RIVER BLUFF NURSING HOME
Facility I.D.: 0005611
4401 NORTH MAIN STREET
ROCKFORD, ILLINOIS 61103
The facility shall have written policies and procedures, governing all services provided by the facility which shall be formulated by a Resident Care Policy Committee consisting of at least the Administrator, the Advisory Physician or the Medical Advisory Committee and representatives of nursing and other services in the facility. These policies shall be in compliance with the Act and all rules promulgated thereunder. These written policies shall be followed in operating the facility and shall be reviewed at least annually by this committee, as evidenced by written, signed and dated minutes of such a meeting.
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, 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.
An ongoing resident record including progression toward and regression from established resident goals shall be maintained. The progress record shall indicate significant changes in the resident’s condition. Any significant change shall be recorded upon occurrence by the staff person observing the change. Nurse’s notes that 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.
Significant observations or developments regarding resident responses to nursing and personal care shall be recorded as they are noted.
Based on record review and interviews the facility failed to:
a) accurately assess the physical condition of a resident;
b) provide services in a timely manner;
c) provide documentation of objective observations prior to sending a resident to the hospital;
d) provide sufficient evidence of the effects of the care provided; and
e) follow its own policy and procedures; for one of seven diabetic residents in the sample.
The findings include:
R18 has diagnosis to include Non-Insulin Dependent Diabetes Mellitus, HTN, CHF, PVD, CVA, and Depression. On 05-02-99 R18 was sent to the hospital after the following incident per medical record review:
?5-02-99 1400 (R18) ate approximately 10% lunch, assisted by staff after taking a few bites (R18) said, "that's enough". Lying in bed resting quietly, skin warm and dry, arouses easily, no complaint.
2020- (R18) accucheck 29 at 1700. Orange juice and sugar given. R18 ate 25% of supper. Accucheck at 1800- 41. Call placed to (Z1), (Z2) on call. Awaiting response. 2100-(Z2) on call for (Z1) with order to send to Emergency Room (ER). Ambulance called for transport. 2115- Administered one full tube of glucotose (tube of oral glucotose was 37.5 grams in weight and was a gel) per E1. Accucheck 41. Paramedics arrived, transported to hospital ER."
Interviews of staff of the events of 05-02-99 regarding R18 revealed the following:
On 06-08-99, E1 indicated she was contacted and went to R18's unit due to his hypoglycemia. E1 indicated that R18 was given oral glucagon because he was still responding and swallowing and that R18 was never unresponsive. E1 also indicated that R18 was not observed vomiting but did have an area approximately 8cm x 8cm on his right shoulder of food-like particles. E1 did not pay attention to the color of the emesis. (The emesis was not documented to include amount, color or consistency, or if was fresh or old.) R18 was lethargic but had been all day.
E4 indicated that E1 thought a doctor's order was needed to give glucagon injections but did not give it because R18 was responsive. (Facility's policy and procedures has Glucagon to be given and is standing order as policy and procedure has been signed per facility's Medical Director.) This was verified by E4.
When asked why wasn't R18's status and assessment documented, E1 indicated that E12 was responsible for the assessment and documentation. E1 and E13 indicated that E12 was not in the room all the time during R18's incident.)
On 06-08-99, E13 indicated that she became aware of R18's low blood sugar and went in to see if she could help and that E1 was there. E13 was holding R18's head and massaging his throat and telling R18 to swallow and that R18 swallowed, looked at her and nodded his head. There was a wet spot on R18's right shoulder. R18 was responsive but lethargic. When asked if R18 was drooling, E13 indicated that there was some drooling out of R18's right side of mouth and that R18 was diaphoretic, cool and more pale, (as he is always pale.) These observations were not documented.
On 06-09-99, E13 was asked per telephone why was it necessary to massage R18's throat if he was alert and responding. E13 indicated it was to make sure that he was swallowing and that she had learned in school that this helped to aid in swallowing.
Review of facility's policy and procedures for Diabetic Coma/Insulin Shock the following should be done:
a) Fruit juice with 1-3 tablespoons sugar
b) Rub honey or sugar on the buccal surfaces
c) Give Glucogen which is on each medication cart.
d) Do not give oral intake to an unconscious person-inject glucagon found in the emergency medication box.
3. Report the episode to the physician and follow procedures as ordered and the residents' advanced directives when applicable.
Facility failed to assess R18's condition accurately prior to giving oral glucose (assessment to include respirations, mental status, signs of distress, integrity of the skin, pupil reaction, mouth and swallowing); failed to give glucagon injection to a resident who was unresponsive; failed to call physician in a timely manner regarding low blood sugars.
