WESTABBE HEALTHCARE CENTER
ID Number 0043687
2301 W. Monroe St.
Springfield, IL 62704
As a result of a complaint/incident survey conducted on April 17, 1999, by representative(s) of the Department, it has been determined the following violations occurred.
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.
All nursing personnel shall teach and assist residents with safe transfer activities in an effort to help them retain or regain their maximum level of independence.
All necessary precautions shall be taken to assure the safety of residents at all times, such as but not limited to: nonslip wax on floors, safe equipment, assistive devices properly maintained, and proper use of physical restraints and adaptive equipment.
These regulations are not met as evidenced by:
1.) Based on record reviews and staff interviews it was determined that the facility failed to provide adequate supervision to prevent elopement in that: R18 is an 84 year old individual that resides in the "RC" building of this facility.
R18's diagnoses include Schizoaffective disorder, Organic Mood Disorder, history of Seizures, history of Pneumonia 1/99, and Alzheimer's Type Dementia.
R18's quarterly review of 02/23/99 reflected that R18 has long and short term memory problems and her cognitive skills for daily decision making are severely impaired. R18 had a "1:1" for wandering (under behavior symptoms) which indicated that wandering had occurred 1 to 3 days in the 7 days prior to the assessment date and that this behavior was not easily altered.
R18 was also at risk for falls and had a fall within the previous 31-180 days prior to this assessment. R18's Physician Progress Notes for 9/4/98 indicate "...weak, wobbly today. unaware of surroundings...." Observation of R18 on 4/13/99 revealed her to be resting in bed. She would respond to her name only. Other conversational attempts resulted in either no response or totally inappropriate response.
R18 receives "Paroxetine HCL" at 8p.m.(for "depression") as well as "Clozapine" ("for schizophrenia") at the same time.
Review of R18's nurse's notes reveal the following: "04/02/99 0030 Resident left facility without notifying nursing staff. Returned to facility without incidence per staff. assessment done No injury noted. Resident returned to bed. Alert to name only as usual. Confused to time & place. R+O [reality orientation] given [R18's physician] & family ...notified incident & aware...continue with 15 min location checks...."
Facility's investigation of this incident indicated that "...resident had never before showed signs of wandering or elopement...." However, staff interviews completed by surveyor revealed that R18 has had to be brought back in to the building from the courtyard area in times past.
The RC building is shaped in a square Q type formation with a center courtyard. The "tail" of this Q faces towards the east. This building has six exit doors that are alarmed with a system that requires an alarm panel to be reset in order to silence and reset the system if a door is opened without the correct numbers and sequence being implemented. This alarm system was put in place in January 1999 to provide for safety although facility has continued to have incidents of elopement occur.
Per staff interviews there was another resident that kept "setting off" the alarms the evening of 04/01/99. This resident would not leave the building, but would open exit doors thus setting off the alarm. The one staff person working in this building on this night indicated that she checked the "east" door--looked out and saw no one there, so thought that it must have been the same resident that had set the alarm off again.
Other staff interviews revealed that an individual (from the community) that had been out walking entered the main building sometime between 10:45 p.m. and 11:30 p.m. and told the staff there that he'd seen a person that seemed somewhat confused behind another set of buildings that are west of this facility.
Some staff went then to try and find this person. Others did a head count in the main building and the one staff person in the RC building was notified of possibility of a resident having eloped.
At this time, the RC employee did a head count and found that R18 was missing.
A staff person was sent from the main building to the RC building so the RC building staff person could search for R18.
Per the D.O.N.(director of nursing), she was notified by a main building nurse of the missing resident sometime shortly after midnight on 4/2/99. About 5-10 minutes later, the D.O.N. called the facility before leaving home to come to the facility and she was told the resident had been found. The D.O.N. came to the facility and did a check of R18 and called the assistant administrator.
Per staff interviews this resident was found near another nursing facility in the area, which is 0.9 miles from this facility when driving the most direct route.
