Facility I.D. Number 0005439
Date of Survey: 01/25/02
Annual and Complaint Investigation
The facility shall notify the Department of any incident or accident which has, or is likely to have, a significant effect on the health, safety, or welfare of a resident or residents. Incidents and accidents requiring the services of a physician, hospital, police or fire department, coroner, or other service provider on an emergency basis shall be reported to the Department.
The facility must provide the necessary care and service to attain or maintain the highest practicable physical, mental, and psychosocial well-being of the resident, in accordance with each residents comprehensive assessment and plan of care. 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 necessary precautions shall be taken to assure that the residents 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.
AN OWNER, LICENSEE, ADMINISTRATOR, EMPLOYEE OF A FACILITY SHALL NOT ABUSE OR NEGLECT A RESIDENT.
Based on interview and record review the facility failed to give appropriate emergency care/services to a resident having respiratory problems.
1. On 10/09/01 at 6p.m., R4 was observed by E7 to be having difficulty breathing and coughing. E7 attempted to suction resident unsuccessfully with a bulb syringe and then did a mouth sweep and obtained food. E7 stated R4 seemed to "pass out" and stopped breathing and had no pulse. E7 called for help and CPR (Cardio-Pulmonary Resuscitation) was started. No Heimlich Maneuver was done on R4.
Fire Department Paramedics arrived at approximately 6:13p.m. and attempted to intubate R4 but could not because of R4's mouth was (per report) "loaded with emesis". No patent airway could be established and R4 expired at the facility.
Interview with E8 on 1/17/02 revealed that the incident was not reported because "I did not believe this was an incident."
E2 stated on 1/04/02 that she did not feel it was an incident and had called and reported it to the family.
No incident report was found in the facility, and none was sent to the Department as required regarding R4.
Review of facility policy on "Preparing and Incident Report" states: "The Regional Office of IDPH shall be notified via facsimile transmittal within 24 hours of any incident requiring the emergency services of a physician, hospital, fire department, coroner or other service provider."
Based on interview, and record review the facility failed to give appropriate emergency care/services to a resident having respiratory problems. Facility also failed to have updated policy and procedures which would have given staff the appropriate information needed to act in an emergency. This negligence by 5 staff (E3, E4, E5, E6, E7) on the second floor of the facility led to the death of one resident (R4) on 10/09/01. There are approximately 50 residents residing on this skilled care floor.
1. E3 was interviewed on 1/4/02 regarding checking emergency equipment. E3 stated that he checked the equipment on 10/9 at 7:30a.m. and that the suction machine was working, although he did not plug it in to verify this. E3 stated that he only checks to make sure it is on the cart. He also checked to make sure the oxygen tank was full and put a check in the box on the checklist. Review of this sheet by surveyor showed checks in the respective boxes.
E1 in an interview on 1/4/02 stated that he took over maintenance of the suctioning machines as of December 2001. Prior to this date it was nursing responsibility to take care of the machines, and they are still responsible for the tubing and supplies.
Per interviews with E4, E5, Z5 and Z6, the suction equipment was not working on 10/9/01 at the time of the incident involving R4.
E4 stated E7 left her in the room alone with R4, and went to another floor on the elevator to get a different suction machine because the one in the room did not work.
Z4 and Z5 both stated that the second suction machine brought up to R4's room did not work either.
2. E4, E5, E6, and E7 all had current CPR (Cardio-Pulmonary Resuscitation) cards on file. E5 stated to surveyor the "I'm just not good at it" and called 911 instead of assisting. E4 stated that a back board was never used on R4 while staff attempted CPR. When Z6 arrived at R4's room, E6 was straddling the resident in bed performing CPR without a board. E7 stated that she couldn't initiate chest compressions because she is pregnant and believed that E6 started the CPR after she left the room "for something." E7 left E4 ( who is a CNA) alone in the room during an emergency and before she witnessed any staff starting CPR.
E7 attempted to suction R4 initially (prior to the CPR) with a bulb syringe and was unsuccessful. E6 attempted a mouth sweep of R4 and retrieved food particles out of the mouth. E4 stated that chest compressions were done, "we blew in her mouth", tilted her head back and pinched her nose shut, but no Heimlich Maneuver was ever done. E4 also stated "we did not know what was wrong."
E4 stated that the fire department did a mouth sweep of R4 and got out "chewed up meat." The fire department arrived at 6:13p.m. approximately 13 minutes after 911 was called. Nursing notes state that R4 was found in distress at 6p.m. Upon their arrival Z5 admitted that there were no facility staff in attendance working on R4.
3. E2 stated that the last inservice on emergency preparedness was held December 2001. No specific topics covered in this inservice was listed on the sign in sheet. Review of inservices for one year showed 4 separate inservices held on emergency preparedness and also CPR classes. There were no inservices done on feeding residents, residents with swallowing problems and aspiration precautions, or the Heimlich Maneuver.
4. Review of facility policy and procedure showed that these policies had no dates of implementation, or dates of revision. Th policies on emergency preparedness, Heimlich and CPR were not followed during the incident with R4 on 10/9/01.
The Heimlich policy states that the signs of choking are that the patient is "blue." E4 stated upon arrival to R4's room that she was "blue." CPR and Unconscious Choking policy states that if an airway cannot be established, abdominal thrusts should be performed.
At no time during the entire choking incident and acute emergency did the nursing home staff perform correct and timely Heimlich Maneuver on R4 by doing recommended abdominal thrusts during the incident. Facility staff did improper CPR with no established airway. Facility staff was aware that this incident occurred during mealtime thus, choking suspicion should have been their first assessment and establishing an airway their first priority.