East Side Terrace

Facility I.D. Number: 0040204

3850 E. Fulton Ave.
Decatur, IL 62521

Date of Survey: 1/12/04

Incident Report Investigation of 12/15/03

Repeat “A” violation(s):

The facility failed to follow the IPOC for the survey of July 9, 2003, by failing to ensure “… staff’s responsibility during a medical emergency and “… staff institute CPR,”

The facility shall provide all services necessary to maintain each resident in good physical health. These services include, but are not limited to, the following: Nursing services to provide immediate supervision of the health needs of each resident by a registered professional nurse of a licensed practical, or the equivalent.

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 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 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.

These REGULATIONS are not met as evidenced by the following:

Based on interview and file verification, the facility failed to ensure appropriate health care services, including preventative and prompt treatment for one individual in the facility with seizure activity resulting in his death (R1).

1) Per review of the most recent physician’s orders, R1 is described as a 23-year-old male with a diagnoses of profound mental retardation, Cerebral Palsy, Epilepsy and Dandy Walker Syndrome. The physician’s orders state that R1 receives Tegretol 500 mg in the morning, 200 mg in the afternoon and 500 mg in the evening. The orders also indicate R1 receives Lamictal 150 mg in the morning and 200 mg in the evening. These medications are both utilized for seizure activity.

Per review of the most recent Individual Program Plan (IPP) dated 11/14/03, R1 is described as ambulatory and non-verbal. However, per the IPP, R1 appears to understand most requests from staff. This report states R1 was admitted to this facility on 10/20/03 from his parent's home. The IPP states R1 has displayed three types of seizures: "Atonic - falls flat on face with only a temporary loss of consciousness; Partial - blinks, nods head briefly - no loss of consciousness, and Tonic-clonic - (grand mal) - loss of consciousness, rigidity, shaking, etc. Triggered by fatigue; To prevent seizures, R1 needs 10 hours of sleep at night." The IPP states R1 requires use of a helmet when up due to frequent falls.

Seizure reports completed for R1 include seizure activity on 10/25/03, 10/26/03,11/2/03, 11/22/03, 11/24/03, 11/26/03, 12/2/03, and 12/3/03. Per review of the seizure that occurred on 10/25/03, R1 was described as losing consciousness and vomiting. R1 was transported to the emergency room on that occasion.

Per review of the IPP, R1's father is guardian and does not request use of an Advanced Directive. The IPP states: "R1 has no advanced directive; therefore, in case of medical emergency staff is to administer CPR (Cardiopulmonary Resuscitation) and 1st Aid until Emergency medical staff arrives."

Per review of a facility incident report dated 12/15/03, E4 (direct care staff) had gotten R1 out of bed and dressed at approximately 6:25 A.M. The report states at 6:30 A.M., R1's roommate called E4 to the room stating R1 was having a seizure. Per review of E4's written statement and per interview with E4 on 1/7/04 in the morning, R1 was lying on the floor and his whole body was shaking. E4 stated that E3 (direct care staff) had just entered the facility and assisted E4 with R1. E4 stated at this time E3 contacted the facility nurse by phone and E2 (direct care staff) entered the facility. E4 stated at this time she left R1's bedroom for E2 and E3 to monitor R1.

The written statement submitted by E3 (direct care staff) states the facility nurse was contacted by phone at 6:47 A.M., E3 stated that she felt a pulse at this time. The statement further says E2 and E3 lifted R1 up to place him in bed and he crossed his legs Indian style (normal sitting style) and made a whining noise. E3 stated the nurse (per phone) informed the staff to check R1's vital signs. By means of an electronic monitor

R1's blood pressure was 69/49 with a pulse of 45. E3 stated at approximately 7:00 A.M., R1's temperature was 96.4. E3's written statement further states: AE2 and I watched his chest go up + down cause he was breathing so shallow. Approximately 7:15 A.M. the R.N. wanted us to check vitals again we tried but the B/P machine read Error so E2 got the manual blood pressure kit and attempted to check his vitals and couldn't hear anything so I took the stethoscope and I heard a faint heartbeat." This report states E2 also heard a faint heart beat at this time. "The R.N. was on the phone w/us the whole time until R.N. called his stepmom, (Z1) + RN called us immediately back + said to keep monitoring him + keep him on his side cause stepmom said it was normal. Approximately 7:30 A.M. his stepmom got to (name of the facility) and said it wasn't normal + 911 was called as Stepmom and I putting him on floor. Stepmom started compressions and E2 did breathes."

