| SHERIDAN SHORES CARE & REHAB CENTER Facility I.D. Number 0040444 Date of Survey:10/11/01 Notice of Violation:02/05/02 Incident investigation "A" VIOLATION(S): 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. AN OWNER, LICESNSEE, ADMINISTRATOR EMPLOYEE OR AGENT OF FACILITY SHALL NOT NEGLECT A RESIDENT. (Sections 2-107 of the Act) This REQUIREMENT is not met as evidenced by: Based on staff, family, physician interviews, record reviews and facility’s policy and procedure reviews, the facility failed to ensure that R#1 received the necessary care and services in the areas of monitoring swallowing difficulties, giving assistance with eating, handling aspiration emergencies, and guaranteeing timely physician services. Findings include: E#7, E#3 and E#4 did not follow the facility's policy and procedures for Emergency Care Services by nursing, and Physician Services for New admissions and Change of condition. Facility failed to obtain physician orders and monitor R1 after an initial choking episode on 9/1/01 and then failed to properly perform CPR and Heimlich on another episode on 9/4/01 which resulted in the resident's death. There was no evidence that this resident had been seen by the physician during the resident stay in the nursing home from 8/27/01 until death on 9/4/01. R#1 was initially admitted on 8/27/2001 from the hospital after two falls at home. R#1 had Parkinson's disease and needed assistance with his ADL's (Activities of Daily Life) and Specialized Rehab services. He was in a Medicare bed. R#1 was never seen by his attending doctor from the 8/27/2001 admission to 09/04/2001; a total of 9 days. All orders were telephone orders by Z-13 or Z-12 or Z-14 who were on call for Z-13. R#1's 5 day Medicare MDS (Minimum Data Set) of 8/31/2001 assesses him as having K.b=Swallowing problem, K.5.c. Mechanically altered diet, L.c.Does not have or does not use dentures." Record review and 10/03/01 interview of E#6 revealed that on Saturday, 09/01/2001, during supper, about 5:40 p.m. "R#1 was sitting in bed, feeding himself-choking. I told him to cough it out. I ran out and got the suction machine, in the treatment room. I called the CNA. I tried to suction him. I suctioned some food-mechanical soft- and fluid. When I couldn't get everything out I asked the CNA to call Code Blue and get the crash cart. E#8 and other nurses came. No CPR, we gave Oxygen through the Ambu bag. I took his dentures out. He was not verbally responsive, but not unconscious. He came around. I called Z-13 and got Z-12, on call for Z-13. He said to "monitor the resident." He asked the status and vital signs and response of the resident. R#1 stabilized and was talking, and was on Oxygen @ 6L for 1-2 hours." Facility took no further actions to monitor this resident during meals, contact the physician to possibly change the diet or get swallowing evaluation after this episode. A Speech Therapy Screening was done 9/01/01 with a Recommendation; x (Need) Physician's order to evaluate and treat." This order was not called and written until 10a.m. on 9/04/01 by E#4 and Z-14. R#1's son came to take him home for the Labor Day weekend pass, from 8:00p.m. on Saturday 9/01/01 to Monday evening, 9/03/01, at 7:00p.m. Interview with R#1's son revealed he knew how to feed his father. He gave him small teaspoons of food at a time and small amounts of liquids at a time. E#6 had told him of the choking/aspiration Code Blue incident at supper. R#1's son said he had no problem with choking during R#1's pass and that he fed him small amounts at a time. The IRI (Incident Report Investigation) of 09/04/2001 of R#1 revealed that R#1 had another coughing and aspiration event during lunch on 9/4/01, about 12:05 p.m. and was brought to the hospital emergency room by ambulance, where at 12:40p.m. R1 was pronounced DOA (Dead on Arrival).The report documents his son was notified at 1:05p.m. The Chicago Police Report by Z- 3 at the hospital revealed a call to the facility. E#2 "Nursing Supervisor related to Z3 that victim just finished eating went to his room and a short time later they checked on him and found him unresponsive." Interviews with E#7, E#3 and E#4 were done on 10/03/01 and revealed a different report. E#7's interview revealed, "I took him to the T.V. room/Main Dining Room. He was talking. I tried to feed him. He said he didn't want what we had...refusing the food, didn't want the coffee- wouldn't open his mouth. He wanted the milk and lemonade. I gave him some sips with the straw, but he preferred the lemonade, but he couldn’t tolerate it. He would cough. I gave him fruit cocktail. He was having trouble swallowing it. I tried to give him more lemonade. He was holding his head up and back. He didn't put his hands up. I got the nurse and she was asking him if he was okay. He didn't talk. We took him to his room. He was getting pale. We placed him in the bed, he coughed and nothing came up and I left. About 5-10 minutes later, E#4 called me and said to call "Code Blue" and then I got the crash cart. Per E#1 and E#2, E#3 was working as an RN/LP and E#3 was on orientation with E#4 on 9/04/01 as a nurse. Interview with E#4 revealed that "It was endorsed on the 24 hour report that R#1 needed a speech/swallowing evaluation. I called Z#14, on call for Z#13, for an order." E#3 and E#4 were called by "E#7 to the dining room. He started having coughing episodes. He was still awake, his eyes open, he got stiff, his eyeball began rolling back in his head. E#3 and I put him in bed "The resident's room was Room 206 which is on the other side of the floor from the dining room and required staff move this impaired resident down three hallways. The staff then had to obtain a crash cart also down another hallway from the resident's room. E4 stated " I suctioned him, yellow and white secretions. He had no vital signs. I called E#7 to get the crash cart. I called Code Blue and 911." E#3's interview revealed that, "E#7 said that R#1 was coughing. E#4 and I came from lunch, we were on the other side. R#1 was gurgling. He wasn't talking. His color is okay. We brought him to his bed to suction him. His color was pale. I couldn't get his vital signs. The suction machine was at his bedside. After E#7 left he was coughing and not talking. He talked earlier in the day. CPR? Not yet. No. E#4 didn't do the Heimlich maneuver...finger sweep?, No. E#4 called E#7 to get the crash cart . We started CPR after we got the crash cart and the bag. I started the ambu bag and E#4 started the chest compressions. I'm not certified here. I was certified in the Philippines. I came here in March, 2001. Copy of my CPR? I'm afraid not." From the above interviews, facility staff failed to do a Heimlich when evidence suggested that this resident had become symptomatic while eating and had previously documented swallowing difficulties noted. Further, staff attempted CPR without verifying that a clear airway was present. The staff failed to immediately assess for a clear airway in the dining room before transferring this resident to his room. The son of R1 was upset that he learned of his father's death on his answering machine on 9/4/01 after returning from class. Z 15 was interviewed on 10/10/01 and stated that "they called me from the emergency room (on 9/4/01) and I refused to sign the death certificate. This guy was OK the last time I saw him. The Parkinson disease was attacking him physically. It sounds like the cause of death was aspiration. The first thing they did wrong was to continue to feed him. Then, they should have never put him down in bed to suction. Sitting up is best. Have him sit forward, lean forward or a blow to the back may help." |