RIVER BLUFFS OF CAHOKIA NURSING
Facility I.D. Number: 0045005
3354 Jerome Lane
Cahokia, IL 62206
Date of Survey: 11/16/00
Notice of Violation: 1/23/01
Complaint Investigation 0043988
The facility shall have written policies and procedures which shall be followed.
The facility shall respect the residents' rights to make decisions relating to their own medical treatment, including the right to accept, reject, or limit life-sustaining treatment.
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.
The facility shall not neglect a resident.
These requirements are not met as evidenced by:
Based on clinical record review, interview with staff and others, review of facility's policies on "ADVANCE DIRECTIVES" and "CARDIOPULMONARY RESUSCITATION" (CPR), it was determined the facility failed to follow above policies for one resident, R1, in that R1 had chosen to be a "Full Code" with life sustaining treatment, CPR, to be implemented, which was not done correctly or continued for R1 with R1 expiring at the facility on 8/21/00.
R1's clinical record review revealed R1 to indicate his choice of being a "Full Code", CPR to be done, on 5/15/00, the date of his admission to the facility. Facility's policy on "ADVANCE DIRECTIVES" revealed the resident's choice regarding life sustaining treatment, and as such, will be implemented accordingly.
At the time of R1's initial assessment, Minimum Data Set (MDS) of 5/21/00, R1 was identified to have short term memory problem, no problem with long term memory, some difficulty in new situations only and with cognitive skills for daily decision making, had periods of altered perception or awareness to surroundings, and mental function varied over the course of the day, but last two were not of recent onset.
Clinical record review and interview of E2, Assistant Director of Nurses (ADON), on 10/31/00 at facility, revealed that during 8/2000 R1 was showing increased weakness and was no longer assisting with transfers or attempting to stand.
"NURSES'S NOTES" of 8/21/00 at 5:40a.m. revealed R1 to be very cold; nonresponsive to verbal, pain, or tactile stimuli; and no respirations, lung sounds or apical pulse was noted. An entry of 5:50a.m. revealed Z10, R1's physician, was paged, returned call, and R1 was pronounced dead at 5:40a.m.
"NURSES'S NOTES" of 8/21/00 at 6a.m. revealed, "LATE ENTRY for 5:40a.m., CPR was started...". Entry reflected CPR without results, resident still unresponsive, no apical pulse and no respirations.
Interviews from the facility on 8/30/00 and 8/31/00 of E4 and E5, Certified Nurses Aides (CNAs), revealed they observed no CPR to be done on R1.
E4's interview revealed she found R1 at approximately 5:15a.m. on 8/21/00 on the floor on his left side with "... his shoulders down, arms/hands down in front of him, one leg back like R1 had tried to pull himself up, but too heavy to do that". Also, "neck from shoulder area down where sinks at base of neck was pressed up against corner of night stand. Face was pressed against side of night stand, his head was turned like he was looking up but neck against corner of night stand." E4's interview revealed when she walked into R1's room and found him on the floor, she could just see his shoulders down as R1's head and neck were up between his bed and the night stand. E4 stated she yelled for E6, a Licenses Practical Nurse (LPN), and then pulled R1 off the night stand by placing her arm under R1's and holding R1's face and upper body away from the night stand. E4 stated when she pulled R1 away from the night stand, R1 gasped one time and then did nothing else. E4 stated R1 was warm to touch when she pulled him away from the night stand. E4 stated E6 came and attempted to lift R1's legs, but stopped and told her they needed more help and left to get help. E4 stated she held R1 up while E6 went to get help.
E4 stated when she, E5 and E6 got R1 back onto his bed, E4 asked E6 if R1 was gone with E6 stating, "Yes." E4 stated nothing was attempted. E4 stated R1 was still warm to touch when she, E5 and E6 put R1 back onto his bed. E4 stated that after E6 and E5 helped get R1 back onto his bed, E5 left the room and E6 went back up to the nurses station, got on phone and started writing something in chart. E4 stated she then went on to do R1's clean-up.
