BEVERLY FARM FOUNDATION
Facility I.D. Number 0038604
Date of Survey: 05/30/02
Complaint Investigation and Incident Report Investigation of 05/03/02
The facility shall have written policies and procedures governing all services provided by the facility which shall be formulated with the involvement of the administrator. The policies shall be available to staff, residents and the public. These written policies shall be followed in operating the facility and shall be reviewed at least annually.
These policies shall include:
A written statement for resident care services including physician services, emergency services, personal care and nursing services, restorative services, activity services, pharmaceutical services, dietary services, social services, resident records, dental services, and diagnostic service (including laboratory and x-ray).
Nursing services to provide immediate supervision of the health needs of each resident by a registered professional nurse or a licensed practical nurse, or the equivalent.
The facility shall notify the residents physician of any accident, injury, or change in a residents 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.
Residents shall be provided with nursing services, in accordance with their needs, which shall include, but are not limited to, the following: The DON shall participate in:
1) Pre-admission evaluation study and plan.
2) Evaluation study, program design, and placement of the resident at the time of admission to the facility.
3) Periodic reevaluation of the type, extent, and quality of services and programming.
4) Development of discharge plans, and the referral to appropriate community resources.
5) Training in habits in personal hygiene and activities of daily living.
6) Development of a written plan for each resident to provide for nursing services as part of the total habilitation program.
7) Modification of the resident care plan, in terms of the residents daily needs, as needed.
A registered nurse shall participate, as appropriate, in planning and implementing the training of facility personnel.
The residents record shall include information regarding the physicians notification and response regarding any serious accident or injury, or significant change in condition, as required by Section 350.1220(m) of this Part.
NO RESIDENT SHALL BE DEPRIVED OF ANY RIGHTS, BENEFITS, OR PRIVILEGES GUARANTEED BY LAW BASED ON THEIR STATUS AS A RESIDENT OF A FACILITY. (Section 2-101 of the Act)
AN OWNER, LICENSEE, ADMINISTRATOR, EMPLOYEE OR AGENT OF A FACILITY SHALL NOT ABUSE OR NEGLECT A RESIDENT. (Section 2-107 of the Act)
These regulations are not met as evidenced by:
Based on interview, observation and record review, the facility failed to ensure clients were provided with nursing services in accordance with their needs for 1 of 1 inside the incident investigation (R2 who had a delay in obtaining emergency services and died), and 3 of 3 other clients in the investigation who died (R1 who died of cardiac arrest, R 3 who died of respiratory failure and massive aspiration pneumonia, and R4 who died of pneumonia) with the potential to affect 264 of 264 other clients who reside at the facility.
1) The facility neglected to correct a situation in which emergency equipment was not available when made aware of the lack of equipment when R1, R2, and R3 died. The facility allowed the situation to continue in which there was a potential for serious harm or death to individuals due to lack of a system to ensure availability of emergency equipment in 10 of 10 buildings.
a) R3 expired at approximately 6:30 PM on 4/20/02 after being transported to the hospital emergency room. The death certificate lists the cause of death as acute respiratory failure, massive aspiration pneumonia. Other diagnoses are listed as hydrocephalus and epilepsy. The death is noted as sudden on the death certificate
Licensed nursing staff (E8-facility LPN, Z1-agency RN, Z11-agency LPN), and direct care staff (E21, E23) were unable to locate the emergency equipment of an Ambu bag, the oxygen equipment, the suction machine and/or a CPR mouth shield on Donnelley Cottage during R3's cardiac arrest on 4/20/02, when Z2, an agency LPN, requested the needed equipment.
During a check of the facility's ten cottages for emergency equipment on 5/15/02 at 2:55 PM, the surveyor was informed by direct care E21 that some of the Donnelley staff have been shown the location and use of emergency equipment. E21 stated that the evening staff of 4/21/02 were shown the equipment by E7 the nurse (LPN) per E21's request because of the "crisis" that occurred the night before with R3 where no one could find the emergency equipment. E21 also stated that at that time E7 also labeled the box that contained the Ambu bag.
R3's most current History and Physical completed during R3's last hospitalization for aspiration pneumonia in January 2002 states that R3 was a 54 year old male whose diagnoses include Profound Mental Retardation, Hypothyroidism, Seizure disorder, Gastroesophageal reflux disease and questionable Hypertension and Congestive Heart Failure. On this exam, R3 was alert, not oriented but able to nod his head, state yes and no and open his eyes to command. This record also states that R3 "is quite contracted both in his upper and lower extremities."
Z2, an agency nurse (LPN), stated during 1:30 PM interview of 5/16/02 that she was doing a medication pass on Donnelley Cottage when she heard somebody "hollering, get the nurse, get the nurse." Z2 indicated that she saw E21, the evening staff supervisor (non-nursing) and was told that R3 was not breathing. Z2 then stated she told E21 to call 911 stat and E21 immediately picked up the phone.
Z2 stated she ran down the hallway to R3's bedroom where R3 was slumped over strapped in his wheelchair with a "bluish type of color." Z2 stated there were "a lot of straps" she had to get loose. Then Z2 stated "I started to holler for a suction machine, Ambu bag and O2 (oxygen). Those are my three words I always holler for. The same three things. I want everything right there."
Z2 further indicated that she did not get the equipment she needed because they couldn't find the equipment. Z2 stated she heard staff say "I can't find it!" to which she told them "you all look again, its there, you find it!" because the equipment was suppose to be there.
Z2 further stated that she called to Z1, an agency nurse (RN), who was at the bedroom door thatshe needed an Ambu bag. Z2 indicated that by the time Z1 returned, the Emergency Medical Services (EMS) were there.
Z1 stated per 5/15/02 4:18 PM interview that he came to assist Z2 during R3's code and left the building to get an Ambu bag because he was unable to locate one on the building. During phone interview 5/15/02 at 3 PM, Z1 stated he got an Ambu bag and an airway from the Stahl Cottage.
Z11, an agency nurse (LPN), indicated during interview 9:41 AM, 5/20/02 that she did respond to R3's code, that she was unable to locate Donnelley's Cottage emergency equipment. Z11 also stated during this interview when asked by the surveyor, "What equipment do you expect in the buildings?", "What I would like to have in every building is an Ambu bag, oxygen and a suction machine."
