East Side Terrace
Facility I.D. Number: 0040204
Date of Survey: 07/09/2003
Incident Report Investigation of June 11, 2003
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 staffs 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 yet 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 were not met as evidenced by:
Based on interview and file verification, the facility neglected to implement its own policies and procedures to prevent neglect of the resident (R1) by its failure to:
1. The facility neglected to provide medical intervention, as per their facility policy, for R1's non-responsive state.
Per review of a facility incident report dated 06/11/03, R1 was found in his room lying on the floor beside his bed at approximately 5:00 a.m. R1 was found by E1 (Unit Aide) and was, "unresponsive to staff". Per the report, E1 called E7 (RSD/QMRP) then called the paramedics. Per the facility's emergency policy, it states, "Call Resident Services Director in each instance after contacting ambulance service". Paramedics arrived and proceeded to call the coroner who pronounced R1 dead. The coroner's death certificate, dated 06/12/03 and signed by the coroner, documents R1's death on 06/11/03 at
6:03 a.m. due to, "sudden cardiac death".
A document entitled "Client Roster", provided by the facility on 07/02/03, documents that R1 functioned in the severe range of mental retardation. R1's 05/05/02 IPP (Individual Program Plan) documents that R1 communicated mostly with one word utterances and that his speech was normally very soft. His most recent physician's orders (05/01/03) provide the following medical diagnoses: Fragile X Syndrome, HTN (Hypertension), Schizo-Affective Disorder, Depression and Phimosis, with a birth date of 07/22/40. Per the physician order sheet, R1 received daily medication for his Hypertension (Captopril HCTZ 25/25 mg tabs, l tab every a.m. and p.m.). R1's 04/29/02 dental exam documents that R1 was edentulous.
Nursing notes dated 06/03/02 document that R1 had been seen for a swallowing evaluation. Per the notes, R1 was to remain on a mechanical soft diet with regular thin liquids.
A document entitled, "Emergency Medical Consent" was located in R1's personal file. This document was signed by his guardian and was dated 05/03/00. Per the consent, the consent was valid until discharge. The emergency medical consent states, "In no event shall treatment be withheld from the above named individual due to his or her age, disability, quality of life, or legal status."
A review of R1's "medical history" in his personal chart documents the following:
A.) 04/28/02 - R1 choked at his lunch. He subsequently "passed out" and the food was dislodged with abdominal thrusts and finger sweeps. 911 arrived and R1 was transported to the emergency room with release back to the facility on the same day.
B.) 06/03/02 - swallowing evaluation noting that R1 has difficulty monitoring bite size and speed of intake. Eats very quickly and puts new bites into his mouth before he has swallowed the other bite - tongue is enlarged - recommendation to remain on mechanical soft diet and to be visually monitored at meals, with reminders to slow down and take a drink.
C.) 06/10/02 - R1's surgery for removal of foreskin on penis was canceled due to results of abnormal echocardiogram. A cardiology evaluation was to be scheduled prior to rescheduling his surgery.
D.) 06/17/02 - R1 was evaluated by the cardiologist with the following finding - abnormal EKG with evidence of a right bundle branch block, new since 1992.
Per the recommendation - R1, "appears to have a possible underlying coronary artery disease without any acute symptoms or changes on the EKG.....is at moderate cardiovascular risk for non-cardiac surgeries under general anesthesia...would not suggest any active intervention from a cardiac standpoint at this time.......surgery may proceed as planned....".
E.) 03/03/03 - was transported to the emergency room, for what appeared to be a seizure - final diagnoses Musculoskeletal injury and Myalgia. 03/25/03 notes document an EEG within normal limits and no acute disease noted from CT results.
Review of the, "Weekly Time Schedule" presented by the facility to surveyor on 07/03/03 documents that E1 was scheduled to work at the facility on 06/10/03 from 12:00 p.m. - 8:00 a.m.
A phone interview was conducted with E1 on 07/02/03 at approximately 9:30 a.m. E1 confirmed that she was the only staff on duty at the facility, when at approximately 5:00 a.m., E1 found R1 on the floor of his room. E1 stated that when she arrived at the facility for her work shift, R1 was already in bed. E1 stated that when she checked on R1 at approximately 4:00 a.m., R1 was lying flat on his back in his bed and that his body was not totally covered. E1 stated that at 4:30 a.m., R1 was lying on his side in his bed and was under the bed covers with his whole body covered.
E1 stated that when she checked on R1 at approximately 5:00 a.m., R1 was on the floor of his room between his bed and his night stand. E1 stated that she observed R1 when she came out from the bathroom at that time as another resident of the facility was in the shower and she had been checking on that resident.
