The Cornerstone Home Facility I.D. Number: 0033837 Date of Survey: 3/12/03 Annual Survey "A" VIOLATION(S): The facility’s governing body shall exercise general direction of the facility, and shall establish the broad policies and procedures for the facility related to its purpose, objectives, operation, and the welfare of the residents served. 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 the staff, residents and the public. These written policies shall be followed in operating the facility and shall be reviewed at least annually. All personnel shall have either training or experience, or both, in the job assigned to them. Orientation and In-Service Training: All new employees, including student interns, shall complete an orientation program covering, at a minimum, the following: general facility and resident orientation; job orientation, emphasizing allowable duties of the new employee; resident safety, including fire and disaster, emergency care and basic resident safety, and; understanding and communicating with the type of residents being cared for in the facility. In addition, all new direct care staff, including student interns, shall complete an orientation program covering the facility’s policies and procedures for resident care services before being assigned to provide direct care to residents. This orientation program shall include information on the prevention and treatment of decubitus ulcers and the importance of nutrition in general health care. 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: Modification of the resident care plan, in terms of the resident’s daily needs, as needed. A registered nurse shall participate, as appropriate, in planning and implementing the training of facility personnel. Direct care personnel shall be trained in, but are not limited to, the following: 1) Detecting signs of illness, dysfunction or maladaptive behavior that warrant medical, nursing or psychosocial intervention. 2) Basic skills required to meet the health needs and problems of the residents. 3) First aid for accident or illness. Sufficient, appropriately qualified nursing staff shall be available, which may include licensed practical nurses and other supporting personnel, to carry out the various nursing service activities. Nursing service personnel at all levels of experience and competence shall be assigned responsibilities in accordance with their qualifications. Every facility shall respect the residents’ right to make decisions relating to their own medical treatment, including the right to accept, reject, or limit life-sustaining treatment. Every facility shall establish a policy concerning the implementation of such rights. Included within this policy shall be: procedures for providing life-sustaining treatments available to residents at the facility; Procedures detailing staff’s responsibility with respect to the provision of life-sustaining treatment when a resident has chosen to accept, reject, or limit life-sustaining treatment, or when a resident has failed or has not been given the opportunity to make these choices; procedures for educating both direct and indirect care staff in the application of those specific provisions of the policy for which they are responsible. 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. Based on interview and file verification, the facility failed to implement their written policies to prevent neglect when they did not protect one individual (R16) in the facility who was found in bed without a pulse or respiration, and with the potential to impact 15 other individuals (R#'s 1-15) who reside in this facility and do not have a DNR (Do Not Resuscitate) order, when the facility neglected to:
Findings include: 1. Per review of the current Physician's orders dated 1/03, R16 is a 73 year old female with a diagnosis of Hypertension and Angina Pectoris. Per review of a letter sent to the facility on 2/10/03, this letter from R16's attending physician states R16 had a history of Coronary Artery Disease, Degenerative Arthritis and some episodes of Congestive Heart Failure. This letter further states R16 was treated for Bronchitis with antibiotic therapy and an increase in diuretic medication on 2/6/03. Per review of an Investigative Summary dated 2/12/03, this summary states R16 functions in the severe range of mental retardation. The most current Nursing Health Review and Physical Assessment dated 2/5/03 states R16 was verbal, aware of environment, aware of familiar staff, displayed the ability to ask for help, and was calm. Per review of the Occupational Therapy Notes dated 12/30/02, a recommendation was made to place a motion detector and remote alarm on R16's bedroom door so that staff can hear R16's moves in the night from 75 feet