E8, a facility LPN, when interviewed on 5/21/02 at 2:07 PM in regards to R3's code, stated that "I believe I went over there but by the time I got there, EMS was arriving." E8 further indicated that she didn't remember whether she helped look for emergency equipment or not.
E21, direct care evening supervisor (non-nursing) on Donnelley, per 5/15/02, PM interview stated, "There was an Ambu bag, but nobody could find an Ambu bag that night because nobody knew what it looked like. Z2, the agency nurse, looked and couldn't find it. Even E8, the nurse, Z1 agency nurse and Z11, agency (nurse) couldn't find the Ambu bag. Nurses looked and couldn't find it. It was right in the box (a brown, cardboard unlabeled box)."
E23, direct care staff, per 5/15/02 3:38 PM interview stated, "Didn't know what an Ambu bag looked like or how to use it. The nurse ask(ed) if I would go get the Ambu bag. I looked in the nurse's bag." E23 further indicated that she did not know where the emergency equipment was kept.
Z2 stated, " I tried to sweep his mouth out the best I could. I tried to give him mouth to mouth, but couldn't because I could see where it would be unsuccessful, because his mouth was full (emesis), and I kept on sweeping his mouth. I may have put my mouth on him. I don't remember. I was just trying to save a life. I didn't have a mouth piece. They couldn't find it and I couldn't leave him."
Z2 further stated, " I believe E8, Z11 and Z1 couldn't find the Ambu bag. The signs (emergency equipment sign posting on the cabinets) were there, but the equipment wasn't there." Z2 stated, " I believe the (CPR mouth shields) are suppose to be kept in the top drawer (med cart). I gave the keys to a staff to get the (CPR mouth shield) from the med cart and they said they couldn't find it. And I remember the nurses said that night, E8, Z11 and Z1, they couldn't find it. They even told E2, the director of nursing, it wasn't there. They said they couldn't find the Ambu bag and shield. They said they couldn't find it."
Z2 stated that she was so upset that she called E2 that night (4/20/02) at home to let her knowthat she couldn't find the equipment she needed. Z2 stated, " I feel every building should have O2, suction and Ambu equipment in case needed."
The EMS record indicates that EMS received the call at 6:04 PM, arrived at Donnelley at 6:10 PM to find R3 on the floor, in cardiac arrest, with CPR in progress. This report also indicates that R3 had massive amounts of emesis and had aspirated. Record also indicates R3 had to be suctioned continuously, that EMS departed Donnelley Cottage at 6:24 PM, arrived at a local hospital at 6:29 PM where resuscitation efforts were unsuccessful, and terminated at 6:38 PM.
b) R1 was an 86 year old female resident of Hillier building who expired on 4/24/02 at 7:17 PM after being transported to the hospital emergency room.
The death certificate lists the cause of death as sudden cardiac death. Other diagnosis includes CVA and Mental Retardation. The death is noted as sudden on the death certificate.
The staff on Hillier were not able to find an Ambu bag for resuscitation for R1. E14 said in an interview 5/15/02 at 1:20 PM that when R1 died, they had to go to another building (Stahl) to get an Ambu bag for resuscitation of R1 and "again when R2 died (about 2 weeks later) we had to do the same"[go to Stahl to get an Ambu bag].
c) R2 died on May 3 following respiratory and cardiac arrest.
R2 was a 77 year old female with a diagnosis that included Esophagitis with Barrett's Epithelium, DVT (Deep Vein Thrombosis), Pulmonary Emboli, UTI (Urinary Tract Infection) and CVA according to the diagnosis on the current medication record and physician orders.
R2 was re-admitted to the facility from the hospital on 5/3/02 at 11:50 AM per nursing notes written by E31, LPN. A nursing note written by E8, LPN, at 5:45 PM on 5/3/02 stated R2 was placed on O2 per nasal cannula at 2 liters per minute for respiratory distress reported by staff.
The Oxygen had to be obtained from another building according to interview with E8 on 5/21/02 at 2:15 PM. Per E8, she and another staff went to Donnelley building to obtain an oxygen concentrator to start oxygen for R2. She stated that another client was using the other oxygen concentrator in the building.
E8 said she was not aware of other emergency oxygen in the building and thought an oxygen concentrator was to be used.
Per interview on 5/16/02 at 3:00 PM, E7, LPN, said the oxygen concentrators were generally used specifically for individual clients who had orders for oxygen and were not usually used for emergency oxygen.
E7 knew there were small oxygen tanks in the buildings for emergency oxygen, but said she did not know how to regulate the liter flow since there was no regulator on the tank. Additionally, E7 said she did not know which buildings had suction machines if a client would require emergency suctioning.
Per interview and written statements, when R2 required rescue breathing at approximately 7:30 PM, the staff were not able to find the Ambu bag at the building and had to go to Stahl building to obtain an Ambu bag . E8 verified per interview that the Ambu bag was obtained from Stahl building. E10 verified in interview on 5/15/02 at 12:55 PM that she went to Stahl building to get an Ambu bag for R2 on 5/3/02 because they could not find the Ambu bag on Hillier.
Per interview with E5 at 5:00 PM on 5/16/02, rescue breathing was not initiated on R2 when she had respiratory distress at 7:30 PM until the Ambu bag was brought to the building.
Per E8 interview, the Ambu bag was used when R2's respirations dropped to 6 per minute. E8 said there was no need to initiate mouth to mouth resuscitation prior to the arrival of the Ambu bag from Stahl.
E10 said direct care staff had no access to emergency equipment prior to R2's death - that all of the equipment was locked in the medication room of Hillier.
E27(direct care staff) also said in interview on 5/15/02 at 12:45 PM at Hillier building that all emergency supplies were kept locked in the nursing office (medicine room) prior to R2's death. E27 said she told the "regular nurse", E31(LPN), that the staff did not have oxygen or an Ambu bag on 5/3/02 when R2 died. E27 said E31 then found both the emergency oxygen and an Ambu bag on a top shelf of the locked medicine room.
