WESTABBE HEALTHCARE CENTER
Facility I.D. Number 043687
2301 W. Monroe St.
Springfield, IL 62704
Date of survey July 14, 2000 Complaint survey
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.
All necessary precautions shall be taken to assure that the resident's environment remains as free of accident hazards as possible. All nursing personnel shall evaluate residents to see that each resident receives adequate supervision and assistance to prevent accidents.
These REQUIREMENTS are not met as evidenced by the following:
1. On 5/24/00, at 2:05p.m., a telephone interview was conducted with Z1, She said that the facility contacted her about 8:30a.m. or 9:00 a.m. on 5/14/00. Z1 said that E9 called her and said that R1 had got her foot caught in the heating grate and tore off her large toenail and her third and fourth toenail was ripped out. Z1 said that when she went to the hospital to see R1, Z19 said that R1's foot had been burnt and then burnt again and was deep. She said that Z19 and Z20 noted R1 may have to have her toes amputated due to the burns on her right feet.
On 7/6/00, at 10:30a.m., during the entrance conference, E1 said that the heat was on in the building on 5/14/00 due to the cool weather. He said that he was not sure how R1 sustained the injury to her right foot.
On 7/12/00, at 9:00 a.m., R1's closed medical record was reviewed in the facility conference room. R1's physician order sheet, dated 5/00 through 5/31/00, noted R1 has the following diagnosis: Dementia, Constipation, HTN, Depression, CHF, UTI, Dehydration, and Weakness.
On 7/12/00, at 9:00a.m., Resident Assessment dated 5/10/00, noted that she had moderately impaired Decision making abilities.
On 7/12/00 at 9:10a.m. R1's nurse's notes were reviewed. R1's nurse's notes, dated 5/14/00 at 9:28a.m., noted the following: CNA called this writer to the room. Resident was lying supine with right foot over left leg. Right great toe nail was gone skin was peeled off. 2nd toenail hanging by skin which is peeled off. 4th toenail hanging with skin peeled back also. CNA found resident with foot out of heating grate. Skin and toenail remain in the heating grate. R1's physician and family were notified of the incident. R1 was sent to the hospital via ambulance.
On 7/12/00, at 9:15a.m., the incident report regarding R1's injury was reviewed. The accident/incident report stated the following: CNA called this writer to room. Resident found lying supine with right foot propped over left leg skin peeled back with toenail off rt. Great toe. 2nd toenail hanging by skin. Looked at heating grate per CNA request. Toe nail of right great toe and skin of other toes in place behind heating protection grate. Transferred to hospital. The supervisor's investigation of the event and interventions on the back of the accident/incident form was written by E2 and noted the following: Called hospital and spoke to charge nurse. Nurse stated that R1 arrived at the hospital at 10:14a.m. with diagnosis of Dehydration. The burn team saw her toes on her right foot (Deep partial thickness burn) on 1st, 2nd, and 4th toes.
On 7/12/00 at 9:35a.m., the investigation of the incident was reviewed. The written statement of E9, the nurse that cared for R1 when her injury was discovered, was reviewed. In the statement (dated 5/16/00), E9 noted that she saw R1 at 8:15a.m. on 5/14/00. She said that she gave R1 her medications. She said that about 9:20a.m., the CNA (E10) came and got her and told her about R1's injury. She said that she went to R1's and the heating grate was not hot to the touch. She said that she notified the family and physician and R1 was sent to the hospital.
The written statement (dated 5/16/00) of E10 was reviewed. E10 was the Certified Nurses' aide who cared for R1 the day she sustained the injury to her right foot. In the statement she noted that she checked on R1 at approximately 6:00a.m. She wrote that at that time she gave R1 a drink of water and put a pillow on the grate covering the heater. E10 wrote that she checked on R1again at approximately 7:30a.m. E10 wrote R1 had taken the pillow off the grate and put it up by her head. E10 wrote that she put the pillow back on the grate and repositioned R1. E10 again wrote that at 8:25a.m. she checked on R1. R1 had removed the pillow from the heating grate and so E10 placed the pillow back on the grate. At around 9:05a.m., E10 wrote that she came down the hall to check on R1. R1 had moved the pillow and R1's foot was on the top of the grate. R1 had three red toes and the toenail of the big toe was on top of the grate and the skin and nails of the other two toes were hanging on the back of R1's foot. She wrote that she went and told the nurse immediately.
On 7/12/00, at 1:00p.m., an interview was conducted with E2 (the former DON). E2 noted that she did not think that R1 sustained a burn from the injury on 5/14/00. E2 said that R1 tore her toenail on the grate. E2 said that she is not sure how R1 sustained the injury to her right foot. She said that R1 could not have touch her foot to the register due to the register was covered by a grate. She said that the grate was not hot to the touch when the incident occurred.
On 7/13/00, at 9:30a.m., Z8 was interviewed on the telephone. Z8 was the paramedic who was called to pick up R1 via ambulance on 5/14/00. He said that R1 did not complain of pain when they entered her room. He said that the skin had been torn away from three of R1's toes, but the skin was not weeping. He said that the heater grate was warm to the touch, but not hot. He said that the bed was pushed very close to the heating unit. He said that prior to transporting R1 to the hospital, R1's toes were scarlet red and dry as if they had been exposed to heat.
On 7/13/00, at 10:30a.m., E11 was interviewed in the conference room. The initial interview had been conducted with E11 on 5/18/00. E11 said that she was the third staff member to see R1 after the incident occurred on 5/14/00. She said that E10 called her into R1's room. She said that R1 did not complain of any pain after the incident occurred. She said that R1 had a history of continually throwing her feet over the sides of the bed.