away. Per review of a letter to be sent to R16's guardian dated 1/3/03, however, the fax date states that this letter was sent from this facility to the guardian on 1/24/03. This form is dated as signed by the guardian on 1/24/03 and faxed back to the facility. Per interview with E2 on 3/6/03 at 10:00 A.M., E2 stated that at the time of R16's death, the room monitoring device had not been obtained or initiated in the facility. E2 stated that the facility was waiting to receive a room monitor for R16's use. R2 further stated the monitor to be used was being sent from another facility in this corporation. E2 stated that a client who had resided at the other facility had recently expired, and the facility planned to use this monitor. E2 confirmed the facility had not yet obtained this device as of 2/8/03. Per review of R16's records, the Statement of Illinois Law on Advanced Directives form states: "...Do Not Resuscitate or (DNR) or "no code" orders are doctors' orders which tell nursing and hospital staff that if a client suffers a cardiopulmonary arrest (heart attack) the patient does not have to be revived. Good medical practice and the policies of most facilities require that CPR (cardiopulmonary resuscitation) be started unless there is an order to the contrary in the client's personal history file...". this document further states: "...IT IS THE POLICY OF THIS FACILITY THAT SHOULD A CLIENT GO INTO CARDIAC ARREST WHILE UNDER THE SUPERVISION OF FACILITY STAFF, ALL MEASURES WILL BE TAKEN TO SUSTAIN LIFE UNTIL QUALIFIED MEDICAL STAFF ARRIVE OR THE PERSON IS TRANSFERRED TO THE HOSPITAL..." (typed as written). This document is signed by R16's guardian and dated 9/9/02. The facility policy entitled Medical Services includes directions for: Cardiac Arrest states: "According to resuscitation orders obtained from individual, family and physician, institute CPR according to American Heart Association standards, 2nd person immediately call ambulance; notify physician and family." Per review of R16's physician's orders, there is no order which states: do not resuscitate (DNR) or no code. Confirmed per interview with E3 on 3/6/03 at 8:50 A.M., there are currently no clients residing in this facility with a physician's order which states: Do Not Resuscitate. Per review of an incident report dated 2/8/03, this report states staff: "went into (R16's) room at 6AM on 2/8/03 and noted that she was blue and cool to the touch. Staff attempted to take vitals. No pulse, respiration or blood pressure are noted...Staff at the house called 911. EMS (Emergency Medical Services) personnel arrived to take vitals and also were unable to appreciate pulse, respiration, or blood pressure. EMS personnel transported (R16) to (name of hospital)." This incident report further states: "(R16) was pronounced dead upon arrival at (name of hospital). The primary physician, who is also the county coroner, stated that coronary artery disease with acute MI (Myocardial Infarction) was the likely cause of death." Per review of the Investigative Summary completed by E2 on 2/12/03 regarding this incident, E2 stated: "Staff member E4 (habilitation aide) stated that he arrived at work on the morning of Saturday, 08 February 2003 just prior to 6:00 AM. E4 stated that he began to assist an individual in taking their AM medications. He stated that shortly thereafter, staff member E10 approached him and stated that there was no response from (R16). E4 stated that he went to check R16 and noticed that she was pale and cool to the touch. He attempted to take vitals and could not get either a pulse or respirations. He then contacted the local emergency number which dispatched both police and an ambulance. E4 stated that when the ambulance arrived, they attempted to take R16's vitals and also could not get a response. E4 stated that the ambulance personnel then transported (R16) to the local emergency room." The report further states: "Staff member E7 lives near the home and arrived just prior to emergency personnel. She attempted to take vitals and could not appreciate a pulse or respirations." Per interview with E10 (overnight direct-care staff) on 3/6/03 at 11:25 A.M., E10 stated that at 6:00 A.M. she was going to check on R14 and when in the area observed R16 laying sideways in her bed with her legs hanging off the side. She stated that she discovered R16 unresponsive. E10 stated that E4 (Habilitation Aide) had arrived at the facility, and she told him about R16. E10 stated that E4 then checked on R16 who was observed to be without pulse or respirations. E10 stated that E4 made all the phone calls such as 911. E10 confirmed that neither she nor E4 initiated CPR; she stated R16 was already gone. Per interview with E4 on 3/5/03 at 3:20 P.M., E4 stated