility failed to assess R1 for interventions regarding this problem and failed to revise the one intervention (handmitts) when it failed.