This facility is located next to a heavily traveled 4 lane road in this city. The speed limit in the area is 40 mph. The temperature the evening of 04/01/99 got to a low of 58 degrees.
Some staff indicated that R18 was dressed with a coat and hat; other staff believed she had on a flannel nightgown.
The one employee that was working the RC building that night was terminated for failure to follow the facility's "Resident Safety and Elopement" policy.
The RC building houses approximately 43 residents. At least six of these individuals are at risk for eloping and are on hourly checks for their whereabouts. (Note that R14 was placed on 1:1 on 04/11/99 due to his attempts to leave the RC building; thus indicating the monitoring and staff involvement necessitated by some of the individuals residing in this building). There are at least 11 individuals that are incontinent and require at least every 2 hour toileting and checks. Of note, on the 10 p.m.- 6 a.m. shift in this building on 04/16/99, there again was only one staff member on duty.
2.) Family, resident and staff interviews and record review revealed R24 was being transferred from bed to wheelchair at 7:40a.m. on 4/16/99 per hoyer lift with assist of two, "hoyer lift malfunctioned" and R24 ended up on the floor, resulting in a fractured left knee.
Interview with DON revealed she and a CNA were transferring R24, had her in the lift, off the bed, was turning to put R24 down in the wheelchair and the hoyer lift tipped over. R24 was sent the emergency room and returned with a diagnosis of a fractured knee and orders for this. R24 is a 74 year old female with diagnoses including polio and diabetes. R24's last weight in March 1999, was 249 pounds. The care plan reveals R24 is a total assist with transfer and does not ambulate.
Interviews reveal this hoyer lift had a spreadbar lever missing which has reportedly been missing "for a while". R24 is interviewable and confirmed "pieces missing...I have been telling them". Staff interviews reveal the spreadbar lever was missing, therefore the hoyer lift base had to be spread manually. When asked how that was done, the procedure was explained to use ones feet.
The hoyer lift was out of service and "in the trash" as of 4:30p.m. 4/16/99. The owners manual was not available for review. The length of time this hoyer was in service is not available and the length of time the spreadbar was missing is unavailable. Staff interviews and resident interview confirms this hoyer lift was not complete, was in service for use on two residents by several different staff members on a daily basis. After R24's fall and fracture on 4/16/99 the hoyer lift was taken to the trash.
3.) Observation 4/13/99, at approximately 8:30a.m. R25 was observed to be sitting on the bathroom toilet with no one in attendance. Review of R25's clinical record revealed she is a 78 year old female with the diagnosis, in-part, of multi-infarct dementia and anxiety. R25 does take Warfarin 7mg. daily. R25 has a physician's order for a lap tray when up in a wheelchair and is to have side rails due to decreased balance/coordination and weakness of lower extremities.
Review of the 1/4/99 significant change assessment revealed resident to have a short and long term memory problem, to be severely impaired cognitively, to sometimes understand, is dependent on one for transfers, does not ambulate, has no standing balance and sits with partial physical support or could not follow directions for the test; dependent for activities of daily living. Review of the Fall Rap revealed resident to be at a risk for falls. Care plan also identified her to be a risk for falls.
4.) Observation on 4/11/99 at approximately 7:02 p.m. revealed R4 to be in her room, in her wheelchair with lap buddy in place. Staff entered R4's room. The staff removed R4's lap buddy, then left her in her wheelchair behind pulled curtains while the staff person went into R4's bathroom to moisten a towel. R4 is a 94 year old individual with multiple diagnoses that include: alzheimers, history of fractured right hip, cerebrovascular accident, and others. R4 has decreased balance, coordination, and Lower extremity weakness; as well as decreased cognitive awareness.
5.) R61's bed was noted to move easily when leaned against on 4/15/99. R61 is a 77 year old individual with diagnoses that include cerebrovascular accident with left sided weakness and osteoporosis.
