Westbury Care Center

FacilityI.D. Number: 0042226
1800 Robin Lane
Lisle, Illinois 60532

Date of Survey: 08/22/2003

Complaint Investigation

"A" VIOLATION(S):

Facility staff will promptly notify each resident's physician of any significant change in the resident's condition. Facility staff will obtain and record the physician's plan of care for this notification in the resident's medical record.

General nursing care shall include at a minimum the following and shall be practiced on a 24-hour, seven-day-a-week basis. This includes, but is not limited to:

Medications including oral, rectal, hypodermic, intravenous, and intramuscular shall be properly administered and

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.

In interviews and record review, it was determined that the facility failed to ensure its nursing staff immediately notify physician about R1's objective and subjective changes that occurred on 08/12/02 and 08/13/02 and that its nursing staff follow acceptable standards of practice regarding enema administration. R1 was sent to the hospital, and according to the initial operative consult, was admitted with diagnoses including perforated rectum secondary to enema placement. R1 went for emergency sigmoid colostomy.

Review of the R1's medical record revealed that R1 was admitted to the facility on 01/15/02 with diagnoses including Benign Prostatic Hypertrophy, Neurogenic Bladder and Dementia with agitation.

Review of the nurses notes dated 08/12/02 reveals:

6:30 a.m. - CNA notified writer, resident yelling out while she is trying to get him out of bed. Resident holding right side of abdomen and grimacing at times. Right abdominal area tender

to touch. Some swelling noted to abdomen.

7:00 a.m. - Aide states resident very uncomfortable during transfers, complaint of pain to rib area,

right upper quadrant distended and hard with palpation. Difficult to assess.

These observations and complaints of rib and abdominal pain and abdominal distention were not conveyed to the Attending Physician until 1:30 p.m. according to the nurses notes. The notes continue:

9:00 p.m. - R1 had an emesis of approximately 100cc of undigested food. . . . [complaining of pain] to

[right] [upper quadrant] area. . . small amount of bright red fluid noted in the diaper. R1's vital signs reflected a blood pressure of had 160/90, an increase from R1's normal range of 110/70 to 120/70 (as per the facility monthly weight and vital sign documentation for 2002). R1 also had a temperature of 99.5 at this time.

The next note is on 08/13/02 and states:

5:30 a.m. - [complaint of] some sore when moving, enema given. . . noted after giving some [sm]

[amount ]of light red mucus. [Right] upper [abdomen] some swelling noted, tender to touch, bowel

sounds present, will continue to monitor. In the column on the left side of the page R’s vital signs

are documented to include a blood pressure of 150/80.

On 08/13/02, at 8:00 a.m., a late entry is documented for 08/12/02 at 2:30 p.m.:

Fleet Enema was given with much difficulty due to resident not cooperating. Digital exam done prior to Fleet's - unable to feel any stool. . .

R1 continued to present signs of distress including a distended, firm abdomen and poor appetite. At

10:00 a.m., nurses notes document the physician was called and orders were received to transport R1 to the hospital.

These observations of bright red bleeding noted on his diaper, emesis, abdominal distention, pain and changes

in vital signs were not promptly conveyed to the doctor.

A review of the hospital progress note dated 08/13/02 disclosed that R1 was admitted with a diagnosis of perforated rectum secondary to enema placement. The hospital history and physical reveals that R1 was admitted with diagnoses including status post rectal tear traumatic post enema. Review of the abdominal CT scan done at this admission evaluation reflects that a large perforation of lateral rectal wall was seen and an emergency sigmoid colostomy was done. R1 expired at the hospital on 08/23/02. The DuPage County Coroner's Office disclosed on 03/20/03 that R1's primary cause of death was pneumonia and perforation of the rectum.

During the interview with E3, on 12/24/02 at approximately 10:00 a.m., E3 stated that she remembered she had a hard time giving the enema to R1. E3 stated AI gave him the second enema. He was moaning, so I withdrew it then, reinserted it again. After giving the enema, I observed a moderate amount of light pink blood on the rectum. I endorsed it to the next shift."

In an interview with the E4, on 12/24/02 at approximately 1:15 p.m., E4 stated that R1 was sometimes agitated especially if he was not comfortable.

In an interview with Z2, on 08/01/03 at approximately 1:15 p.m., Z2 stated AI was the one that check him for impaction; I didn't feel any stool present. After the rectal check, I noticed a smear of blood that's just normal because of the finger manipulation, and then I instructed the nurse to call the doctor to obtain an order for enema. The patient was very uncooperative. I was told he didn't have BM for more than three days; our policy is to notify the doctor if no BM for more than three days.@

A review of the resident care flow record dated August 2002, disclosed that R1 had no BM for only two days - August 11th and 12th.

Nursing staff (Z4) did not follow the Fleet enema manufacturers direction, the facility policy and procedures and the nurses guide to clinical procedures on enema administration to position R1 in side lying position with knees flexed to allows good exposure of anal opening. In a follow-up phone interview with Z2 done on 08/21/03 at approximately 10:30 a.m., Z2 stated that the nurse gave the enema to R1 while standing in the bathroom with his legs spread out.

A phone interview with the Z4 on 08/22/03 at approximately 12:10 p.m., disclosed that she observed R1 with abdominal distention and R1 was complaining of a lot of abdominal and rib pain. AI was concern about him. I wanted him to go to the hospital but the Director of Nursing (DON) didn't want me to. She wanted to do something first in the facility before we transfer him. The DON checked him for impaction and I gave the enema in the bathroom while R1 was standing up. I observed a little blood after the enema. He was wrestling with us. I was really uneasy about the situation, I really thought he could have gone to the hospital.@

The enema manufacturers directions and the Nurses Guide to Clinical Procedures reveals that enema administration should be done with positioning the client in a side-lying position, with knees flexed, to allow good exposure of anal opening.

A phone interview with Z1 was conducted on 08/01/03. In this interview Z1 stated that “Yes! No question about it” when asked if the enema could have caused the rectal perforation.