that he came in at 6:00 A.M. to administer medications. E4 stated that shortly after his arrival, E10 told him that there was a problem with R16. E4 stated that she was laying crooked in the bed, and that she was cold to the touch and her color was ashen-grey. E4 stated that she had no pulse or respiration, and he was unable to obtain a blood pressure. E4 stated that he called 911 and told the dispatch that there was a resident who was apparently deceased and that an ambulance was needed. E4 stated he also notified E7 (habilitation aide) who lived nearby. E4 confirmed that he did not start CPR; he felt that she was gone based on her appearance. E4 stated that he has since been informed that he should have initiated CPR as per facility policy. Per interview with E7 on 3/6/03 at 8:15 A.M., E7 stated that she received a phone call from E4 and was informed that R16 had "passed". E7 stated that she asked E4 if he had notified 911 and said she was informed that he had. E7 stated that she came into the facility (approximately 15-20 minutes) later and that EMS had not yet arrived. E7 stated that she called 911 again and was told they were en-route. Confirmed per interview with E1 on 3/6/03 at 12:30 P.M., E7 also did not initiate CPR. Per review of the EMS (Emergency Medical Services) reported dated 2/8/03 and regarding the call received from this facility: this document states the 911 dispatch was contacted at 6:22 A.M. and the ambulance was sent to the facility at 6:30 A.M. This record states: "Called to a care facility for a triple zero (no pulse, no respirations and no pupillary response). (Name of Physician) (Coroner) requested for us to bring the Pt. (patient) to (name of hospital). UOA (upon our arrival) Pt. found lying supine in bed. Pt pulseless, O (with a line through it) breathing. Pt obviously dead. Pts pupils fixed and dialated. Rigor Mortis to Appendicular and cervical neck. Lividity noted to posterior gluteal and scapular areas. All phalanges mottled. Employee at Care Center stated Pt. was last seen alive at 0300. Pt. was found at 0600 0 (line through it) pulse + not breathing. 0 (line through it) CPR. Pt at the least has been down for approx. 45 min. Pt. transported to (name of hospital)." Per review of the facility job description for the overnight staff person, this job description includes hourly bed checks. When E10 was asked regarding her awareness of the facility policy regarding hourly bed checks, E10 confirmed that she was aware of this duty. However E10 also confirmed that she did not complete the hourly bed checks at 3:00 A.M., 4:00 A.M. or 5:00 A.M. Per review of the documentation for hourly bed checks, the documentation states R16 was asleep at 3:00 A.M., and the documentation is marked out for 4:00 A.M.- 6:00 A.M. When E10 was asked what training she had received since employment (records indicate hire date as 11/14/02), E10 stated she had received only 1 day of Habilitation Aide training on 2/13/03 since she was hired. E10 stated this training was related to activities and a description of the corporation's make-up. Per review of E10's personnel file, there is no evidence of any facility training being provided for this employee. Per review of the facility inservices which have been held since E10's employment on 11/14/02, E10 was not documented to have attended any training sessions. E10 confirmed that she had received no training on emergency procedures and was not CPR certified. Per interview with E2 on 3/5/03 in the afternoon , E2 confirmed that E10 was not a Certified Habilitation Aide on 2/8/03 at the time of R16's death, nor was E10 CPR certified. E2 stated on 3/6/03 at approximately 1:00 P.M., E10's training was on-the-job and that she was trained as per the facility handbook. Per review of the facility handbook, there is no training describing emergency care policies or CPR. Per review of the facility staffing schedule, there is one direct care staff member scheduled from 10:00 P.M. to 6:00 A.M. Per review of facility records and confirmed per interview with E2 on 3/5/03 , E9 is not a Certified Habilitation Aide. Per interview with E1 and E2 on 3/7/03 at 12:30 P.M., they confirmed that E9 works the overnight shift alone. Per interview with E1 on 3/6/03 at 12:30 P.M., E1 stated that he was aware that CPR was not initiated at the time of R16's cardiac arrest. E1 further stated that since that time, a discussion was held with E4 and E7 regarding the lack of initiating CPR. The facility failed to implement their policy to prevent neglect for R16 who was found without pulse or respirations when the facility neglected to: provide direct care staff training related to medical emergencies and Cardiopulmonary Resuscitation, provide initial and ongoing training to direct care