E7 (LPN) said in interview 5/16/02 that she did not know there were no "standing orders" for oxygen use and has never "not been able to find emergency equipment in the buildings".
Interview with Z5 per phone at 11:20 AM on 5/22/02 indicated she was with R2 when she stopped breathing while she was bathing R2 in a whirlpool tub at about 5:45 PM on 5/3/02. Z5 said when she leaned R2 back about 40 degrees to wash her hair, R2's chest stopped rising up and down, her eyes closed, she became limp and unresponsive. Z5 said she sat R2 upright, rubbed her and called her name and she opened her eyes and began breathing again. Z5 said she called on the intercom in the bathroom for E12, the supervisor (non-nursing). E12 did not answer. Z5 said she then called out / yelled for Z6. E8 then came to the building. Z5 said E8 and E17 had to go to Donnelley to get oxygen.
Z5 said R2's fingertips were purple after she stopped breathing. Z5 asked the nurse if they were going to do an O2 sat. (oxygen saturation level). Z5 said the nurse did not respond to her. E 11(direct care staff) said in interview at the facility on 5/20/02 that R2's color was a "horrible grey."
E7(LPN) said in interview on 5/16/02 that the facility used to have pulse oximeters to measure oxygen levels, but did not have any now.
E2 said the facility did not have pulse oximeters to measure oxygen levels of a client. E2 said the facility used to have one, but it is missing and has not been replaced as of 5/23/02.
If the building's emergency oxygen had been used, there would have been no means to regulate the amount of oxygen delivered to the client.
Per interview with E2 on 5/23/02 at 10:30 AM the emergency oxygen tanks on the buildings were pre-set at 3 liters per minute and had a 20 minute supply. She said there was no way for a nurse to gauge the oxygen level if it was to be given at 2 liters per minute. The tanks did not indicate what the pre-set liter flow was.
Per observation 5/15/02 and interview with E2 on 5/23/02, none of the oxygen tanks had regulators to determine liter flow. The tanks only had an on / off mechanism. The tanks had no regulator to indicate the liter flow.
Per E2 interview on 5/23/02, the liter flow was pre-set at 3 liters per minute. E23(direct care staff) said there was no way to adjust liter flow for specific physician orders.
A survey of the buildings conducted by the surveyors on 5/15/02 beginning at 2:55 PM for emergency equipment showed the following buildings did not have the following emergency equipment available:
Donnelley - no airways.
Logan - expired oxygen tank.
Laventhal - no suction machine, no suction catheters.
Evans - No suction machine.
Herring - 2 suction machines with no tubing or catheters; oxygen without tubing or mask.
Hillier - a suction machine with a used suction catheter; no clean suction catheters; no oral airways; expired O2 tank.
Stahl - no suction machine; the only face mask for the oxygen was soiled. No nasal oxygen cannulas were available.
Beverly - No suction machine; no oral airway.
Smith - suction machine covered with dust. No clean tubing or suction catheters; no oral airways. Z10 said on 5/15/02 at 3:35 PM that she had never seen an airway in that building.
Chappee - oxygen tank expired 9/86, suction machine but no suction catheters; no Ambu bag. E41 said the Ambu bag was last used 5/01 when it was used on a client who went to the hospital.
E41 did not remember the Ambu bag being returned from the hospital.
All 10 buildings have clients with medical needs.
Per interview with E42 (LPN)on 5/15/02 at 3:32 PM, the CPR microshields used for protection for mouth to mouth resuscitation with CPR are locked in the medicine carts.
Based on observation of emergency equipment on afternoon of 5/15/02, the emergency equipment was kept in a different location in each building. Some are kept in chart rooms, some in the nursing office, some at nurses station. No system was observed to be in place to tell staff where all of the emergency equipment was located.
The facility had no system in place to ensure all equipment was available for all buildings.
There was no policy or protocol for monitoring and maintenance of emergency medical equipment.
A check list for oxygen was observed in the oxygen cases at Beverly (last check date 11/3/99) and Chappee (last check date 12/8/00).
A different check list was given to the surveyors on 5/16/02 by E3 (Asst. Executive Dir.). The checklist that was given on 5/16/02 said the oxygen and Ambu bags were present in all buildings on 4/15/02 and 5/15/02. E3 said there was no check list available prior to 4/15/02.
Z1 said on 5/16/02, that he made up the list in April because he could not find a checklist. Z1 said the list did not include suction machines, airways, tubing, etc.
2) The facility neglected to adequately monitor, provide nursing supervision, and intervene for R2 who had a serious medical condition of pulmonary emboli and deep vein thrombosis.
a) The facility neglected to identify R2's lower leg swelling and / or monitor the swelling after it was found by the physician on 4/25/02.
Record reviewed indicated R2 was a 77 year old female who was admitted to the Hillier building from a group home per wheelchair at 1:45 PM on 4/22/02 with a diagnosis of Right Sided CVA (Cerebral Vascular Accident) per the nursing admission notes.
A nursing note dated 4/25/02 at 10:00 AM states R2 was seen by Z4 MD in the nursing office.
E2 said in interview on 5/23/02 at 10:30 AM in the nursing office that R2 was being seen as part of a routine admission physical exam. E2 said the physician does a thorough physical assessment. E2 verified the physician found the swelling as a result of the physical assessment / exam
The physician note of that day (4/25/02) states "seemed to have some problem with swallowing...does have delayed swallowing successful on the 2nd and 3rd attempt."
The physician note continues, "Venous Doppler right leg due to that I failed to mention that her right calf is much bigger than the left with 2+ pitting edema and a question of calf tenderness but negative Homan's sign "(a test for pain that is indicative of a thrombosis).
R2 had paralysis of the right side of her body due to the CVA.
Per phone interview with Z4 on 5/22/02 at 11:35 AM, he thought the nurse brought the leg swelling to his attention, but he was not sure.
Per record verification, there was no documentation of the leg swelling or difficulty swallowing prior to the physician visit.
E31 said in interview on 5/21/02 at 12:55 PM that she was not aware of the right leg swelling until the physician found it when he raised R2's lower pants leg to reveal a swollen right calf.
