SKYVIEW TERRACE
Facility I.D. Number 0036848
1021 N. Church ST.
Jacksonville, IL 62650
Date of Survey:03/20/01
Complaint Investigation
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.
General nursing care shall include at a minimum 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.
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.
If for any reason, a physician’s medication order cannot be followed, the physician shall be notified as soon as is reasonable, depending upon the situation, and a notation made on the resident’s record.
The facility shall also immediately notify the resident’s family, guardian, representative, conservator and any private or public agency financially responsible for the resident’s care whenever unusual circumstances such as accidents, sudden illness, disease, unexplained absences, extraordinary resident charges, billings, or related administrative matters arise.
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.
AN OWNER, LICENSEE, ADMINISTRATOR, EMPLOYEE OR AGENT OF A FACILITY SHALL NOT ABUSE OR NEGLECT A RESIDENT.
These REQUIREMENTS were not met as evidenced by:
Based on interviews, observations and record review, the facility failed to 1) notify the physician of R1's inability to take fluids, food and medication on 1/21/01following R1's emergency room visit which resulted in a diagnosis of cellulitis of the right arm, 2) ensure that licensed staff provided accurate assessments including vital signs and wound care which were consistently conveyed to other staff caring for R1, 3) ensure that R1 received medication ordered by the physician and failed to notify the physician of failure to take medication, 4) to notify R1's Power of Attorney of R1's condition change on two occasions prior to R1's death from cellulitis on 1/22/01.
Examples are as follows:
1) Per the clinical record, R1 was an 87 year old female admitted to the facility with a diagnosis of hypertension, Organic brain syndrome, transient ischemic attack, hiatal hernia, dehydration and renal insufficiency. R1 was ambulatory with a walker and assist. R1 was assisted with activities of daily living. R1 had a memory deficit with moderate cognitive impairment but was able to make her needs known. According to interviews with direct care staff, R1 was able to walk about her room and go to the bathroom unattended.
Based on interviews and record observations, R1 had a documented condition change which was first identified on 1/19/01 and continued to decline and expired on 1/22/01 from Cellulitis of the right arm. The facility neglected to provide adequate and reasonable medical care for R1 from 1/19/01 until her death on 1/22/01.
Based on nurses notes dated 1/19/01 at 9a.m., R1was noted to be sluggish at breakfast which required assistance with eating breakfast. At 10:55a.m., R1 was found in her room in a wheelchair slumped over, all extremities flaccid, color ashen, eyes rolled backward with blowing "snorting" respirations present. The physician and POA were notified according to nurses notes. Per nurses notes dated 1/19/01 at 10p.m., nursing staff noted R1 to have "R arm swelling "puff" elbow to approx. 4" below et above. Area warm to touch but not hot. Note puncture type wound in lower swelling appears not fresh wound - no bleeding, no drainage". According to the nurses notes, the physician was notified of R1's arm condition at 12:45a.m. on 1/20/01. The POA, who is an interested legal party, was not notified of the arm condition until the POA visited the facility at approx. 6:45p.m. that evening.. This was confirmed in interview with Z10 on 2/9/01 when she stated they visited the facility after receiving confusing information from the nurses at the home regarding R1's condition and decided to visit themselves. Z10 stated the nurse on duty asked if they knew about R1's arm and then pulled the covers back and lifted her arm to expose the wound. Z10 stated they had not been informed prior to their visit and had no idea R1 had anything wrong with her arm. They had been told that R1 was not doing well and the physician had ordered "comfort measures". Z10 stated they left the facility and consulted another physician who advised them to send R1 to the emergency room. Z10 stated they then called the nurses at the home and requested that R1 be sent to the hospital.
A) During this time, the facility neglected to consistently and accurately document and assess R1's regression in general condition along with regression of the wound on her right arm which was identified as cellulitis. The facility neglected to ensure that vital information regarding R1's condition was consistently and accurately conveyed from one shift nurse to the next in order to ensure continuity of care. This was evidenced when the nurse (E4) working day shift on 1/20/01 was unaware that a "puncture" type wound with redness and swelling was documented as found on R1's right elbow at 10p.m. on 1/19/01. Therefore, no assessment or monitoring was done by 7-3 on 1/20/01. The 3-11 nurse (E7) came on and was informed by CNA's that R1's arm had been red and swollen the night before. Interview with E7 indicates that the arm was extremely red and swollen, obviously a regression from the evening before.
B) R1 was transported to the emergency room at approx. 7:35p.m. on 1/20/01 where her arm was diagnosed as cellulitis. R1 returned to the facility with a physician's order for Keflex 500mg qid (4 times daily). Review of the medication administration sheets for 1/21/01 indicate R1 did not receive Keflex as ordered. Interview with E5, who was R1's primary care nurse on 1/21/01, stated on 2/8/01 at approx. 1:50p.m. that she did not give the Keflex as it had not come in from the pharmacy yet. E5 said she did not know when the medication would have been in. E5 stated she thought the convenience box might have had the Keflex 250mg in it but did not know for sure. In addition, E5 stated R1 could not have taken the medication anyway as she was not taking anything by mouth. Per interview with the pharmacist on 2/6/01 at approx. 2:55p.m., nurses should have taken the Keflex from the convenience box. Z11 also stated according to the pharmacy records, no order for the Keflex had been received. Z11 also confirmed that no Keflex been taken from the facility convenience box. R1 was unresponsive on 1/21/01 therefore E5 did not give the Keflex nor did she notify Z1 that R1 was unable to take Keflex by mouth due to being unresponsive. R1 missed 3 doses of antibiotic before the physician was notified by the 3- 11 shift nurse at approx. 4:35p.m. 1/21/01. Per interview and confirmed in a letter written to the facility by Z1, he would have ordered a paranteral antibiotic earlier in the day had he known she was not taking anything by mouth. Z1 ordered Rocephin 500mg IM (Intramuscular) daily and the first dose was given on 1/21/01. R1 should have received the next dose at 6p.m. on 1/22/01. Review of the medication administration record and interview with E6 and E4 confirmed the second dose on 1/22/01 was not given. E6 stated in interview that she did not give the Rocephin on 1/22/01 at 6p.m. because she did not have time. R1 expired at 8:45p.m. on 1/22/01. E6 was asked by the surveyor if she understood the seriousness of R1's illness at the time and E6 replied she knew R1 was going to die. E6 neglected to administer medication.
R1 expired on 1/22/01 at 8:45 p.m.. An autopsy was performed and the cause of death was listed as "Cellulitis of the right arm due to Infection with Beta Streptococcus Group A due to a Puncture wound of right forearm". The conclusion states no other causes were considered to be contributory to death.