SKYVIEW TERRACE

Facility I.D. Number 0036848
1021 N. Church St.
Jacksonville, IL 62650

Date of Survey 08/28/2000

Complaint Investigation 0043790

"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, including, but not limited to, the presence of incipient or manifest decubitus ulcers or a weight loss or gain of five percent or more within a period of 30 days.

The facility shall obtain and record the physician's plan of care for the care or treatment of such accident, injury or change in condition at the time of notification. 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 FACILITY SHALL IMMEDIATELY NOTIFY THE RESIDENT'S NEXT OF KIN, REPRESENTATIVE AND PHYSICIAN OF THE RESIDENT'S DEATH OR WHEN THE RESIDENT'S DEATH APPEARS TO BE IMMINENT.

ALL MEDICAL TREATMENT AND PROCEDURES SHALL BE ADMINISTERED AS ORDERED BY A PHYSICIAN. ALL NEW PHYSICIAN ORDERS SHALL BE REVIEWED BY THE FACILITY'S DIRECTOR OF NURSING OR CHARGE NURSE DESIGNEE WITHIN 24 HOURS AFTER SUCH ORDERS HAVE BEEN ISSUED TO ASSURE FACILITY COMPLIANCE WITH SUCH ORDERS.

These requirements were not met as evidenced by:

1. Review of R1's records reveals that the R1 was noted to be having seizures on 08/07/2000 at 9:45 p.m., and was non responsive to verbal stimuli.
   
   R1's physician was called at 10:15 p.m. per E6. The nurses' notes dated 08/07/2000 at 10:15 p.m. reveal that the physician was made aware of the resident having seizures, and that E6 was unable to give the resident his seizure medication.E6 did not document that R1's physician was made aware that R1 was unresponsive to verbal stimuli. The physician gave E6 a physician order to monitor seizure activity, give oral meds when alert,and obtain complete history from previous facility of seizure activity and include any recent labs. Obtain drug levels on all seizure meds, CBC, and BMP this week.
   
   E6 charted at 10:30 p.m., that R1 remains unresponsive to stimuli and continuing to have seizure activity.
   
   E6 charted that R1 was observed to be clamping his mouth shut tightly, and that his lips were slightly blue. E6 started oxygen at 5 liters per nasal cannula.
   
   E6 continued to chart that R1 remained unresponsive to stimuli, lips blue and continued to have seizures, at 11:30 p.m. R1 was observed to be diaphoretic and a temperature of 99.8, A.X. (Arm pit temperature), and that R1 was continued on oxygen at 5 liters.
   
   Nurses notes 12 midnight reveals same activity, with Audible congestion, and resident has a weak cough.
   
   Nurses notes from 1:00 a.m. to 1:45 a.m., on 08/08/2000, reveals that R1 remained unresponsive and continued to have intermittent seizure activity. Nurses notes at 2:15 a.m. reveals that R1 had a small emesis, and that his vital signs were taken, BP 100/70, pulse 68, and respirations 34 and temperature AX 99.
   
   Nurses notes from 2:15 a.m. to 4:00 a.m. revealed that the resident remained non responsive and that he continued to have intermittent seizures and the oxygen remained on at 5 liters per nasal cannula.
   
   Nurses notes on 08/08/2000 at 5:00 a.m., reveals that the staff went into R1's room to reposition R1, and R1 was found to have dry, cool skin to touch, cyanotic to lower extremities, no B/P, pulse, and noted with no respirations, eyes fixed and dilated, pupils not reacting to light, and nail beds purple.
   
   Nurses notes reveals that the facility staff did not initiate CPR (cardio-pulmonary Resuscitation). Nurses notes reveal that R1's physician was contacted at 5:15 a.m. and reported findings that R1 had expired.
   
   5:20 a.m. R1's family was contacted that R1 had expired.
   