E31 (LPN) stated she had reported R2's difficulty swallowing to the physician because the direct care staff noted it at breakfast. There is no documentation regarding the difficulty swallowing or type of swallowing difficulty that was reported by the direct care staff.
E31 stated R2 required help with all of her ADL's due to her stroke and did not know why staff did not notice that the right leg was twice the size of the left leg.
Physician orders written at the 4/25/02 physician visit included orders for Venous Doppler to right leg; a substance to thicken liquids; TED knee high to right leg. R2 was started on anti-coagulant therapy (Levonox 30 mg sub Q every 12 hours) as a precaution until a venous Dopplar was done.
There is no evidence of further nursing monitoring or follow-up of R2's difficulty swallowing or R2's response to the thickened liquid.
There is no evidence of monitoring of the right leg swelling nor of the response of the swelling with the use of the TED hose.
There is no evidence of monitoring for side-effects of the anti-coagulation therapy following the physician's visit.
The only nursing entry is that the Foley catheter was D/C'd (4/25 at 10:30 AM) and staff reported "ate poorly for supper" (4/25 at 6 PM) and "drank fluids ref [refused] to eat" (4/25 at 10:00 PM).
R2 the next nursing note is written 11:30 AM on 4/26/02 "admitted to [hospital] with dx DVT [deep vein thrombosis]."
E31 and E2 verified there was no evidence of nursing monitoring and follow-up for the right leg swelling and difficulty swallowing.
R2 was admitted to the hospital on 4/26/02.
The hospital admission history and physical written by Z4 states R2 was admitted 4/26/02 when R2 was found to have swelling of right leg involving the right thigh and calf with obvious tenderness. The note continues, "apparently the problem has been going on for a few days."
The Venous Dopplar showed extensive deep venous thrombosis of the right leg from the common femoral vein to calf level.
While in the hospital, a lung scan showed "high probability for pulmonary emboli". R2 was admitted for treatment with IV and oral anti-coagulant therapy and discharged on 5/3/02.
b) Per record review, R2 was re-admitted back to Hillier unit on 5/3/02 at 11:50 AM. E31, LPN, was the admitting nurse.
There is no evidence a physical assessment was done upon re-admission. E2 said in interview on 5/23/02 that R2 was admitted about 2 hours before E31 was to go home and there may not have been time for a re-admission assessment before R2 went to the hospital about 7:30 PM and died.
There is no evidence the nurse closely monitored R2 after R2 returned from the hospital with a diagnosis of pulmonary emboli and had respiratory arrest at 5:45 PM. R2 continued to exhibit the symptoms of pulmonary emboli as written by the nurse on the special instruction sheet for R2's staff: "shortness of breath and Lethargy". The nurse neglected to contact the physician or obtain emergency services when R2 displayed the stated symptoms from about 6:15 PM until 7:30PM when she experienced respiratory and cardiac arrest and died.
Per E31 interview, another client was readmitted back to Hillier from the hospital within a half hour of R2. When R2's record was reviewed on 5/15/02, a copy of the other client's physician's orders were in R2's chart with R2's name on it. E31 said she noted the error on 5/3/02 and changed the client names on the original copy of the orders that go to the nursing office to be signed by the doctor. E31 said she did not change the client's name of the carbon copy (that stays in the chart until the original copy is signed by the doctor). The facility was not aware the of the wrong name on the orders until the surveyor brought it to their attention on 5/15/02. E3 said in an interview on 5/23/02 at the facility that the wrong client's orders were not in R2's record at the time of the internal review on 5/9/02.
R2's nursing notes indicate her vital signs and bowel sounds were documented. R2's respirations were documented as being even and non-labored. There is no evidence the lower extremities were assessed or lung sounds were assessed. The physician orders were noted and diagnosis including that of pulmonary emboli, UTI and DVT.
Z5 and E30 (QMRP) stated in interview that R2 was alert, verbal and requested to go to the bathroom several times prior to supper after readmission from the hospital. Z5 was assigned to R2 for the shift. Z5 said she asked a supervisor what R2's diagnosis was and was told she had a urinary tract infection. R2 asked for a shower, but Z5 was instructed by a supervisor to bathe R2 in the whirlpool tub. Z5 said when she tilted R2 back to a 40 degree angle to wash her hair, she stopped breathing and became unresponsive.
E11 also heard Z5 calling for help at about 5:45 PM. E11 said R2 was then pulled out of the tub and put into a wheelchair by Z5, E11 and E12. E12 called the nurse. Z5 said in interview that Z5 felt a faint irregular pulse on R2 before the nurse (E8) arrived. Per Z5, E8 told her that maybe R2 had not stopped breathing. She was not asked by E8
if she closed her eyes, became limp and unresponsive - all signs R2 exhibited at the time of the apnea per Z5.
Z5 asked if R2 was going to be "sent out" according to her written statement. E8 said it would not be necessary. Z5 said 2 nurses came for the emergency and both nurses (E7 and E8) tried several times to take R2's blood pressure.
Z5 said the tips of R2's fingers were purple, but there is no note of observed cyanosis in the nursing notes. E8, LPN, and E17, direct care staff went to Donnelley building to obtain an oxygen concentrator that had been used by another client. After the oxygen concentrator was brought to Hillier building, R2 was started on oxygen at 2 liters per minute per nursing note and interview with E6.
The physician (Z4) was not notified of the respiratory emergency and no order was obtained for R2 to continue on oxygen.
E7, LPN was the nursing supervisor for the evening and was the only nurse on the campus to have a pager. During interview on 5/16/02 at 3 PM, E7 said she was the evening supervisor for the campus on May 3. She was also was assigned as the nurse for Logan and Donnelley buildings. E7 said when she went to Hillier the "first time" at 5:45 PM, she saw R2 coming from the shower in a wheelchair.. E7 said she did not know a lot about R2's medical condition other than she had come back from the hospital. E7 said R2 had difficult respirations as evidenced by increased respirations, "kind of labored, kind of quick". E7 said she asked direct care staff what R2's diagnosis was. E7 said as far as she knew, R2 had pneumonia based on what the direct care staff said. E7 said she did not know if E8 knew R2's diagnosis of pulmonary emboli. E7 said she did not know if E8 called the physician or obtained an order for the oxygen.