E1 stated that she called R1's name, but he did not respond. E1 stated that she also shook him and that it "didn't seem like he was breathing". E1 further stated that R1 usually gets up around 5:00 a.m. E1 stated that she then called E7 (RSD/QMRP) and the paramedics. E1 confirmed that she took no further action, that she was "nervous and scared.....by myself", that she then "waited for paramedics" to arrive.
When again asked by surveyor, E1 confirmed that the only action taken by her was to call R1's name and shake him and call E7 and the paramedics. E1 stated that R1 was okay through the night at her previous checks; and that when she found R1 at the 5:00 a.m. check, that R1 had not been incontinent and no emesis was present. E1 further stated that R1's roommate (R2) was sleeping and continued to sleep until he was awoken to remove him from the bedroom. E1 stated that she did not go into the room with the paramedics and that residents of the facility were then getting up for the morning. E1 stated that she obtained R1's records and medications for the paramedics and that the coroner arrived shortly after.
E3 (Housekeeper), was interviewed at the facility on 07/03/03 at approximately 9:40 a.m. Per this interview, E3 stated that she and E4 (Dietary staff) were called and requested by E7 to come into the facility on the morning of 06/11/03. E3 stated that E7 lives approximately an hour away from the facility and that E7 had called for E3 and E4 to come in and assist with the morning routine. E3 stated that she and E4 arrived at approximately 6:00 a.m. and that she did not go into R1's room as the door was closed. E3 stated that she observed R1 being removed from his room and from the facility by paramedics utilizing a blanket that R1 had been using to cover himself. E3 stated that she was responsible for cleaning up R1's room, that she removed the bottom sheet from the mattress, the pillow and pillow case. E3 stated that no blood or other body fluids was observed on R1's bed articles or on the floor.
Facility policies were reviewed on 07/02/03. Under the section labeled "Disaster Plan" a copy of the AHA (American Heart Association) instructions for, "Obstructed Airway: Unconscious Adult" was found. On 07/02/03, an interview with E2 (Administrator) was conducted at the facility at approximately 11:00 a.m. E2 confirmed that the AHA instructions as described above should be implemented by staff when a resident is found in a non-responsive state and believed to be not breathing. (Per the instructions, airway assessment is to be made, breathing attempts, Heimlich Maneuver, foreign body check, breathing attempts and repeat attempts are to be performed).
2. The facility neglected to thoroughly investigate and thoroughly document R1's 06/11/03 death.
Per review of R1's" Medical Examiner's - Coroner's Certificate of Death" dated 06/12/03, R1 expired on 06/11/03 at 6:03 a.m. due to "Sudden Cardiac Death".
On 07/02/03 at 1:10 p.m., an interview with E2 (Administrator) was conducted requesting any documented information with regards to the facility's investigation into the 06/11/03 death of R1. At this time E2 stated that to the "best of my knowledge" she was not aware of an investigation conducted by the facility.
On 07/03/03, at approximately 9:00 a.m., E6 (Administrator) presented to surveyor a typed two page document dated 06/20/03. This document was entitled "Incident Report Summary" with R1's name and the facility's name directly underneath. The report had E7's name typed at the end of the second page. Per E6, E7 is currently on vacation and this document was retrieved from E7's personal computer from her home by a relative of E7 and given to E6.
Per the document, "This report is a summary of the occurrences of the incident which occurred on June the 11th, 2003......and our subsequent follow up.....This summary has been prepared after interview with all staff involved during the incident.......".
In an interview with E6 on 07/03/03 at 11:45 a.m., E6 confirmed that the two page report dated 06/20/03 (nine days after R1's death) is the only documentation for the facility's investigation into R1's death. The report discusses the interview with E1, but there is no reproducible documentation with regards to what other staff were interviewed or their statements ("interviews with
all staff involved"). E7 returned from vacation and was present at the facility on 07/08/03 and 07/09/03. No further investigation documentation was presented to surveyor.
3. The facility neglected to provide re-training for facility staff following R1's 06/11/03 death.
Per review of the 06/20/03 Incident Report Summary with regards to R1's death, it states, "After a review of the events, we concluded that as far as she could tell we had done things correctly and that we needed to write our report for (the Department) and submit it". At the end of the written portion of the document E7's typed name appears.
In an interview with E2 on 07/02/03 at the facility at approximately 1:10 p.m., E2 confirmed that as of this interview date, "to the best of my knowledge", there had not been "but there will be" re-training for staff of the facility with regards to staff intervention when a resident of the facility is found in an unresponsive state.
Review of facility policy (under General Policy) states, "Additional in-service training for an employee not achieving the desired level of competency will be provided."