ROSEWOOD CARE CENTER OF PEORIA

Facility I.D. Number 0035352
1500 W. Northmoor Road
Peoria, IL 61614

Date of Survey 1/10/00

Complaint Investigation

"A" VIOLATION(S):

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.

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 owner, licensee, administrator, employee, or agent of a facility shall not abuse or neglect a resident.

These requirements are not met as evidenced by:

Based on staff and confidential interviews, and record reviews it was determined that the facility failed to appropriately monitor the condition following a fall, failed to analyze the change in medical symptoms, and failed to seek appropriate medical care in a timely manner for R2.

Findings include:

R2 was 77 years old and had been readmitted to facility on 09/04/99 following hospitalization for a deep vein thrombosis. R2 also had diagnoses including Parkinson's disease, severe dysphagia with G-tube placement, cerebrovascular disease, and progressive dementia.

The physician order sheet notes R2 had been receiving medication including anticoagulant Coumadin 3 mg daily and aspirin 81mg daily.

Nurses notes dated 12/16/99 at 1:05 p.m., document that R2 had sustained a fall and was found "on the floor on right side with blood on floor", with a "laceration to right outer eyebrow area"," right eye was swollen and bruising", and there was bruising on the right hand and elbow. At that time R2 was noted to be responding normally, pupils were equal and reactive to light, and hand grasps were equal.

Record review notes and staff interviews confirm that prior to this fall, R2 was normally alert to surroundings, was up in wheelchair, propelling about hallways. R2 was noted to have garbled speech partially in German, but usually did understand what was said to him. R2 was ambulatory with 2 assists, walked with a fast pace and bore weight well.

Facility protocol instructs staff "to monitor residents neurological status following a head injury"and "to notify the DON (director of nurses), the physician, and family of the incident and any other significant change resulting from the incident." Although the Neurological check form instructs the nursing staff to conduct a neurological exam including vital signs, level of consciousness(LOC), pupil reaction, and hand grasps every 15 minutes for the first hour after a head injury, the nurse did not begin documentation of R2's neurological exam until 2 p.m., almost an hour after R2's fall. At 2 p.m., the nurse documents that R2's blood pressure was 104/62, pulse- 88, respirations-28, LOC- alert, pupils -equal, hand grasps - equal and strong. The 2:15 p.m. and 2:30 p.m. neuro checks remained consistent with the 2 p.m. check.

Documentation notes that the nursing staff failed to perform another neuro check until 3:30 p.m., one hour later. This was confirmed in interview with E-8 on 01/04/2000. At this 3:30 check, the nurse documented that R2 was in wheelchair out at nurses station, drowsy, arouses to verbal stimuli, R2's blood pressure had elevated to 152/76, pulse had dropped to 76, and hand grasps were equal but weak.

By 4:05 p.m., R2 was noted to be "very limp" in wheelchair, "expectorating thick phlegm". Nurses notes document that it took 4 staff to assist R2 into bed and that R2 was unable to bear weight. Neurological check form notes that R2 was " sleepy arouses slow to name." The nursing staff failed to notify the physician of this decline in R2's condition. At 5 p.m., the nurse noted that R2 was drowsy and pupils reacted sluggishly to light. Nursing staff failed again to notify R2's physician of the continued decline in condition.

At 6 p.m., nurse documents that R2 had become lethargic, but staff failed to check R2's pupils. Again the nurse failed to notify the physician of R2's declining condition.

At 7 p.m., the nurse documents that R2's blood pressure was 158/72, LOC was lethargic, again no pupil exam was documented, and at this time R2 was unable to perform hand grasps.

At 7:30 p.m. the nurse called the physician's office and reported R2's lab results and condition report. This lab report dated 12/16/99 was a coagulation study which noted R2's protime to be 20.6. This indicated a prolonged clotting time from the previous protimes which were 15.7 on 12/02/99 and 13.4 on 11/04/99. The 12/16/99 lab report also included a INR (International normal ratios) report which was 2.98. Previous INR was 1.71 on 12/02/99 and 1.23 on 11/04/99. This coagulation study report would indicate that R2 was at increased risk for bleeding due to increased coagulation time.

At this time (7:30p.m.), the physician's nurse stated "may send to the hospital - call family." At 7:50 p.m., R2 had "no response with repositioning", and lungs had "faint rhonchi". At 8 p.m., the nurse documents that R2's blood pressure was 160/60, pulse at 68, respirations down to 16, R2 was non responsive, pupils were nonreactive to light, and R2 was unable to perform hand grasps, "bilateral hands stiff."

At 8:30 p.m. the family was contacted and "informed of the order to send to ER". At 8:40 p.m., the doctor's office returned the phone call and ordered "send to the ER (Emergency Room) OSF for evaluation."

At 9:15 p.m., R2 left facility per ambulance. This was more than 8 hours after sustaining fall and more than 5 hours after R2 demonstrated an obvious decline in condition.

In interview on 01/10/2000, Z7 stated that, if the facility had notified the physician earlier, when R2's condition first began to decline, the facility would have been advised to check with the family and send R2 into the Emergency Room at that time.

Hospital records note R2 arrived at the emergency room at 21:25 (9:25 p.m.). Upon arrival, R2 responded only to pain, pupils were nonreactive, and had snoring respirations. R2 expired at 12:28 a.m. on 12/17/99.

Z6 stated that when R2 arrived at the emergency Room, he was already in a pretty deep coma. Z6 stated that a brain CAT scan showed lots of bleeding everywhere, and that the protime showed the blood to be very thin. Z6 stated that R2's medical and neurological condition was such that nothing could be done surgically. Z6 stated that in looking back on what might have been, if R2 had been sent in to the ER earlier after the fall, that non surgical measures might have been attempted.

On 01/06/2000, Z5 confirmed R2's cause of death to be right subdural hematoma with interventricular extension due to head injury due to fall. Z5 stated that other conditions were dementia, Parkinson's disease, and anticoagulation.