E7 said if she would have known R2 had a diagnosis of pulmonary emboli, she would have sent her to the hospital as soon as there was a report of respiratory distress.
Per observation and interview with E7 and E8, all of the buildings have a brief written report that is sent to the nursing office for oncoming shifts to review. For 5-3-02, the report written by day shift for Hillier building said, "R2 - returned DVT, Pulmonary Emboli, VSS." The report for the evening shift for R2 said, "R2 - expired."
No other information for the report is noted regarding R2.
E7 said she reviews the information for her own 2 buildings and did not remember reading information for Hillier.
E7 said only the nursing supervisor has a pager and she carried the pager on 5/3/02 because she was the supervisor.
E7 said the next time after 5:45 PM she was paged, she was at Donnelley and was told "E8 said to get over here" (Hillier). The time was about 7:30 PM.
E7 said R2 was in a tilt wheelchair, R2's mouth was gaping open, her color was ashen and she was not breathing. E7 said direct care staff were pumping the Ambu bag while the nurse (E8) held the face mask in place. E7 said when she asked if 911 had been called, staff said they had been called.
The time of the emergency services call was documented as 7:31 PM with arrival time as 7:33 PM. The pupils were fixed and dilated per the ambulance record.
E5 and E6 reported nursing neglect when E8 failed to assess and/or obtain emergency services for R2 when her physical condition deteriorated.
The nursing note written by E8 at 5:45 PM states she (E8) was called to the building per staff. The note said the staff reported respiratory distress and did not indicate the staff reported there was a period when R2 stopped breathing, became lethargic and unresponsive.
E12 said when she saw R2 in the tub, she was "sort of gasping" and was pale. E12 then called the nurse.
E11 said R2 was "puffing in the side of her cheek" when breathing. E11 said R2 was responding when she saw her after the period of apnea but R2 had a "horrible grey" color.
E12 and Z5 were told by E8, LPN, to keep R2 upright and to closely monitor her. No specific instructions were given as to what to monitor for. No direct care staff, supervisor (Non-nursing) or QMRP interviewed knew what a pulmonary emboli was. E8 said she told the staff to keep R2 up and in the activity room and to "keep an eye on her".
When asked in interview (5/21/02 at 2:15 PM) what R2's diagnosis was, E8 said R2 was "sent home with a deep vein thrombosis". E8 did not mention pulmonary emboli. E8 said she did not call the physician because she thought R2's condition was stable. E8 said she was not aware there was emergency oxygen in the building and did not know there was no standing order for oxygen.
Z5 said that R2 began to deteriorate about 6:15 PM even with the oxygen on. R2 became more lethargic and less responsive. Her eyes were closed and she would not respond to her name, according to Z5. Z5 documented in the event log at "6:15 PM called zero to called Hillier. 6:25 called zero to ask nurse to call Hillier because she [R2] was not really responding."
E5 sat with R2 in D hall activity room from 6:15 until the time of R2's respiratory and cardiac arrest about 7:30 PM. E5 said the nurse never came into the activity room again to check on R2 until she slumped in her chair and stopped breathing about 7:30 PM.
E5 said in interview on 5/16/02 at 5 PM that she was very worried about R2's condition. Per E5, "anyone who came by [D Hall activity room] I asked to call the nurse. " E5 said she asked E11, E15, Z5. The staff said they called the switchboard.
E6 stated she saw E8 at the nurses station about 6:30 PM with another staff all in white with shoulder length dark hair. "When I returned to D Activity room, they [staff] said they had tried to get the nurse. I said she is at the desk. I went to get her, but she was gone." E5 said the nurse did not check R2 while she was at the desk.
E10 (direct care) said in interview on 5/15/02 at 12:55 PM that she saw R2 about 6:15 PM when she returned to the building from an outing with clients. E10 said R2 had her head back, was not responding or talking and was "out of it".
When E10 saw E8 at a campus dance about 6:20, E10 told E8 that R2 was not responding and she should go to Hillier. E10 said E8 told her she was on break and would go when her break was over. While E10 was returning van keys and receipts to the switchboard following interaction with E8, she heard E14 (direct care)call the switchboard to ask E9 to page E8. Per E10, E9 "paged E8 twice while E10 was at the switchboard area and asked "why do they keep paging her" E10 said she told him [E9] there was an emergency at Hillier.
E10 said in interview when she returned to Hillier (she thought about 6:55 PM) E8 was "hot and slapped her hand on the desk and yelled, "why are you calling me?"
E13 reported hearing E8 yell who the h--- keeps calling me? E13 did not hear what staff responded per interview 5/20/02 at 4:40 PM.
Per interview on 5/15/02 at 1:20 PM, E14 reported calling the switchboard to call E8 because it was an emergency. E14 said R2 was "getting worse as time went by "and was told by Z5 that R2 "was scaring her [Z5]".
While E14 had a client in the bathroom, she heard E8 yell who keeps paging me. E14 called out of the bathroom that it was for R2, but according to E14, the nurse must not have heard her and left the building.
E15 said in interview on 5/20/02 at 4:45 PM that E8 and another nurse were sitting behind the nurses desk at Hillier about 6:30 PM. E15 said E8 asked her who "paged" her. E8 said she did not know but it may have been for a client who had fallen earlier on an outing. E5 told her R2 is still not breathing right and asked if the nurse had come. E5 was staying with R2 in D Activity room and told E15 the nurse never came in and asked E15 to page the nurse. E15 said E10 paged the nurse. The direct care staff and supervisors(non-nursing) interviewed thought all nurses carried a pager, therefore kept referring to the fact that they paged the nurse. The staff thought that by calling the switchboard, the building nurse (E8) was being paged.
E8 said she was not made aware of further respiratory distress or increased lethargy of R2 prior to 7:30 PM. E8 said no staff talked to her about R2 while she was at the dance and did not ask who keeps paging me. E8 said she could not have been "paged" because she was not carrying the pager. E8 said she tells the supervisor of a building where she will be when she leaves a building. The supervisor (non-nursing) was on supper break at the time (from 6:30 - 7:15 PM) staff were trying to reach the nurse by calling the switchboard and other buildings.