staff related to health care needs, initiate Cardiopulmonary Resuscitation as per facility policy, ensure the direct care staff working the overnight shift are Habitation Aide certified, and initiate the use of an audio room monitor to ensure R16's safety as per recommendations. Based on interview and file verification, the facility failed to ensure direct-care staff are provided with initial and on-going training related to health-care issues including emergency care policies and the initiation of CPR (Cardiopulmonary Resuscitation) for one individual in the facility who has expired (R16) and with the potential to affect the additional 15 individuals who reside in this facility (R#'s 1-15). Findings include: Per review of the current Physician's orders dated 1/03, R16 is a 73 year old female with a diagnosis of Hypertension and Angina Pectoris. Per review of a letter sent to the facility on 2/10/03, this letter from R16's attending physician states R16 also had a history of Coronary Artery Disease, Degenerative Arthritis, and some episodes of Congestive Heart Failure. Per review of an Investigative Summary dated 2/12/03, this summary states R16 functions in the severe range of mental retardation. The most current Nursing Health Review and Physical Assessment dated 2/5/03 states R16 was aware of environment, aware of familiar staff, displayed the ability to ask for help, was calm, and verbal. Per review of an incident report dated 2/8/03, this report states staff: "went into (R16's) room at 6 AM on 2/8/03 and noted that she was blue and cool to the touch. Staff attempted to take vitals. No pulse, respiration or blood pressure are noted...Staff at the house called 911. EMS (Emergency Medical Services) personnel arrived to take vitals and also were unable to appreciate pulse, respiration, or blood pressure. EMS personnel transported (R16) to (name of hospital)." This incident report further states: "(R16) was pronounced dead upon arrival at (name of hospital). The primary physician, who is also the county coroner, stated that coronary artery disease with acute MI (Myocardial Infarction) was the likely cause of death." Per interview with E10 (overnight direct-care staff) on 3/6/03 at 11:25 A.M., E10 stated regarding this incident: At 6:00 A.M. she was going to check on R14 and when she was in the area, observed R16 laying sideways in her bed with her legs hanging off the side. She stated that she discovered R16 was unresponsive. E10 stated that E4 had just arrived at the facility and E10 told him about R16. E10 stated that E4 then checked on R16, who was observed to be without pulse or respirations. E10 stated that E4 made all the phone calls such as 911. E10 confirmed that neither she nor E4 initiated CPR. E10 stated R16 was already gone. Per interview with E4 on 3/5/03 at 3:20 P.M., E4 stated that he arrived at the facility at 6:00 A.M. to administer medications. E4 stated that shortly after his arrival, E10 told him that there was a problem with R16. E4 stated that R16 was laying crooked in the bed, and that she was cold to the touch and her color was ashen-grey. E4 stated that R16 had no pulse, or respiration and he was unable to obtain a blood pressure. E4 stated that he called 911 and told the dispatch that there was a resident who was apparently deceased and that an ambulance was needed. E4 stated he also notified E7 (Habilitation Aide) who lived nearby. E4 confirmed that he did not start CPR; he felt that she was gone based on her appearance. E4 stated that he has since been informed that he should have initiated CPR as per facility policy. When E10 was asked what training she had received since employment (records indicate hire date as 11/14/02), E10 stated she had received only 1 day of Habilitation Aide training on 2/13/03 since she was hired. E10 stated this training was related to activities and a description of the corporation's make-up. Per review of E10's personnel file, there is no evidence of any facility training being provided for this employee. Per review of the facility in-services which have been held since E10's employment on 11/14/02, E10 was not documented to have attended any training sessions. E10 confirmed that she had received no training on emergency procedures and was not CPR certified. Per interview with E2 on 3/5/03 in the afternoon , E2 confirmed that E10 was not a Certified Habilitation Aide on 2/8/03 at the time of R16's death, nor was E10 CPR certified. E2 stated on 3/6/03 at approximately 1:00 P.M., E10's training was on-the-job, and that she was trained as per the facility handbook. Per review of the facility handbook, there is no training describing emergency care policies or CPR. Per review of the facility staffing schedule, there is one direct-care staff