   Interview with E5 on 08/15/2000 revealed that E5 did not attempt to resuscitate R1. Interview with E2 on 08/28/2000 revealed the following, E2 stated "When I caller her to talk with her about the incident, she stated to me "he was already dead, and I did not see any reason to start CPR." Interview with E2 on 08/28/2000 revealed that the facility does have written policy and procedure for CPR, E2 stated to surveyors "it is expected by the facility staff to initiate CPR when a resident is a full code, and any nurse would start CPR when they find a person without vital signs unless the person is a no code, and E5 was unaware that she should have started CPR on R1, and stated to E2 "he was already dead I did not see any reason to start the CPR."
   
   Review of R1's records on 08/15/2000, 08/16/2000, and 08/28/2000, revealed a written physician order for a full code.
   
   Review of R1's records at the current facility reveals that the resident was admitted to the facility on 08/04/2000, with the diagnosis of seizures, closed head injury, organic affective disorder with psychosis.
   
   Assessment on admission did not reveal the type of seizures, the duration of seizures and the records did not contain any lab values.
   
   R1's records reveal a written physician order dated 08/07/2000, monitor seizure activity, give oral meds when alert. Obtain complete history from previous facility of seizure activity and include any recent labs. Obtain drug levels on all seizure meds, CBC, and BMP this week. Review of R1's records on 08/15/2000 revealed that the facility did not have a complete history of seizure activity from the previous facility, and no recent lab values.
   
   Review of R1's records did reveal that the resident had received all of ordered medications since admission 08/04/2000, except his 9:00 p.m. medications for seizures were held due to seizure activity, and the physician was notified that the medication was withheld.
   
   Interview with R1's physician Z2 on 08/15/2000 revealed that the facility called the physician about the residents seizures, but the physician was never called and informed of the change of conditions. The physician stated "I only got the one call about the seizures, and I was not called again about his change of conditions, but they did call me to tell he had expired, I was not familiar with the resident, I was covering for his regular physician, so I gave the facility an order to obtain a history from the previous facility regarding his seizure activities, and his current labs, and for the facility staff to monitor the seizures, and give him his seizure medications when he was alert."
   
   Interview with E5 and E6 on 08/15/2000, revealed the following:
   
   E5 and E6 were both unfamiliar with R1 and did not know the resident.
   
   E6 did call the physician to report the seizure activity, but did not report to the physician the change of conditions, blue lips, congestion, and diaphoresis, and did not report to R1's physician that R1 was unresponsive to verbal stimuli. E6 stated "I thought it was a nursing measure to put on the oxygen, I did not know I had to have a physician order for that."
   
   Interview with E5 and E6 on 08/15/2000, revealed that E5 and E6 did not call or contact the previous facility to obtain a history on R1's seizure activity or did not obtain any recent lab values.
   
   E6 stated to the surveyor on 08/15/2000, "I did not contact the previous facility after I received the order from the Doctor, because I thought that since he had been discharged from the facility all of his records would have been locked up."
   
   E6 also stated "I thought that R1's physician was not going to do any thing else that night and was waiting for the records from the previous facility, and when he gave me the order to monitor R1 that is what I did and I did not call the physician back, and I did not call his family because I did not know if he really was having a significant change since I didn't really know him, he was just admitted here on 08/04/2000, and I know he was fine previous to when he started having the seizures, he was up and about doing fine." "I didn't take his blood pressure because ever time you touched him he seemed to jerk a little more."
   
   E6 stated "I didn't know this man, and the Doctor did not know him either since he was covering for R1's physician, and I did not think of calling over to the facility and asking the nurses there about his seizure history." (The other facility is a sister facility to this facility and is located in the same city).
   
   Interview on 08/15/2000 with E5, revealed that she did not call and inform the physician of the increased respirations of 34, the small emesis, and that E5 did not remember if R1's lips were blue, but did state, "He never did respond to me so I held his medicine just like the Doctor said to do."
   
   E5 stated to surveyor "The reason I never called the Doctor was because I was told by the previous nurse on 3-11, (E6), that R1's Doctor was not planning on doing anything until he got the records from the other facility in the morning, and I didn't call the Doctor or the family until he was found dead, I did not expect that to happen, and to me he looked the same each time I checked him, and I did not see any reason to call the Doctor or the family."
   
   Review of the facility policies and procedures reveals that the facility staff are to notify the resident's physician and family whenever the resident has a change of condition.