E7 said in interview on 5/16/02 that she was the only nurse (of 5 nurses working on the evening shift) who had a pager. When asked how the nurse is informed of medical needs in buildings, E7 said she is a supervisor and carries a pager when she works. The buildings call the switchboard and the switchboard pages her. The page always shows the extension number to indicate the building, but does not always indicate an emergency. E7 said she would then call the building. If an emergency is indicated, E7 said she would go immediately to the building. E7 said she may not know about individuals of buildings she is not assigned to. E7 said she is responsible for supervision of the entire campus of 264 clients plus 2 buildings assigned to her for the shift.
E7 said she knows the 2 buildings assigned to each of the other nurses and would call the other buildings or the nursing office to find the nurses. E7 said there was no quick way to locate the nurse assigned to specific buildings.
E7 said the night nurse has a pager since she is the only nurse for the campus. This was verified by interview with E2 on 5/23/02. E2 said the facility only needed 1 nurse for the 10 buildings for the night shift. E2 said the situation has never arisen where there were 2 nursing emergencies at the same time. The full time nurse is an LPN.
E8 said in 5/21/02 interview that she went in D Hall activity room at 6:30 PM and assessed R2. She was not aware what staff could have seen her assess R2 at 6:30 PM and did not know why staff stated she was not seen in the activity room prior to 7:30 PM.
E8 documented in nursing notes of 5/3/02: "6:30 PM returned to building, client continued onO2 / 2L/NC [nasal canula] with no respiratory distress noted. R [respirations] 24 to 28."
E8 said she did not get the impression any staff were concerned about R2's health.
E8 said in interview, R2's respirations were rapid, but she did not interpret this as respiratory distress at 6:30 PM.
E16 said in interview on 5/20/02 at 3:40 PM that he was called to the D activity room by the OJT staff (E5 and E6) right as E12 returned from her break (about 7:15 PM). The OJT (on the job training) staff asked if they should call 911. E16 said R2 "looked bad". Her face was blue or purple. E16 said they should wait because the supervisor E12 was just coming from her break. E16 said the nurse was not at Hillier yet but E12 came to the building and took action to get the nurse and call 911.
Per interview, E14 said R2 just slumped over. Per E14, the nurse came about 5 minutes "before she [R2] died. She observed the nurse patting her cheek, calling her name and trying to get her to respond. E14 stated she did not see R2 breathing but E8 did no rescue breathing before the Ambu bag was obtained from Stahl building.
E5 stated in 5/16/02 interview that while she sat with R2 from about 6:15 PM, R2 had labored breathing. E5 described the breathing as breathing rapidly through her mouth like she was trying to catch her breath. R2's shoulders were described as moving up and down when breathing. E5 said R2's color was very pale and her hands were very cold to touch.
E5 said the nurse did not come to the living unit until E5 called out to call 911.
Per interview E8 was called at Stahl building after a staff from Hillier saw her going to Stahl building.
E8 then came to Hillier.
E8 said in interview of 5/21/02 that when she came to Hillier on 5/3/02 at 7:30 PM, R2's "head was back - she was in the wheelchair. She was not responding at that time. I called staff to call E7 and 911. I was rubbing R2's arm and talking to her trying to get her to respond. Her color was ashen - respirations were 10 and shallow."
Per interview, E5 said R2 slumped to the right side and quit breathing. E5 said when R2 quit breathing, E5 leaned R2 back in the wheelchair and rubbed her chest. E5 said E8 did not start rescue breathing until staff brought an Ambu bag from Stahl building.
Interview with E6 indicated E8 patted her cheek and called R2's name after she collapsed.
E11 said R2 slumped back, sat up and slumped to the right side. The right side of her face was slumped down and she was drooling. E11 did not think R2 was breathing. E11 said she again called the switchboard about 7:30 PM to get E8 to come to the building. When E8 came to the building and saw R2, according to E11, E8 yelled for someone to call Donnelley to get the nurse.
The emergency medical services were called, according to the ambulance log, at 7:31 PM and arrived at 7:33 PM The ambulance log showed no blood pressure, a carotid pulse of 46 and respirations "24 bagged" at time of arrival. The ambulance notes said R2 was sitting in the wheel-chair being "bagged" by staff. R2 was moved to the floor and had cardiac arrest. The diagnosis on the ambulance record said DVT (deep vein thrombosis) and made no mention of pulmonary emboli.
The "chief complaint" on the ambulance record states "cardiac arrest". When asked why the staff did not call 911 when the nurse did not respond to calls and pages, the following staff said they learned in training classes that they should call the nurse and the nurse would determine if 911 should be called: E5, E6 (only life threatening situations), E10, E11, E12, E14, E27, E28. The staff said in interviews that they were trained in the hab tech class to call 911 only if life was threatened (as taught in CPR training for cardiac arrest), but not for serious medical problems or lack of nursing response.
All staff said after R2 died, they were told they could call 911 directly and did not have to go through the switchboard or wait for a nurse.
R2 was transported to the emergency room and according to the nursing notes at 8:25 PM, the hospital said R2 expired.
The facility neglected to ensure there was adequate information given to direct care staff as to how to monitor R2 with a serious medical condition of pulmonary emboli and deep vein thrombosis.
The facility neglected to ensure the nurse responded in a timely manner to requests to evaluate R2 when she had respiratory distress and lethargy.
The facility neglected to ensure there was thorough nursing assessment and monitoring for serious health needs of R2's pulmonary emboli following respiratory arrest at 5:45 PM.
The facility neglected to ensure policies and procedures were in place to ensure medical equipment was available and staff were trained in emergency procedures.
The facility neglected to ensure physicians were notified of clients change of condition when R2 had respiratory distress following hospitalization for deep vein thrombosis and pulmonary emboli.
The facility neglected to ensure staff called emergency services when nursing failed to respond to staff requests to come to the building for R2's deteriorating physical condition.
