SWANN SPECIAL CARE CENTER I.D. NUMBER 0035485 109 KENWOOD ROAD CHAMPAIGN, IL 61827 As a result of a complaint survey conducted on October 28, 1998, by representative(s) of the Department, it has been determined the following violations occurred. "A" VIOLATION(S) The facility shall have a written program of Nursing Services, providing for a planned medicalprogram, encompassing nursing treatments, rehabilitation and habilitation nursing, skilled observations, and ongoing evaluation and coordination of the resident's individual habilitation plan. There shall be a sufficient number of nursing and auxiliary personnel on duty 24 hours each day to provide adequate and properly supervised nursing services to meet the nursing needs of the residents. There shall be at least one registered nurse seven days a week, for 8 consecutive hours. There shall be at least one registered nurse or licensed practical nurse on duty at all times and on each floor housing residents. Nursing staff personnel shall include registered professional nurses, licensed practical nurses, and auxiliary personnel as defined in Section 390.330 of this Part. The responsibilities of the director of nursing shall include, at a minimum, the following: Developing and maintaining nursing service objectives, standards of nursing practice, written policies and procedures, and written job descriptions for each level of nursing and auxiliary personnel. Participating in the development and implementation of resident care policies and bringing resident care problems, requiring changes in policy, to the attention of the facility's policy development group. Nursing care shall include at a minimum the following: All treatment such as: enemas, irrigations, catheterizations, applications of dressing or bandages, supervision of special diets, restorative and habilitative measures in Section 390.1620(a)(11) and other treatments involving a like level of skill, shall be properly administered. An Owner, Licensee, Administrator, Employee or Agent of a facility shall not abuse or neglect a resident. These regulations are not met as evidenced by the following: 1) Per record review Z-1 was a 1 year, 9 month old female with a diagnosis of Cerebral Palsy with Spasticity, Impaired Vision, Impaired Hearing, Tracheostomy, Gastrostomy, Encephalopathy and Seizure Disorder. Per review of physician's orders, Z-1 required an Apnea monitor to be used at all times with a 20 second delay for alarm, for her respiratory deficits. She was to receive oxygen at all times to maintain her oxygen level at more than 90%. Z-1's oxygen saturation was to be assessed by the nursing staff every 4 hours. Per record review and review of the investigation report provided by the facility. On 9/30/98 at 6:15 pm E-7 checked Z-1 and she was observed to be breathing and moving around in the bed. At 6:30 pm E-10 checked Z-1 and she was in no distress. At 6:50pm when E-7 came back to change Z-1, Z-1 was found in the prone position and when she turned her over, she found the client cyanotic and not breathing. Per interview with E-1 confirms that clients who utilize a tracheostomy would not be positioned prone, however this client was able to turn herself. Z-1 was suctioned by E-2 and CPR was initiated by E-8 and E-3. Z-1 was transferred to the hospital by ambulance with CPR continued. Per report provided by the facility Z-1 expired at 7:36 pm at the hospital. Per report provided to this surveyor by the facility states that on the AM of 10/7/98 E-2 was placed on suspension due to reports that at the time of Z-1's death her apnea monitor was not turned on. Confirmed per interview with E-1 that there is currently not a specific policy regarding who is to perform the duties associated with an apnea monitor. Per interview with E-7 states that she does not remember if the monitor was turned on, but does remember that the alarm was not sounding at the time of her respiratory arrest. E-3 and E-8 also concurred that there was no alarm sounding at the time of her respiratory arrest. Per interview with E-2 confirms that the apnea monitor was not turned on at the time of her respiratory arrest. E-2 states that she turned it off "for a while, not too long" due to Z-1's restlessness in the bed. E-2 also concurred that during this time span when her monitor was turned off was when she was found with a respiratory arrest. Per interview with Z-2 and E-4 state the nursing staff are expected to follow physicians orders at all times unless the physician is notified. Per interview with Z-2 states that Z-1 was hospitalized prior to admission to this facility due to respiratory distress related to a respiratory arrest and that he continued to order this monitor due to this history. On 10/14/98 at 8:10 pm, this surveyor assessed the clients who are to have apnea monitors at bedtime only. Per interview with E-1 on 10/7/98 states that after the tube feeders receive their 7:00pm feeding and are in bed for the night the monitors are to be turned on. Per review of facility records on 10/16/98 a policy was implemented regarding which identified bedtime as 8:00 pm. 2) Per observation of R-2, a 17 year old male at 8:10 pm, he was observed in bed with his head elevated. His tube feeding was complete and his apnea monitor was turned off. When this surveyor took E-3 to this client's room to inquire as to the reason the apnea monitor was not on, E-5 came into the room and told the surveyor and E-3 that she had turned the apnea monitor off because it was making so much noise. E-3 stated that she was going to tell the nurse but she had went into the adjoining bedroom and changed another client. Confirmed per E-3, E-5 should not have turned the apnea monitor off. 3) At 8:15, R-3 a 4 year old male client was observed in his bed with his tube feeding complete, asleep. His apnea monitor was not turned on. Per interview with E-9 states that she had completed his tube feeding but had not turned on his apnea monitor because she was not sure he was asleep. During this conversation, E-9 turned on the apnea monitor. 4) R-1 a 6 year old male was also observed in bed without his apnea monitor turned on. It was turned on during this observation time. E-3 and E-9 confirmed that the nurse is responsible to ensure that the apnea monitor is turned on according to physician's orders. At 8:40 pm on 10/14/98, E-4 was notified of a serious and immediate jeopardy for failure to furnish supervision or monitoring consistent with client needs of apnea monitors. The serious and immediate jeopardy was abated on 10/28/98 at the time of the exit. The facility failed to ensure that Z-1's, R-1's R-2's, R-3's and R-4's apnea monitors are in place, and used per physician's order to monitor the clients' medical condition.