member scheduled from 10:00 P.M. to 6:00 A.M. Per review of facility records and confirmed per interview with E2 on 3/5/03 , E9 is not a certified habilitation aide. Confirmed per interview with E1 and E2 on 3/7/03 at 12:30 P.M., E9 currently works the overnight shift alone. The facility failed to ensure that individuals working alone on the overnight shift are trained in emergency care, are Habilitation Aide certified, and are trained in Cardiopulmonary Resuscitation Based on observation, interview, and review of facility records, the facility failed to demonstrate knowledge and competencies in addressing the emergency medical needs by initiating CPR (Cardiopulmonary Resuscitation) for one individual in the facility who has expired (R16). Findings include: Per review of the current Physician's orders dated 1/03, R16 is a 73 year old female with a diagnosis of Hypertension and Angina Pectoris. Per review of a letter sent to the facility on 2/10/03, this letter from R16's attending physician states R16 also had a history of Coronary Artery Disease, Degenerative Arthritis and some episodes of Congestive Heart Failure. Per review of an Investigative Summary dated 2/12/03, this summary states R16 functions in the severe range of mental retardation. The most current Nursing Health Review and Physical Assessment dated 2/5/03 states R16 was aware of environment, aware of familiar staff, displayed the ability to ask for help, was calm, and verbal. Per review of an incident report dated 2/8/03, this report states staff: "went into (R16's) room at 6 AM on 2/8/03 and noted that she was blue and cool to the touch. Staff attempted to take vitals. No pulse, respiration or blood pressure are noted...Staff at the house called 911. EMS (Emergency Medical Services) personnel arrived to take vitals and also were unable to appreciate pulse, respiration, or blood pressure. EMS personnel transported (R16) to (name of hospital)." This incident report further states: "(R16) was pronounced dead upon arrival at (name of hospital). The primary physician, who is also the county coroner, stated that coronary artery disease with acute MI (Myocardial Infarction) was the likely cause of death." Per interview with E10 on 3/6/03 at 11:25 A.M., E10 stated regarding this incident: At 6:00 A.M. she was going to check on R14 and when she was in the area, observed R16 laying sideways in her bed with her legs hanging off the side. She stated that she discovered R16 was unresponsive. E10 stated that E4 had just arrived at the facility, and E10 told him about R16. E10 stated that E4 then checked on R16, who was observed to be without pulse or respirations. E10 stated that E4 made all the phone calls such as 911. E10 confirmed that neither she nor E4 initiated CPR; she stated R16 was already gone. Per interview with E4 on 3/5/03 at 3:20 P.M., E4 stated that he arrived at the facility at 6:00 A.M. to administer medications. E4 stated that shortly after his arrival, E10 told him that there was a problem with R16. E4 stated that she was laying crooked in the bed, and that she was cold to the touch and her color was ashen-grey. E4 stated that R16 had no pulse, or respiration and he was unable to obtain a blood pressure. E4 stated he called 911 and told the dispatch that there was a resident who was apparently deceased, and that an ambulance was needed. E4 stated he also notified E7 (Habilitation Aide) who lived nearby. E4 confirmed that he did not start CPR; he felt that R16 was gone based on her appearance. E4 stated that he has since been informed that he should have initiated CPR as per facility policy. Confirmed per review of E4's personnel file, E4 was CPR certified in 5/02. Facility records also indicate E7 was CPR certified at the time of this incident, however also did not initiate CPR. The facility policy entitled Medical Services includes directions for: Cardiac Arrest states: "According to resuscitation orders obtained from individual, family and physician, institute CPR according to American Heart Association standards, 2nd person immediately call ambulance; notify physician and family." Per review of R16's physician's orders, there is no order which states: do not resuscitate (DNR) or no code. Confirmed per interview with E3 on 3/6/03 at 8:50 A.M., there are currently no clients (R#'s 1-15) residing in this facility with a physician's order which states: (DNR) Do not Resuscitate. Per review of R16's records, a document signed by the guardian and dated 9/9/02 states Cardiopulmonary Resuscitation should be initiated in the event of a Cardiopulmonary Arrest. Per review of the facility job description for the overnight staff person (E10), this job description includes hourly bed checks. When E10 was asked about her awareness of the facility policy regarding hourly bed checks, E10 confirmed that she was aware of this duty. However E10 also confirmed that she did not complete the hourly bed checks at 3:00 A.M., 4:00 A.M. or 5:00 A.M. Per review of the documentation for hourly bed checks, the documentation states R16 was asleep at 3:00 A.M., and the documentation is marked out for 4:00 A.M.