The facility neglected to ensure there was a way to immediately contact the nurse assigned to their building since only 1 nurse per campus carries a beeper and other nurses must be contacted via phone calls to switchboard or buildings. Not all staff know how or where to contact the nurse for their building.
3) There is no documented evidence nursing staff provided an ongoing physical assessment for R4 on 5/19/02 prior to his admission to the hospital on 5/19/02. R4 died in the hospital on 5/20/02.
R4 was a 44 year old ambulatory male with limited communication skills who had a diagnosis of Down's Syndrome, Seizure Disorder and who functioned in the Profound Range of Mental Retardation.
Review of R4's current physician order sheet revealed that R4 was on the following medications: Levothroid 100mcg 1 tablet daily; Multivitamins 1 tablet daily; Guaifenesin PSE 600-120mg 1 tablet twice daily; Lamictal 25mg 2 tablets at 8AM and 12 noon and 1 tablet at 4PM and HS; Dilantin 100mg 1 cap at 8AM, 4PM and HS, omit 4pm dose every other day; Calcium Carbonate 10gr 1 tablet twice a day; Tegretol XR 400mg 1 tablet twice a day; Vitamin B-12 injection 1000mcg/cc - to receive 1cc every month; and Robitussin DM 10cc P.0. every 4-6 hours prn.
E53 (LPN) was interviewed on 5/28/02 at approximately 9:07AM in the dining room in the Herring building. E53 stated that she was the nurse for Evans, Laventhal and the Herring building on 5/19/02. E53 stated that when she went to the Herring building between 6:15AM - 6:30AM she was informed by E54 that R4 had an axillary temperature (AX) of 101.5 and that he did not feel good. E53 went on to say that she went into the main TV room to look at R4 and he appeared
to be congested. E53 stated that she placed a call to Z12 but Z13 returned the phone call as he was on call for Z12 for that weekend. E53 states that she told Z13 that R4 had an elevated temperature of 101.5 (AX) and that he was very congested with labored breathing. Z13 gave the following orders: Levoquin 500mg every day times 10 days, Tylenol 325mg 2 tabs for elevated temperature and Robitussin DM 2 teaspoons every 3 - 4 hours prn. E53 stated that she asked Z13 specifically if she could send R4 to the hospital for an evaluation and Z13 stated that he felt that R4 could be treated at home. Review of the nurses notes for 5/19/02 revealed that E53 made the following entry: 6:30AM temperature 101.5(AX) - Tylenol tabs 2 given, very congested - labored breathing. Z12 called, Z13 returned call with new orders for Levoquin 500mg every day, Tylenol for elevated temperature and Robitussin DM 2 teaspoons prn for cough.
Surveyor asked E53 if she did a complete assessment of R4's physical condition at 6:30AM. Surveyor asked E53 if she took a full set of vital signs i.e. Blood Pressure, Pulse, Respirations, assess his lungs per stethoscope, check for edema, assess his level of consciousness, hydration and color. E53 stated that she visually assessed him but did not actually listen to his lungs or take any vital signs. She stated that after she received the physician orders she left Herring building so she could pass her am medications on Evans and Laventhal. Surveyor then asked E53 when she saw R4 again and E53 thought it was around 9:30AM. Stated he was laying in a cradle type chair in the main living room and felt that he was doing okay, although direct care staff had told her that he did not eat breakfast but had taken some liquids. Surveyor asked if she assessed him at that time and she said that she checked his pulse which was 80 and regular. Surveyor then asked if she documented anywhere in R4's record what R4's physical condition was and if his temperature had come down since she gave the Tylenol approximately 3 hours earlier and she said, "No". According to the nurses notes for 5/19/02, the next entry made by E53 was not until 11AM when she writes that the Levoquin was started and R4's axillary temperature is 98.8 and Tylenol given. According to the nurses notes and confirmed per interview with E53 on 5/28/02, E53 never did take a full set of vital signs, listen to R4's lungs per stethoscope or check for edema during her entire shift which was 6AM to 2PM. There is no evidence to support that she monitored his level of consciousness, his overall color or if he had a cough since the physician had ordered Robitussin for cough. Record verification revealed that R4 had a history of getting pneumonia as he was admitted to the hospital on 11/05/01 and diagnosed with pneumonia. There is no evidence to support that E53 was closely monitoring and assessing R4's physical condition on a regular on-going basis as there are only 2 entries made in the nurses notes for her entire shift. The first entry was at 6:30AM and the 2nd entry was at 11:00AM
Surveyor interviewed E2 (DON) on 5/28/02 at approximately 2PM in the nurses building. E2 stated that the assessment done by E53 on R4 was poor as it should have been more in depth and she would expect an entry in the nurses notes to be made at least every 2-3 hours and should have at least included vital signs, assessment of his lungs and his color. E2 stated that R4's temperature should have been taken approximately 2 hours after he received the initial Tylenol
to see if it was effective or not.
Phone interview with Z13 on 5/28/02 at approximately 3:10PM confirmed that he was notified per E53 on 5/19/02 and was told that R4 had a temperature and was congested. Stated that he felt that he had an upper respiratory infection and felt that he could be treated at home with oral antibiotics. Z13 went on to say that he is pretty sure that E53 told him that R4 had had pneumonia in the past but he still thought that he did not need to go to the hospital at that time.
Review of the nurses notes on 5/19/02 revealed that at 2:20PM, E57 was called to evaluate R4. E57 writes the following entry: R4 lying flat on mat. Respirations very congested and labored at approximately 28 -30 per minute. Temperature 100.0 (AX). Unable to palpate or auscultate blood pressure. Radial pulse very faint and thready - unable to count. Unable to hear apical pulse due to much congestion. Breath sounds coarse throughout but worse on left. Staff assisted position R4 in recliner. Still unable to count pulse due to very faint. Oral mucous membranes extremely dry. Color pale. Skin warm/dry. Alert but lethargic. Z13 was notified and orders received to transport R4 to emergency room for evaluation.
R4 was seen in the emergency room and admitted to the hospital on 5/19/02. Chest x-ray was done and it showed that R4 had minimal bilateral interstitial infiltrates and possible more focal mild right basilar infiltrate. R4 expired at 8:15PM on 5/20/02. According to the death certificate, the cause of death was Pneumonia.