Per review of E1's (R.N. Consultant) written statement, it states: "I received a phone call at approximately 6:47 A.M. from E3 at (name of facility). E3 reported R1 had a seizure. E3 stated E4 saw him jerking...I instructed E3 to check for pulse and breathing. E3 immediately reported both pulse and respirations were present...I asked E3 to check R1 for injuries and take his vitals. E3 reported there were no obvious injuries...I remained on the phone with staff. E3 took vitals. B/P (blood pressure) 69/49. P (pulse) 45. After vitals were reported I instructed one staff to remain with R1 and monitor his breathing and pulse...At approximately 7:15, I instructed staff to recheck B/P and pulse. The electronic B/P read "error" 2 times. Staff reported he was breathing and warm to touch. Instructed to get manual cuff and stethoscope. E3 was able to hear apical pulse with stethoscope. Heart beat was confirmed by E2." (Note written statement does not state what pulse was at this time. Per interview with E3 on 1/7/03 in the morning, E3 stated she did not count R1's pulse but it was slow). Per interview with E2 on 1/7/04 at 9:30 A.M., E2 was asked if at any time after the initial blood pressure and pulse was obtained at approximately 7:00 A.M., if R1's pulse was counted. E2 stated "No".

Per review of a report completed by E5 (additional RN consultant), it states that E2 and E3 were observing R1 during the time of this incident and that R1's color was pale and his nailbeds were slightly purple. The report states this was reported to E1 who then contacted R1's stepmother (Z1).

E1's report states that she contacted R1's stepmom (Z1) at 7:20 A.M. per phone. E1 states that she reported the seizure and that R1 had a blood pressure and pulse and staff were staying with him. E1's report states that Z1 said it was normal for R1 to sleep after a grand mal seizure. E1's report states when she contacted the facility after her phone call with Z1, E2 stated that R1 was warm, pale and breathing. E1's written statement states: "...When I arrived at (name of the facility), Z1 was giving chest compressions, and E2 was providing breaths. Staff informed me that 911 had been called. I checked for apical pulse. None auscultated. CPR continued...". E1's statement says the paramedics arrived at 7:37 A.M. and R1 was transported to an area hospital.

A written report submitted by E2 (direct care staff) states upon arrival at the facility on 12/15/03, she was summoned to R1's bedroom by staff. E2 stated that at the time R1 was placed into the bed from the floor after the seizure, R1 was observed to place his legs in Indian style sitting and that this was normal behavior for him. E2's report states she informed the nurse who was monitoring the situation by phone that R1's color was pale, his lips were "very dark pink" and his fingernails were slightly purple. E2 stated at about 7:20 A.M., she got down on her knees and while level with him and looking at his chest saw it was rising slightly.

Per interview with E2 on 1/7/03 in the morning, E2 confirmed that upon arrival at the facility she assisted E3 with monitoring R1. When asked if E2 assessed R1's fingernails, she stated that she did later after she was unable to hear his blood pressure and that his nail beds were a little bit pink. E2 stated that R1's lips were dark pink. When E2 was asked if at any time after the initial blood pressure and pulse were obtained if R1's pulse was counted. E2 stated no. E2 was asked by the surveyor if at any time after lifting this individual into bed, and the observed noises and the moving of his legs Indian style, was there any further response from the client prior to initiating CPR, E2 stated "no".

E2 stated that she was in constant communication with E1 until E1 disconnected the call to contact R1's stepmother. E2 stated upon arrival of Z1 at the facility (approximately 7:30 A.M.), Z1 walked into the room, looked at R1 and stated this is not normal. E2 stated that she asked Z1 if she wanted 911 called and Z1 said yes. E2 then confirmed that CPR was initiated by Z1 and that she assisted with respirations.

Per interview with Z1 on 1/7/04 per phone in the afternoon. Z1 stated that she is a Registered Nurse and that she has cared for R1 for approximately 15 years prior to placement at this facility. Z1 stated that R1 has a long history of seizures and that she was familiar with his needs. Z1 stated that she was notified by phone by E1 on 12/15/03, that R1 had a grand mal seizure and that he was slow to wake up (Z1 stated this was normal). Z1 stated she was asked by E1 if it would be difficult to find a pulse. Z1 stated she informed E1 only if he was still shaking.

