Oak Park Healthcare Center Facility I.D. Number 044602 Date of Survey: 01/17/02 Complaint Investigation "A" VIOLATION(S): The advisory physician or medical advisory committee shall develop policies and procedures to be followed during the various medical emergencies that occur from time to time in long-term care facilities. These medical emergencies include, but are not limited to, such things as: Other medical emergencies (for example, convulsions and shock). There shall be at least one staff person on duty at all times who has been properly trained to handle the medical emergencies listed in subsection (a) of this Section. This staff person may also be counted in fulfilling the requirement of subsection (d) of the Section, if the staff person meets the specified certification requirements. 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. 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. Objective observations of changes in a resident’s condition, including mental and emotional changes, as a means for analyzing and determining care required and the need for further medical evaluation and treatment shall be made by nursing staff and recorded in the resident’s medical record. AN OWNER, LICENSEE, ADMINISTRATOR, EMPLOYEE OR AGENT OF A FACILITY SHALL NOT ABUSE OR NEGLECT A RESIDENT. Based on Interviews with Z1, Z2, Z3, E2, E5 and record review of nursing home and hospital records, as well as paramedic transport records, the facility failed to provide timely assessment and emergency care to one resident suffering with grand mal seizures from 3:55a.m. until abated by paramedics at 5:10a.m. on 1/11/02. Resident was not transported to a hospital until 5:40a.m. for care and evaluation. Facility failed to recognize that emergency services were needed in a timely manner when seizure 300.1030a)5)activity did not stop and respond to 02. Seizures did not stop until paramedics administered Versed IM at 5:10a.m--1 hour and 15 minutes after symptoms started. Findings include: R2 with known history of seizure activity had previously low Dilantin levels, on 12/10/01 the level was 0.4mcg/ml and on 12/20/01 the level was 1.3 mcg/ml. Normal levels are 10-20 mcg/ml (micgrogram/milileter). Per interview with Z3, the facility had made Z3 aware of the levels and he had ordered Neurontin and observation to check if R2 was med compliant. R2 has care plans to monitor for seizures; medication administration; to monitor labs and to notify MD (medical doctor) of abnormal levels; to establish airway and loosen clothing, observe and record progression of a convulsion and to monitor the time, intensity and duration of a convulsion. There was no documentation or interview indicating that any of this was done. Computerized medical records from the facility dated 01/11/02 at 7:17a.m, after R2 had already been transferred to the hospital, stated that R2 had episode of seizures at 4:00a.m. and M.D. ordered transfer to hospital, but was refused and R2 was diverted to another hospital. Surveyor interviewed Z1, Z2, and E2, who denied that R2 was diverted from one hospital to another. There was no evidence that R2 was observed or positioned to maintain the airway as per care plan. And there was evidence that the facility failed to differentiate petit mal seizure activity from grand mal seizure activity that was identified by the emergency medical team upon arrival to the nursing home. Per interview, Z1 stated that on 01/11/02 at approximately 4:30a.m. at the hospital, he received a call from E5 stating that R2 has been having seizures since 3:55a.m. (35 minutes earlier)." I asked the nurse at the facility what had they done to stop the seizures. The nurse stated "nothing - we are still waiting on Superior ambulance. Z1 continued " I then asked the nurse if this resident was still seizing and he stated, yes. I told the nurse to call 911 since they are faster and they can stop the seizing". Per ambulance records, it was not until after E5 spoke with Z1 that E5 placed a call to the ambulance service --even though R2 was having continuous seizure activity since 3:55a.m. Per interview with Z2, the facility had placed 02 at 2 liters on R2 and taken minimum vital signs and nothing else had been done. When Z2 arrived in the room at 4:50a.m., R2 was having grand mal seizures and was left unattended. Z2 told Surveyor that E5 told Z2 that R2 was having petit mals but upon observation, R2 was having tonic/clonic movements indicating severe grand mal seizures. Z2 also felt that R2 was febrile because R2 felt extremely hot. Facility had not obtained any temperature readings from R2 during this time. Z2 responded to the emergency by giving Versed IM, increasing 02 to 4 liters, and applying ice packs to both axillas. Z2 left the facility at 5:40a.m. after stopping the seizures around 5:10a.m. The run time record indicates that the resident arrived at the hospital at 5:45 a.m. Surveyor interviewed E5 on 1/16/02 at approximately 2:40p.m. E5 denied he had waited until 4:41a.m to call the ambulance and stated that he called 5 minutes after seizures started for R2 at 4:00a.m. E5 stated that he administered 02 and never left the room. This conflicts with the interviews with Z1 and Z2 and the run sheet for the ambulance company which clearly states that ambulance was called at 4:41a.m. not 4:00a.m. E5 admitted to talking to Z1 but at 4:00a.m. instead of 4:30a.m. This is also contradicted in hospital record review which lists the time of call clearly at 4:30 to 4:40a.m. Surveyor requested all nursing notes related to incident - all notes that were available were received and read. The nursing notes received concerning the incident is the 01/11/02 at 7:17a.m entry. Interview with E7 on 01/17/02 at the facility on speaker phone with E1 present , E7 stated that R2 was found unresponsive and with white of eyes showing at 3:55a.m. on 01/11/02. E7 continued "I called E5, who came in and checked her and gave her oxygen." E7 continued, "I continued to make my rounds on the floor, but I kept going back to check on her. I went back at 4:00a.m., and noticed her jerking, her whole body was jerking, and she was foaming at the mouth. I got E5 again and he checked on her, took her vital signs and then left the room to call her doctor. I left the room to see where E5 was. We both left the room!" |