On 7/13/00, at 11:45a.m., an interview was conducted with E10. The initial interview was conducted with E10 on 5/18/00. E10 said that she initially saw R1 at approximately 6:00a.m. on 5/14/00. She said that she repositioned R1 in her bed because she was too close to the right siderail. She said that R1 did not have any siderail up on the left side of the bed.
She said that she saw R1 again at approximately 7:15-7:30a.m. She said that R1 had her right foot lying over the side of the bed near the window. E10 said she took a pillow and placed it on the top of the heater grate. She said that she was not sure if the heater was on, but the grate was not hot. E10 said at 8:20a.m., she came back to R1's room. She said that R1 had removed the pillow from the grate. E10 said she repositioned R1 and put the pillow back on the grate. E10 said she came back to R1's room about 9:05a.m. or 9:10a.m. E10 said she saw R1's right foot with the ball of the right foot resting on the grate. E10 said she picked up R1's foot and her leg and saw the big toe, 4th toe and little toe were all skinned. She called for the nurse. She said that R1 never called out for help and that the heater grate was never hot to touch. On 7/13/00, at 2:30p.m., E10 said that R1's bed had been pushed against the wall with the electric heater in lieu of a side rail. She said that R1 only gets the right siderail up and staff push the bed against the wall to act as a siderail. She said that she did push the bed away from the wall enough to get around the bed. She said this was several inches. She said that she put the pillow on the heating grate because she knew that it wasn't safe to move the bed away from the wall.
On 7/13/00, the heating grate in R1's room was observed. The grate was metal and covered the electric heater. The grate had small openings which measured 1 ½ inch by 3/4 inch in diameter and were diamond shaped. There were no gaps or openings in the metal grate around the heater. The heat was not on.
On 7/13/00, at 2:30p.m., the emergency medical service/ambulance report was reviewed at the hospital. The report noted that "the patient had apparently hung her right leg over the side of the bed and got her toes caught in the metal grate which covers the electric heater....toes are scarlet red and dry and apparently as though they may have been exposed to the heat from the heater for some time...heat was on grate is warm to touch but not actually hot." On 7/13/00, at 2:30p.m., the consultation report of the attending physician (Z20) who cared for R1 at the hospital upon her admission was reviewed at the hospital. The physical examination noted the following: "On examination the patient has full-thickness burns on the right first, second, third and fourth toes circumferentially with dry gangrene at the tipsdistally. There is no evidence of pus or erythema." The assessment and plan noted the following: Patient with full-thickness burn to the toes on the right foot with dry gangrene distally at the tips. The patient will likely require toe amputations of the involved areas." On 6/16/00, R1's great toe, 2nd, 3rd, and 4th toe were amputated.
At no time did the facility identify that the heater was a hazard to R1. At no time did the facility attempt to move R1's bed away from this heater, although staff were aware that R1 was attempting to place her footnear the heating grate.
2. On 7/6/00, R11's medical record was reviewed at 11:00a.m. in the facility conference room. Per her physician's order sheet, dated 7/1/00 through 7/31/00, R11 is a 70 year old confused woman with a diagnosis in part of Dementia and Alzheimer's Disease.
On 7/6/00, at 11:20a.m., R11 was in her room in her wheelchair. She had her arms crossed over her chest with her hands grabbing at her upper arms. She did not respond to the surveyor.
On 7/6/00, at 11:30a.m., R11's nurse's notes were reviewed in the facility conference room. Her nurse's note, dated 5/2/00 at 6:30a.m., noted that she was found on the floor next to her bed with a small laceration to her lower lip. The nurse cleansed the area with normal saline and applied Vaseline to her lip. An incident/accident report was filled out by the nurse at the time the incident occurred.
Her nurse's note, dated 5/8/00 at 1550, noted the following: CNA brought to writer's attention that resident has bruising to right arm and above both breasts on chest. Resident moves right arm with some facial grimaces noted. Physician called and informed of condition. Physician ordered x-ray and family informed.
Her nurse's note, dated 5/9/00 at 0915, noted the following injury: Resident found to have bruising to anterior chest above both breasts.
Right breast has bruise approximately 15 cm long by 6 ½ cm wide with yellowing extending to 9 cm. Left breast has bruising approximately 12 cm wide by 5 cm long with yellowing noted around edges. Right anterior arm noted to have bruising approximately 21 cm long by 19 cm wide with yellowing and fading. Noted also to have 3 ½ cm yellowing bruise on right lower arm. At the time the bruises were noted on R11's chest and arms, no incident report was made. E2 updated the incident report dated 5/2/00 and noted the following under the section "Supervisors Investigation of Event and Interventions: Received an incident and accident report 5/8/00 noted resident with large biceps bruise on right arm and large bruise on chest (anterior) above both breast. Can raise right arm without difficulty but noted resident with grimacing facial expression during lifting. Decided to ask M.D. for order to x-ray right arm just in case possible fracture."
On 7/7/00 at 12:30p.m., E12 said that a CNA came and got her when he noticed the bruises on R11. She said that she thought she received the bruises from the fall that occurred prior that week. She said that the bruises were yellowing and older.
On 7/6/00, at 2:00p.m., E17 said that the facility staff should report any unexplained bruises to the charge nurses immediately. She said that she was not sure why R11's bruises were not reported immediately to the nurse.
On 7/7/00, at 2:30p.m., E12 who conducted the measurements of the bruises on R11 on 5/9/00 noted that the staff felt she fell with her arms crossed over her chest. She said that R11 always puts her arms this way. She said that she thought that an investigation was completed by E2, but she did not know the location of this information.
At no time did the facility investigate the incident of 5/2/00 in which the resident allegedly fell out of bed and at no time did the facility conduct a thorough investigation including interviewing staff to determine how R11 sustained the bruises to her chest and to her arms.