Alden Park Strathmoor
Facility I.D. Number: 0044909
Date of Survey:09/15/2003
The facility must provide the necessary care and services to attain or maintain the highest practicablebphysical, mental, and psychosocial well-being of the resident, in accordance with each residentsbcomprehensive assessment and plan of care. Adequate and properly supervised nursing care andpersonal care shall be provided to each resident to meet the total nursing
and personal care needs of the resident.
General nursing care shall include at a minimum the following and shall be practiced on a 24-hour, seven-day-a-week basis:
Objective observations of changes in a residents 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 residents medical record.
The DON shall supervise and oversee the nursing services of the facility, including:
Developing an up-to-date resident care plan for each resident based on the residents comprehensive assessment, individual needs and goals to be accomplished, physicians orders and personal care and nursing needs. Personnel representing other services such as nursing, activities, dietary, and such other modalities as are ordered by the physician shall be involved in the preparation of the resident care plan. The plan shall be in writing and shall be reviewed and modified in keeping with the care needed as indicated by the residents condition. The plan shall be reviewed at least every three months.
These REQUIREMENTS are not met as evidenced by:
Based on interview and record review, the facility failed to:
a. promptly intervene to prevent R9 from pulling out his tracheostomy tube while on a
ventilator from 03/26/03 to 04/18/03;
b. assess the effectiveness of interventions when R9 continued to pull out his tracheostomy tube.
The findings include:
1. R9's Accumulative Diagnosis Record and Record of Admission and Hospital Status sheet dated 03/26/03 documents the following diagnoses: Respiratory Failure, Diabetes, Chronic Obstructive Pulmonary Disease, Coronary Artery Disease, Congestive Heart Failure, Deep Vein Thrombosis, Anoxic/Metabolic Encephalopathy, Agitation and Anxiety. The assessment dated 04/09/03 documents that R9 has short and long-term memory problems and is moderately impaired in his daily decision- making skills. R9 requires supervision. The assessment further documents that R9 requires oxygen therapy, suctioning, and tracheostomy care. R9's Advanced Directives dated 03/26/03 document that R9 was a full code.
R9's Nurses' Notes were reviewed from 03/27/03 to 04/19/03. The Nurses' Notes document that on the following dates: 03/27/03, 04/08/03, and 04/18/03, R9 had either displaced his tracheostomy tube or pulled it out. The 04/08/03 incident required R9 to be sent to the hospital so his tracheostomy tube could be reinserted. R9's face was turning blue and respiratory therapy had to resuscitate him with an Ambu bag. At 1:35 a.m., R9 pulled his trach half way out again. The Nurses' Notes dated 04/19/03 further stated, "In room instructing resident not to pull on trach and feeding tubes replaced all disconnected tubes. At 1:15 p.m., RT walked into room and found resident unresponsive. No blood pressure, respiration or pulse CPR started." At 2:00 p.m., "Hospital called and informed by emergency room nurse that R9 did not pull through."
2. During an interview conducted on 09/04/03 at 3:00 p.m., E13 (Respiratory Therapist) stated "He was always pulling at his tubes. He had mitts on most of the time. He was off of the ventilator he only needed the trach for suctioning. When I found R9 on 04/19/03, he was blue from the neck up. He pulled his trach out with the cuff inflated. He was confused and he could not be trusted. When I found him I do not remember if the mitts where on or off. I did not try to reinsert the tracheostomy tube because R9 was very cyanotic (blue). I did examine the trach tube and it was not plugged or occluded. I discussed with nursing about the need for restraints many times. I was told that we could not restrain R9 because we are a restraint free facility. He is not the only resident we have had concerns about."
During an interview conducted on 08/29/03 at approximately 2:00 p.m., E9 (LPN) stated "Respiratory went into R9's room and yelled out that he had pulled his tracheostomy tube out. R9 did have medical mitt restraints ordered. One of the mitts was half on and the other was completely off the right hand. RT was not able to reinsert the trach tube."
During an interview conducted on 09/04/03 at approximately 11:55 a.m., E10 (LPN) stated "We had made rounds and everyone was doing fine. I do not recall him having restraints. He did not have wrist restraints and there were no mitts. R9 could understand simple things. He was very confused most of the time. At one point mitts were tried and then we could not find
them. I am sure because of the facility's policy they try to be restraint free. If restraints are causing agitation we remove them which means they need more supervision."
3. R9's care plan dated 04/14/03 for restraint documents that R9 is currently using a restraint. The need for the restraint is related to R9 attempting to take out his trach and remove his oxygen. There is no documentation on the care plan to indicate what type of restraint R9 was using.
Physician's Orders dated 04/14/03 states, "May use bilateral hand mitts as needed to prevent res. from pulling at trach and tubes. Change Xanax 0.25 mg per peg tube twice daily (BID) to Xanax 0.25 mg per tube as need (PRN) BID.
During a phone interview on 09/11/03 at approximately 3:50 p.m., Z2 (pulmonologist) stated "There is a potential for bleeding with self extubation. R9 required a cuffed trach tube because he required intermittent ventilation." Z2 was asked if R9 could have remained off of the vent and on a trach collar. Z2 stated, "R9 had end-stage COPD and would have required some sort of ventilatory support on and off because of his advanced disease." Z2 further stated "I was told by facility staff that we could not restrain resident even when they are pulling on their tracheostomy tube."
The Pre-hospital Care Report Narrative dated 04/19/03 states "They (staff) stated that they had checked on him just moments ago and he was ok. When they came back into his room, his trach tube had been pulled out and the patient was in cardiac arrest....Ventilations were difficult due to patient's trach tube hole."
The Emergency Room Report dictated on 04/19/03 states, "It appears that the patient (R9) may have had a respiratory arrest as he pulled out his tracheostomy tube although this is unclear, certainly on ambulance arrival he was in asystole with no response to any intervention other than the EMD (electrical mechanical disassociation).