Based on interview, record review and review of staff training, the facility failed to ensure direct care staff received training in monitoring specific health needs of clients including, but not limited to, training in detecting signs and symptoms of illness or dysfunction and skills for emergency health needs for 1 of 1 in the incident investigation (R2 who had swelling of a leg that went undetected by staff and had signs of pulmonary emboli that staff were not trained to recognize prior to her death) with the potential to affect 264 of 264 clients at the facility.
The facility failed to train direct care staff in skills needed to monitor for signs for Deep Vein Thrombosis (DVT) and Pulmonary Emboli (PE).
R2 was a 77 year old female who was admitted from a group home to the facility on 4/22/02 with a diagnosis that included CVA (Cerebral Vascular Accident). R2 was paralyzed on the right side.
R2 required staff assistance with all bathing, grooming, dressing and transfers due to her paralysis. There is no mention of R2 having swelling in her right leg prior to a physician routine admission physical exam. At the exam, the physician discovered that the right leg was swollen and had 2+ pitting edema. R2 was hospitalized on 4/26/02 after extensive thrombosis (blood clots) were noted from her femoral vein to her calf level.
The physician's admission (to hospital) physical stated the swelling had been present for several days. E8 stated in interview on 5/21/02 that R2 needed assistance with all her ADL's and E8 did not know why the swelling was not noted or reported to her when she worked the evening of April 23 or 24, 2002, when E8 wrote a nursing note. There is no evidence E8 assessed for edema but documented the urine was very concentrated.
There is no evidence direct care staff were trained in monitoring the possible blood clot after the physician made the observation.
There is no evidence the direct care staff were trained to monitor for side effects after the physician began anti- coagulation therapy for R2 on 4/25/02.
Nursing notes make no mention of staff training or nursing monitoring of R2's symptoms of DVT and response to treatment (TED hose and anticoagulation therapy).
The physician also noted on 4/25/02, according to the dictated note, that R2 had difficulty swallowing, "does have delayed swallowing successful on the 2nd and 3rd attempt." Thickened liquids were ordered. Nursing documentation does not reflect staff were trained on monitoring for difficulty swallowing which could result in aspiration. The note does not reflect response to the thickened liquid. There is no evidence direct care staff were trained to detect signs and symptoms of her swallowing dysfunction.
R2 returned from the hospital on 5/3/02 at 11:50 AM according to the nursing notes. Her re-admission diagnosis included DVT, UTI (Urinary Tract Infection), and Pulmonary Emboli according to the nursing notes.
No direct care staff, QMRP, or non-nursing supervisory staff interviewed knew what a pulmonary emboli was.
E8 said in interview on 5/21/02 that she doubted if direct care staff would know what a pulmonary emboli was (a blood clot that has moved to a blood vessel in the lung).
E31 said in an interview on 5/21/02 at 12:45 PM in the conference room that she was the nurse who re-admitted R2 on 5/3/02 from the hospital. She said she completed a "special instruction sheet" for R2. The label of the sheet states, "special instruction sheet for clients returning from hospital. The reason for the instructions is identified as "post- hospital".
The special instructions written are as follows: "Returned from hospital treated for blood clot. New orders TED hose to thigh high both legs. Needs encouraging to eat and take meds. Recent stroke right side. Support right side during transfers and care. Watch for signs of pulmonary emboli - 1) shortness of breath; 2) Lethargic; 3) signs of bleeding -R/T blood thinned medicine. Also on Antibiotic for urinary tract infection."
E31 said the staff were told to read the instructions and ask her if there were questions. E31 said she could not remember to whom the instructions were given. E8 said the special instructions are given to the non-nursing supervisor or QMRP (a non-nursing person) and the supervisor is to give the special instructions to the direct care staff.
During interview on 5/20/02 at 11:55 AM, E30, QMRP for R2, said E31 wrote up special instructions for R2 on 5/3/02 and put them on the nurses station desk for the direct care staff to sign. E30 said E31 talked to him about another client who was re-admitted from the hospital about the same time. The nurse (E31) talked to E30 about R2's constipation and blood that was seen on her mouth and teeth because "she bit her tongue at the hospital". E30 was told R2 was on blood thinner but did not remember specific instructions.
E30 did not know what a pulmonary emboli was. E30 said the special instruction sheet is left on the desk and as staff read the instructions, they are to sign the paper.
The paper had the signatures of 11 staff for the day and evening shift. There was no system to ensure all staff read and understood the instructions. E11 and E16 had not signed the paper.
Nursing staff did not train the staff on the symptoms of the UTI, DVT and PE.
When R2 exhibited the symptoms described as those of pulmonary emboli, direct care staff did not know the life- threatening significance because the supervisory or direct staff did not know what a pulmonary emboli was.
There is no evidence a system is in place to ensure nursing services train direct care staff how to implement the special instructions.
When R2 had a period of respiratory distress as described by Z5 as "not breathing" about 5:45 PM on 5/3/02, E8 told direct care staff to "keep her up in the activity room and keep an eye on her". E8 did not elaborate or train staff what they were to watch for.
E11 said in interview on 5/20/02 at 1:10 PM that she received "no special instructions in caring for her (R2). Not one bit." E11 said non-nursing staff tell the direct care staff what to watch for with clients and the nurses do not tell the direct care staff anything.
Direct care and supervisory staff were taught to call the nurse before calling 911 for medical emergencies. The direct care staff were told to only call 911 if there was a life threatening emergency.
The staff said this was taught by E28 in the hab tech training class.
E28 was interviewed on 5/16/02 at 11:30 AM in the conference room. She said she never told staff to call the nurse first if a client is in cardiac arrest and told them to call 911 if there were a life-threatening situation. When asked how direct care staff were trained to detect what a life-threatening situation may be, E18 said they received training in the hab tech class about medical emergencies. E18 said the medical aspect of the training class was taught by E22, a non- medical QMRP. E18 said he teaches basic signs and symptoms of seizures, etc.
Direct care staff were not trained in skills needed to care for clients with special health needs.