Per nurses' notes 3/30/99 at 0810 "CNA summoned writer to room et found pt lying on floor on her Rt. side between her bed et room mates bed [with] head against night stand. Pt states she was sitting on side of bed et stood up to balance self on bed et fell forward on floor hitting lt side of head on night stand...."
Later R61 had complaints of a painful right wrist.
X-rays revealed a fractured right radius. This arm is now casted. Interview of R61 indicated agreement with assessment that her bed is easily movable. When asked if her bed moved on her the day of her fall-thus causing her fall, R61 indicated that "...that very well could be what occurred." Per R61's 2/24/99 significant change assessment, R61 has no long or short term memory problems and has "some difficulty in new situations only" with her "Cognitive skills for daily decision making".
6.) R33 was observed on 4/12/99 at 12:02 p.m. to be transported per wheelchair by staff. The wheel chair did not have any foot peddles and R33's feet were observed to be dragging on the floor. Direct care staff were observed to instruct R33 to lift feet. Staff continued to transport R33 with feet dragging under the wheelchair.
A regular program to prevent and treat pressure sores shall be practiced on a 24 hour, seven day a week basis, including, but not limited to --
An evaluation of each resident shall be conducted upon admittance and as necessary to determine the susceptibility of the resident to skin breakdown. Preventive measures and treatment measures shall be carried out by facility staff.
Skin care shall be provided which includes but is not limited to bathing, clean linens, and clothing each time the resident, the bed or clothing is soiled.
Residents shall be assisted in being up and out of bed as much as possible and shall be repositioned whether in bed or out of bed as their condition indicates.
Proper equipment shall be utilized to prevent or treat pressure sores, such as proper padding between pressure points, adaptive equipment, splints and water.
These requirements are not met as evidenced by the following:
1) R3 is an 85 year old female, alert and oriented, has diagnoses including diabetes, seizures, status post cerebral vascular accident, congestive heart failure, status post deep vein thrombosis, status post Meniere's disease, Parkinson's disease and osteoporosis. R3 requires a two person transfer, as observed and as assessed. R3 is assessed as frequently incontinent of urine, is care planned for a toileting deficit and requires assist of 1:1 or 2:2 for toileting and transferring.
R3 was observed continuously on 4/11/99 in the dining room, positioned in a wheelchair from 3:47p.m. to 6:35p.m., when resident was taken out of the dining room and put in her room. A puddle was noted under R3's wheelchair at 6:33p.m. Surveyor followed R3 to her room. At 6:44 p.m., R3 stated she was "very uncomfortable and exhausted"..."have to beg afternoon crew to get me out" (of the wheelchair). The call light was pushed by surveyor, as R3 was grimacing as if in pain and uncomfortable. R3 had a strong urine odor about her and added "I'm fighting a bedsore". Six facility staff walked by the open room door, with the call light on, before a CNA came in at 6:54p.m. to see what resident needed. A nurse came in the room and discussed the odor with the CNA, but did not move R3 out of the wheelchair or clean resident. Surveyor informed the staff a puddle was observed under R3 in the dining room. The two staff left the room. The CNA came back in the room at 7:03p.m. and told R3 "just got to wait"...for another CNA to help this CNA. While waiting, surveyor observed the med nurse, the ADON, the care plan coordinator, along with the administrator, the director of social services and a corporate employee in the hallway. At 7:15p.m. the two CNA's placed a gait belt around R3 and transferred R3 to bed. R3 was total assist with this transfer. The bed rolled away and R3 was then lifted into the bed. The pad in the wheelchair was very wet, soiled with urine and had brown stains and a strong urine odor. R3 had an area on the left upper thigh where she had a healed area. As the CNA was washing R3, R3 stated "it's sore.
R3 was observed in a wheelchair for three hours and twenty eight minutes without having position changed.