- 6:00 A.M. The facility failed to ensure facility staff are adequately trained in emergency care and the initiation of Cardiopulmonary Resuscitation for those individuals without a "Do Not Resuscitate" physician's order. Based on observation, interview, and file verification, the facility nursing staff failed to adequately assess, monitor, or provide recommendations for follow-up to health related concerns for one individual in the facility who has expired (R16). Findings include: Per review of the current Physician's orders dated 1/03, R16 is a 73 year old female with a diagnosis of Hypertension and Angina Pectoris. Per review of a letter sent to the facility on 2/10/03, this letter from R16's attending physician states R16 had a history of Coronary Artery Disease, Degenerative Arthritis and some episodes of Congestive Heart Failure. This letter further states R16 was treated for Bronchitis with antibiotic therapy and an increase in diuretic medication on 2/6/03. Per review of an Investigative Summary dated 2/12/03, this summary states R16 functions in the severe range of mental retardation. The most current Nursing Health Review and Physical Assessment dated 2/5/03 states R16 was aware of the environment, aware of familiar staff, displayed the ability to ask for help, was calm, and verbal. Per review of a Medical Visit Synopsis/Consultation form dated 2/6/03, R16 was seen by her physician for unstable walking and cellulitis of her legs. Per review of this document, R16's diagnosis include Bronchitis, GI Bleed, and Cutaneous Candidas. Per physician's orders at this time, Lasix was increased from 40 mg every A.M., to add a noon dose of 20 mg daily. R16 was also started on antibiotic therapy and medications for her stomach. Per review of nursing notes dated 2/03, there is no documentation by nursing which indicates R16's diagnosis of Bronchitis nor any evidence of nursing recommendations for monitoring this client's condition. Per review of R16's records and confirmed per interview with E2 on 3/12/03 at 10:15 A.M., the facility was unable to locate any evidence that R16 was monitored for Bronchitis or Congestive Heart Failure from 2/6/03 until her death on 2/8/03. Additionally the facility was unable to provide the surveyor with any evidence that the medications ordered by the physician on 2/6/03 were initiated. Medications included an increase in Lasix and the initiation of Pepcid and Biaxin. Per review of an incident report dated 2/8/03, this report states at 6:00 A.M. staff: "went into (R16's) room at 6 AM on 2/8/03 and noted that she was blue and cool to the touch. Staff attempted to take vitals. No pulse, respiration or blood pressure are noted...Staff at the house called 911. EMS (Emergency Medical Services) personnel arrived to take vitals and also were unable to appreciate pulse, respiration, or blood pressure. EMS personnel transported (R16) to (name of hospital)." This incident report further states: "(R16) was pronounced dead upon arrival at (name of hospital). The primary physician, who is also the county coroner, stated that coronary artery disease with acute MI (Myocardial Infarction) was the likely cause of death." Per interview with E10 on 3/6/03 at 11:25 A.M., E10 stated regarding this incident: E10 stated that at 6:00 A.M. she was going to check on E14 and when in the area, observed R16 laying sideways in her bed with her legs hanging off the side. She stated that she discovered R16 unresponsive. E10 stated that E4 had came into the facility and she told him about R16. E10 stated that E4 then checked on R16 who was observed to be without pulse or respirations. E10 stated that E4 made all the phone calls such as 911. E10 confirmed that neither she nor E4 initiated CPR; she stated R16 was already gone. Per interview with E10 on 3/6/03, at 11:25 A.M., E10 stated that she was unaware that R16 was receiving treatment for an illness. Confirmed per interview with E2 on 3/6/03 at 9:30 A.M., E2 stated that she was unable to locate an assessment by nursing regarding R16's illness requiring a physician's visit on 2/6/03. E2 further stated that recommendations for monitoring and follow-up generally are not provided by nursing recommendations but by recommendations of non-nursing personnel in the facility. The facility nurse failed to ensure R16's health care needs are assessed with recommendations made for the facility staff to monitor. |