FAIRVIEW NURSING PLAZA
Facility ID Number: 0037655
321 Arnold Av.
Rockford, Illinois 61108
Survey Date: 2/10/2000
Complaint Investigation
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 personal care shall be provide to each resident to meet the total nursing and personal care needs of the resident.
General nursing care shall include at a minium the following and shall be practiced on a 24-hour, seven day a week basis.
All treatments and procedures shall be administered as ordered by the physician.
AN OWNER, LICENSEE, ADMINISTRATOR, EMPLOYEE OR AGENT OF A FACILITY SHALL NOT NEGLECT A RESIDENT.
These regulations are not met as evidenced by:
Based on observation, interviews and record review the facility failed to provide necessary services to avoid physical harm, by not keeping a resident who is tube fed NPO (nothing by mouth) as ordered by the physician for 1 of 6 residents in the sample.
Findings Include:
Review of R1's clinical record revealed R1 has diagnoses to include but not limited to bipolar disorder, decubtius ulcers, dehydration and osteoarthritis. Assessment dated 11/1/99 revealed R1 is totally dependent on staff in the areas of bed mobility, dressing and toileting, and extensive assistance with eating.
Review of R1's clinical record revealed an Emergency Room Report dictated 1/22/00 stating 'The intraoral airway was filled with thick mucous and possibly even food substance like she may have had even an aspiration event.' R1 was admitted to ICU for close observation and vent managment until she became stable. R1 was receiving tube feedings and was also being fed a pureed diet prior to hospitalization. R1 was discharged to the facility on 1/29/00.
Review of Prehospital Care Report (ambulance report) dated 2/2/00 states 'Nurse stated that pt is to be NPO and was given food orally last night and this morning choking both times. Pt was conscious but not to normal state, PERL, lungs with rales in the uppers and normal in the lowers, trachea, M+M no JVD, skin hot and flushed axillary temp was 104. Pulse ox was 74% on room air. We moved pt to cot sitting up, O2 at 10 liters per non-rebreather, pulse ox to 96%.'
Review of Emergency Room Report dated 2/2/00 states 'on arrival, our nurse, (Z3) reported to me that she did suction out a small pinky size piece of bread from the back of her throat and that she does not seem quite as agitated.'
Review of Hospital record revealed a Social Service progress note dated 2/3/00 'Per CICU nursing today, verbal report received from shift charge indicated CICU staff also suctioned out a piece of bread from pts airway.
' R1 was observed on 2/09/00 at the hospital in CICU. R1 was noted to be lethargic, receiving tube feeding and intravenous antibiotics, had a foley catheter and a rectal tube with greenish drainage. R1 was lethargic and unable to answer questions.
Z4 indicated she was R1's nurse for the day and verified that she had suctioned R1 upon admission to the unit. Z4 indicated that a "chunk of bread" was suctioned from R1 on the unit.
E3 stated during a phone interview on 2/9/00 at 11:30 am "I am not aware of what she ate or which CNA gave it to her. CNA stated to me that she was on the feeder list. I was also told that some of the girls do not know what N.P.O means. There was a sign posted above her bed that she was N.P.O. She was fed in her room they did not get her out of bed."
E2 produced a written statement on 2/9/00 stating 'I spoke with (E4) about feeding (R1) at breakfast and (E4) said she fed her a few bites.'
E2 stated during an interview on 2/9/00 "I am not sure what type of food she ate, I did not think to ask (E4) that when I talked to her." Z2 stated during a phone interview on 2/9/00 at 2:00 p.m. "The major concern was that she was hospitalized for pneumonia and was discharged N.P.O. She was then readmitted with respiratory distress and she was suctioned several times with a return of large amount of food items, bread and other food like materials. It was very well documented that she was to be NPO. This endangered her respiratory status and her life."
Review of facility's policy regarding residents who are N.P.O. reveals: "1. The term N.P.O. shall designate the resident who shall receive nothing by mouth. 2. Nothing by mouth shall be all inclusive and defines that there will be nothing taken in by the resident orally."
The facility failed to have a safeguard system in effect to ensure that residents with orders of 'nothing by mouth' receive nothing by mouth. Facility staff did not know how R1 received a tray.
Facility failed to follow its' policy and procedures on Residents who are N.P.O.