2) Review of R8's clinical record revealed he was admitted 2/22/99 with a diagnosis of mild to moderate mental retardation, osteomyelitis, T7 & T8 mass, peripheral vascular disease, myocardial infarction, coronary artery disease, depression, iron deficiency anemia and renal failure. R8 had lost 50 lbs. in 6 months per hospital history and physical dated 3/1/99 which also noted he has been going down hill since 12/98. Review of the 3/12/99 hospital dietary note revealed he should have Jevity plus a can of Ensure twice daily to meet resident's calorie/protein needs. Review of the 3/22/99 facility dietary note revealed resident is receiving Jevity at 70cc's per hour which provides 1781 calories, 74/45gm. protein, 1411cc's fluid per day; needs 1810 calories, 93 gm. protein and 1550-1860cc fluid per day. Facility RD recommended Jevity FACE at 65cc's per hour with 100cc's flush every shift. Facility RD stated resident to have depleted protein stores and severe weight loss and more calories/protein/fluids needed. R8, per 4/7/99 skin record, has Stage 4 pressure sore on the right buttocks 3x4.5cm. "black" admitted with, Stage 4 right inner foot 3x1.5cm. "brown" - acquired in facility, Stage 3 left hip 2x1cm. "black"- acquired in facility, Stage 2 right outer foot 1x1cm. scabbed-acquired in facility.
Facility did not follow through with the dietary recommendations by calling physician until surveyor asked questions and 4/14/99 the RD, early morning, re-wrote her recommendations after facility had her to come in because of surveyor's questions. It was still 4/15/99 before the facility notified the physician of the recommendations of the dietitian, therefore he even went one more day before he was given feeding to meet his needs. Decubitus were worsening as skin report revealed the right buttock pressure is 9cm.x3cm., left hip 2x1cm. Stage 4, right outer foot 2x2cm. and a new 2x2cm. Stage 2 on the right inner knee. Observation 4/11 and 4/13/99 revealed no padding between legs. On 4/16/99, at approximately 4:40p.m., the Director of Nurses stated the measurement on R8's right buttock pressure sore was in error and she had just re-measured the area and it had lessened in width but increased in length; stated area was 8x2cm.
3) Observation 4/14/99 of R48, at 10:05 a.m., revealed her to be in bed with no dressing on the pressure sore on the right outer heel. R48 has 4 Stage 2 pressure areas; right and left buttock, right inner heel and left outer ankle. Noted were left mid foot, outer aspect, with black area under the skin but not open; left little toe area deep red, left outer foot near little toe dark area but not open. Interview of E8 revealed the latter areas were called to the physician "yesterday and he ordered protective dressing to blister areas aspect of left foot."
R48 was rubbing her right heel on top of the left foot which was resulting in a dark area to the top of the left foot. R48 had no padding between her legs or feet. R48 is totally dependent for all activities of daily living and at a high risk for pressure sores.
4.)During tour of facility on 04/11/99, R56 was noted to be lying in bed at 3:25 p.m. wet (incontinent of urine); the edge of the urine was starting to dry, as there was a tannish colored dry ring surrounding the wet area. R56 had an extremely reddened coccyx, and wet area extended from mid back to mid legs. R56 is identified as a high risk for decubs as verified by staff.
5.) During tour of facility on 04/11/99, R53 was noted to be lying in bed at approx. 4:40 p.m. wet (incontinent of urine); the edge of the urine was starting to dry, as there was a tannish colored dry ring surrounding the wet area, extending from mid back to mid thigh. R53 is currently assessed as a high risk for decubs, as verified by staff.
6.) On 4/11/99, R2 was observed to be lying in bed and incontinent of urine at approximately 4:10 p.m.. R2 was not changed or repositioned by direct care staff until 6:10 p.m. Per record review and staff interview on 4/12/99, R2 is at high risk for pressure areas.
7.)R4 was observed on 04/11/99 from 4:30 p.m. thru 7:02 p.m. to be up in wheelchair with lap buddy in place. R4 was not repositioned during this time.
R4 has previous history of decubitus. Review of R4's care plan indicates that R4 is to be turned and repositioned every 2 hours and to ensure relief of pressure due to "skin integrity, impaired: potential."