E4 stated she's CPR certified and if E6 hadn't said R1 was gone, she doesn't think E5 would have left R1's room. E4 stated she hardly knew R1, and had worked at the facility maybe 2 weeks going on 3 weeks. E4 stated she didn't know if R1 was a "full code" or "no code".
E4's interview revealed that prior to finding R1 as stated above at approximately 5:15a.m., she had checked R1 at approximately 2:30a.m.-2:45a.m. and R1 was in bed on his back with head on pillow, face toward ceiling, one leg off the bed, slanted a little toward the door, and he was dry.
E5 stated E6 came to her on the south hall at approximately 5:15a.m.-5:30a.m. on 8/21/00, and asked her to help get R1 back in bed. E5 stated she was helping another resident get dressed, and about 3-4 minutes later when finished, she went to R1's room and assisted in getting R1 back onto his bed. E5 stated when she got to R1's room, E6 was on her knees on the right side of the lo-bed and had a hold of R1's right arm and right leg. E4 had a hold of R1's "upper part". E5 stated she got a hold of R1's left leg and the three of them rolled R1 back onto his bed. E5 stated when she entered R1's room, no CPR was in progress by E6 or E4. E5's interview revealed that while she was helping E4 and E6 get R1 back onto his bed, R1 was warm to touch. E5 stated she was in the room only long enough to help get R1 back onto the bed and then she left to go back to her hall and patients.
Interviews from the facility on 8/30/00 and 8/31/00, revealed E6 to state she was called into R1's room by E4 on 8/21/00 at approximately 5:40a.m. E6 stated R1 was on his left side up against the night stand. E6 stated R1 was too heavy for her and E4 to get back onto the bed so she went to get help. E6 stated while she, E4 and E5 were getting R1 back onto his bed, she realized R1 wasn't responding and she attempted CPR with R1 in bed and just on his mattress. E6's interview revealed she did R1's CPR with 5 chest compressions, then 1 or 2 breaths, then 5 chest compressions, then 1 or 2 breaths, etc. E6 stated she doesn't know how long she attempted CPR but she wasn't getting any response from R1: no apical pulse, no respiration, and R1 was cold; so she went and paged Z10. Z10 returned call and E6 stated she asked Z10 if he wanted CPR continued as R1 was a full code and after confirming R1's status with Z10, Z10 stated to her to pronounce R1.
Review of facility's policy on "CARDIOPULMONARY RESUSCITATION" revealed CPR is to be done on a cardiac board or hard surface; and a cycle of 15 chest compressions to 2 breaths is to be performed and continued until paramedics arrive or a physician pronounces the resident dead and gives orders to discontinue CPR. E6's interview revealed she did not do any of these procedures as per facility's policy.
Z10's interview of 9/11/00 from the facility revealed the nurse who called him on 8/21/00 at 5:50a.m. did not mention CPR to him at any time. Z10's interview revealed the nurse mentioned something about R1 being a "full code"; but the nurse informed him that R1 was cold, dead and she didn't know how long. He stated the nurse did not ask him if he wanted CPR continued. He stated he knew nothing about CPR for R1. He stated the nurse asked if R1's body could be released to the funeral home.
Interview of Z14, paramedic, from Illinois Department of Public Health (IDPH)/Regional Office on 11/13/00, revealed that when he arrived on the scene at the facility on 8/21/00 at 0554a.m., no CPR was in progress. There was a nurse at the nurses station who pointed towards R1's room where Z14 found R1 unattended.
Interview of Z13, coroner, from the facility on 8/31/00, and from IDPH/Regional Office on 11/09/00, revealed Z13 to initially view R1's body at approximately 8:30a.m. on 8/21/00. Z13's interview revealed R1's death to be on 8/21/00 at approximately 6:30a.m. Z13's interview revealed that when he saw R1's body initially at 8:30a.m. on 8/21/00 "...it wasn't cold and it wasn't warm...lukewarm...not to point of being ice cold", and that lividity and rigor mortis were not present.