WASHINGTON HEIGHTS NURSING HOME
Facility I.D. Number 0042044
1010 W. 95TH St.
Chicago, IL 60643
Date of Survey 06/14/00
Incident and Complaint Investigation
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
This REQUIREMENT is not met as evidenced by:
Based on physician and staff interviews and facility record reviews,
facility failed to follow physician's orders from the transferring hospitals
for 2 of 2 residents located on the second floor.
- Medical record review reveals R#11 admitted on 5/25/00 with diagnosis on
Transfer form "Osteomyelitis" and diagnoses on Nurses Notes
"D.M. [Diabetes Mellitus], HTN [Hypertension], CHF [Congestive Heart
Failure], VRE of Urine [Vancomycin-Resistant-Enterococcus], Renal Insuff.
[Renal Insufficiency], Hx of CVA [History of CardioVascular Accident], Central
line to L Subclavian, and G-Tube.... Foley Catheter...Bed sore to sacral
area..". Transfer form under current medications indicated "See
Medication Sheets". The medication sheets from the hospital indicated
0600, 0900, 1800,and 2100 as the medication dose times. The med sheet for
5/25/00 indicates the 0600 time lined out. The med sheet includes "NPH
Insulin 43U q618" and to the right of the entry is written 0600,1800; and
"Accuchecks q618" and to the right of the entry is written 0600,1800;
Nurses Notes start 5/25/00 at 1p.m. Facility had knowledge of R#11's med
schedule at least 2 days prior to this admission. A copy of the medications
sheet found in the record documents a fax date and time line as
"05/23/2000 10:12 a.m....." Care Plan dated 5/25/00 documents
"NPH Insulin 43 units Subcue Sliding Scale
351-400=9U above 400 call MD."
Hospital records titled 'Problem List' document 3/8/00 "altered
metabolism" "unstable blood sugar" and an undated sheet with a
fax date and time of 5/23/2000 10:08 a.m..."very large about 20 x20 cm
deep sacral and coccygeal decub".
Nurses Notes on 6/1/00 at 10 a.m. document...."receiving 8 L O2 per nasal
mask, experiencing labored breathing. Resident lethargic...T.102.1 P 105 R 25
B/P 168/72....Doctor paged...send to hospital."...because of Resident's
unstable vital signs ..to Little Company of Mary Hospital"
Interview with E3 on 6/7/00 revealed that facility became aware that R#11 had
not received her scheduled insulin and proper care for her documented diabetic
condition when hospital called and questioned R#11's elevated blood sugar
history on 6/1/00.
Phone interview with Z#6 on 6/13/00 reveals R#11 hospital admission Blood
Chemistry at 8 p.m. is recorded as 675mg/dl with normal values within the range
of 65-115 mg/dl. E#3 stated that E#9 admitted to E#3 that he was unable to
decipher the transfer order sheets and determine when the meds should be given
as well as the accuchecks because he was not familiar with military times.
Facility then suspended E#9 for three days in response. Phone interview on
6/13/00 with E#9 reveals that E#9 was suspended for failure to monitor R#11's
chart. Phone interview on 6/13/00 with E#11 states tried to 'contact nurse at
hospital','was placed on hold' and did nothing more. No evidence of any NPH
Insulin 43 U twice daily, Accuchecks twice daily, and use of Regular Insulin
sliding scale for R#11 from admission of 5/25/00 to discharge of 6/1/00, a
total of 8 days.
2. R#1 admitted 5/10/00 with diagnoses on face sheet documented as
"G-Tube, Decubitus Ulcer, CVA [Cardiovascular Accident], HTN
[Hypertension], Dysphasia, NIDDM [Non-Insulin Dependent Diabetes Mellitus].
Physician phone orders for 5/10/00 document similar as documented on
Northwestern Memorial Hospital Continuity of Care form under Discharge Plan
with the addition of 1.] Vit C 500mg via PEG tube BID, 2.] FeSo4 220mg liq
daily via PEG tube. R#1's Medication administration sheets document these
medications given as ordered with the exception of Vit C, documented as given
one time a day instead of twice a day. R#1's medical record also included a
separate Northwestern Memorial Hospital Patient Discharge Instructions
documenting physician orders for:
1.] Cardura 4 mg every hour of sleep,
2.] Atenolol 50 mg every day,
3.] Plavix 75 mg every day,
4.] Glipizide 10mg every a.m.,
5.] HCTZ 12.5 mg every day,
6.] ASA 81 mg every day,
7.] Dulcolax 10 mg prn,
8.] Colace 100mg twice a day,
9.] Prevacid 30mg every day, and
10.] Heparin 5000 U sq twice a day.
R#1 was without these medications from 5/10/00 to 5/17/00, a total of 7 days.
Z#2 interview on 6/9/00 reveals Z#2 was informed by the facility on 5/16/00
that another paper was located "in the bundle of hospital records"
listing these medications. Z#2 examined R#1 the following day and ordered the
Nurses Notes of 5/13/00 reveal "Tylenol liq given P.O.for pain" with
no evidence of a physician's order for Tylenol.
The family had R#1 transferred to another facility on 5/22/00.
No evidence R#1 received ten medications from 5/10/00 to 5/17/00, and no
evidence that R#1 received Vit C twice a day as ordered, and evidence that R#1
received a dose of Tylenol liq without a physician's order.