On 06-09-99 E4 was notified of need to question E12 of the events of 05-02-99 as E12 was the licensed nurse for R18's unit. E12 came to facility and dropped off statements of her recollection of the events on the eve of 05-02-99. E12's written statement dated 06-09-99 of the events of 05-02-99 revealed that orders were given 'to send (R18) to ER or start IV fluids D50, whichever more beneficial to (R18).' (This order needed clarification as D50 is normally given as an IV push).
(Review of R18's physician order revealed 'Send to hospital' and did not include the D50 as indicated in E12's written statement.) Notified E1 and E1 suggested sending to ER would be faster. (E4 indicated that D50 is not kept in stock at the facility due to infrequent use.)
E12's written statements of 06-09-99 of the events that occurred on 05-02-99 include the following and times are approximate:
1600 R18 lethargic, but responsive, very hard of hearing, Accucheck 29. Gave orange juice with sugar, large glass consumed. B/P 150/80, pulse 80 and respiration 18, temp 97.8.
1700 Accucheck 41. R18 more responsive, asking to get up for supper. Ate 25% of meal.
1800 R18 appeared very sleepy sitting in wheelchair. Instructed staff to help R18 to bed. V/S 120/79, 81, temp 94.5 axillary. (There is no evidence that R18's temperature was reassessed or doctor notified). Pox 90. No abnormal breath sounds at this time. Respirations even and unlabored. R18 appeared to be resting comfortably.
1830 R18 responsive to loud verbal stimuli, very lethargic. Offered 120 cc of 2cal and sugar. R18 consumed all. Asked if R18 felt ok and he shook his head to answer yes. Asked R18 if in any pain, he shook head to answer no. Accucheck 32. (R18 had consistently low blood sugars even with juice and sugar and doctor not notified from 1600 to 1930).
1930 Call placed to doctor to report signs/symptoms of hypoglycemic.
2000 Received call back from Dr., orders given-see above.
2025 Ambulance here for transport.
Facility's documentation lacks an accurate assessment of R18's condition and there was no further contact with the doctor or attempts from 1800 to 2020 even though R18's blood sugar was 41. There is no evidence to support the care that staff indicated was provided and no response to the treatment.
Review of hospital record and paramedics report contradict facility's assessment of R18. The paramedic report reveals the following:
'On 05/02/99 a medical call was received at 2103 and arrived at the Extended Care Facility at 2123.
First patient contact was 2125. Called to a scene for a patient with a diabetic reaction. Staff states (R18) was found unresponsive with a blood sugar of 40. Staff gave (R18) a tube oral sugar. Staff states (R18) has been running low all day. Staff gave (R18) orange juice with sugar at 1700, after (R18) ate 25% of supper. Upon arrival (R18) in bed oral sugar being given. (R18) has snoring respirations and unresponsive. Skin very wet, cool, and pale. Lung sounds rattley in all fields. (R18) is drooling. Pupils equal and react to light, (R18) withdraws arm to painful stimuli. History from staff. Accucheck at 2126 is 12 (done per paramedics). Two IV attempts unsuccessful , 3rd attempt successful and D50 given. (R18) awakes combative/confused. Monitor, accucheck at 2151 rechecked and was 185. Pulse oximeter (90) O2 15 liter. Placed on cot. (R18) becoming more alert. No changes in lung sounds (possible aspiration). (R18) more alert, follows simple command, remains confused.
Care of (R18) to ER staff with above improvements in (R18's) condition. (R18) arrived at ER at 2204.
On 06-09-99, Z3 was contacted per telephone regarding ambulance services provided to R18 on
05-02-99. Z3 verified that the ambulance report is accurate and that R18 was not responsive upon arrival to R18's room. Z3 indicated R18's respirations could be heard outside his room in the hallway before entering his room. Z3 was asked what assessment was used to determine R18's level of consciousness. Z3 indicated Z3 could not get R18 to respond by patting him on the shoulder, calling his name and performing a sternal rub produced no response from R18. Z3 observed staff talking to R18 with no response.
Z3 indicated that there were 4 people in the room of which 3 were nurses and/or CNAs and the head nurse. One of the 3 people told Z3 that R18 was unresponsive and when R18 was found unresponsive ambulance was called.
Z3 observed oral sugar being given and Z3 assessed R18 as not being responsive during the administration of the oral glucose.
Review of R18's hospital record of 05-02-99 reveals the following:
Emergency room record:
'Possible aspiration from oral glucose after insulin reaction. Diagnosis- Aspiration Pneumonitis.
An 86-year-old male from the nursing home that aspirated after given oral glucose after having an insulin reaction.'
'He has a wet, raspy cough. He is coughing incessantly. Lungs: Scattered rhonchi heard but more prominent on the right.'
On 06-09-99, Z1 indicated per telephone interview that Z1 believed that R18 would have had a hard time swallowing and would have been quite symptomatic because R18 was in poor health and this could affect him more than someone who is healthy. Certainly if someone is massaging the throat aspiration could have occurred but no way of knowing for sure. The picture fits with aspiration.