When Z1 was asked by the surveyor if R1 had a history of having a slow pulse after a seizure, Z1 stated that she was unaware of R1 having a history of slow pulse, however on one other occasion while residing in another facility, R1's color was noted to be bad after a grand mal seizure, and the facility had transported R1 to the emergency room for assessment at that time. Z1 stated that since she was getting ready to leave for work, she decided to stop and check on R1. Z1 stated that when she arrived at the facility (facility investigation states at 7:30 A.M.), that she saw R1 in bed "laying on his back, color poor, rather ashen with some mottling on his right arm." Z1 stated that the mottling was on his lower arm towards his wrist. Z1 stated that E2 was in the room with R1 and had a stethoscope with her. Z1 stated that she checked R1 for a pulse and for respirations and found none. Z1 stated I knew CPR (Cardiopulmonary Resuscitation) needed to be done and I started compressions. Z1 stated that E2 was prompted to give the breaths for CPR. Z1 stated she also directed E2 to contact 911 (per Z1, E2 had a phone on her person).

Per interview with E2 on 1/7/03 in the morning, E2 confirmed that upon arrival at the facility she assisted E3 with monitoring R1. When asked if E2 assessed R1's fingernails, she stated that she did later after she was unable to hear his blood pressure and that his nail beds were a little bit pink. E2 stated that R1's lips were dark pink. When E2 was asked if at any time after the initial blood pressure and pulse were obtained if R1's pulse was counted, E2 stated no. E2 was asked by the surveyor if at any time after lifting this individual into bed, and the observed noises and the moving of his legs Indian style, was there any further response from the client prior to initiating CPR, E2 stated “no.”

Per review of the Emergency Services Report completed by the Emergency medical staff, this report states that the ambulance was called at 7:43 A.M. and arrived at the facility at 7:48 A.M. The assessment sheet completed by the emergency personnel states that upon arrival, R1 was observed on the floor receiving CPR.

R1 was described as cool, pale, cyanotic, dry with 0 respirations, 0 pulse, and in asystole per monitor. The report further states: "...care givers stated he had a seizure at 6:45 am. B/P after seizure was in the 60's pt's stepmother arrived found pt to be on his bed cool mottled 0 pulse 0 respiration. She started CPR...pt still asystole...".

Per review of hospital emergency room record, after continued CPR and medications, R1 expired at 8:35 A.M. Per review of the death certificate, the cause of death is identified as Cardiopulmonary Arrest due to Grand Mal Seizure.

Per interview with Z2 (attending physician) on 1/7/04 at 11:00 A.M. per phone, Z2 stated that normal post ictal state is approximately 20 minutes and that an individual would be slightly hypotensive. Z2 stated that R1's hypotension (as identified by the blood pressure 69/49) would be unusual but reportable to the physician. Z2 stated that they did not recognize any history of "bradycardia or hypotension" with this client. Z2 stated that the facility apparently contacted the stepmom who is an educator of nursing students, who gave the facility some initial advice, which they followed. Then the stepmother came out to the facility and saw he was pulse less and respiration less and started CPR. Z2 stated that he realized this facility is "not a medical facility..." however Z2 stated he was "more than a little disappointed that the staff did not intercede...a great disappointment that there was not apparent recognition that he was pulse less and respiration less at that time."

Per interview with E1 on 1/7/04 at 11:20 A.M., E1 was asked by the surveyor if she was concerned with R1's blood pressure and then lack of blood pressure obtained by the staff. E1 stated that she felt his blood pressure levels would not be a cause of concern based upon R1's height and weight. When E1 was asked what action should be taken when staff are unable to obtain a blood pressure. E1 stated she instructed staff to try again, and stated she was told that R1 had a pulse. When E1 was asked if based upon her knowledge or experience it was normal for an individual to display symptoms of hypotension and bradycardia after a seizure, E1 responded that it would not be normal to display bradycardia. When E1 was asked by the surveyor as to when she felt 911 should have been contacted, E1 stated that she was in constant communication with the staff, and stated that if she felt 911 should have been called, she would have told them to. E1 further stated that she was informed R1 was breathing. When E1 was asked as to why she contacted R1's family during this incident, she stated it was to confirm the necessity of sending this client to the emergency room. E1 stated that the facility had previously sent R1 to the emergency room after a grand mal seizure and the emergency

room physician had stated that the facility had overreacted.

Per review of seizure reports completed by the facility, there is only one report which includes the assessment of an individual's vital signs after a seizure. Per interview with E1 on 1/7/04 in the morning, E1 confirms that this is not a part of the form, and vital signs have not been routinely monitored on individuals after a seizure.

Per review of the facility Medical Emergency Policy, this policy states: "...when a resident is found unresponsive, and has no written "Do Not Resuscitate" order, the facility staff shall check the resident's airway for obstruction, call 911 and apply CPR as soon as possible...If a resident appears to have had a seizure, you should make sure the resident is responsive, if not responsive, call 911 immediately...". The Nursing services policy includes: ensuring direct care personnel are trained in detecting signs of illness, dysfunction...that warrant medical, nursing...intervention."