Champaign County Nursing Home

Facility I.d. Number: 0001636
1701 East Main
Urbana, Il 61801

Date of Survey: DECEMBER 18, 2002

Complaint Investigation

"A" VIOLATION(S):

Adequate and properly supervised nursing care and personal care shall be provided to each resident to meet the total nursing and personal care needs of the resident.

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

All treatments and procedures shall be administered as ordered by the physician.

All medications, including cathartics, headache remedies, or vitamins, shall be given only upon the written order of a physician. All such orders shall have the handwritten signature of the physician. (Rubber stamp signatures are not acceptable.) These medications shall be given as prescribed by the physician and at the designated time.

These requirements are not met as evidenced by:

Based on record review and interviews, the facility failed to ensure that one resident, R1, received the medication Morphine Sulfate as ordered. R1's cause of death was respiratory failure due to high morphine levels. As of 12/12/02, there are four residents who currently receive Morphine Sulfate and could be considered at risk, (R7, R8, R9 and R10).

The findings include:

According to the Resident Profile Face Sheet dated 3/20/02, R1 was a 94 year old resident admitted to the facility 3/19/01. R1's primary diagnosis was listed as "Congestive Heart Failure, Constipation, Depressive disorder and Anxiety State,with additional diagnoses of chronic urosepsis and atherosclerosis of the extremities." The original face sheet, dated 3/19/01, other diagnoses included Non-Insulin Diabetes (NIDDM), Osteoporosis, Ataxic (unsteady) Gait, localized Edema, and Anemia.

According to the nurses notes dated 3/15/02 at 0900 (9:00 A.M.), "Res. (R1) had temp. of 100 on 11-7 shift. Res. is c/o (complaining) sore throat difficulty breathing, frequent cough lung exp. Rhonchi, body ache, running nose..." On 3/15/02 at 1000, (10:00 A.M)., the nurses notes state that Z7, Medical Director, ordered the antibiotic Erythromycin 333 three times daily after meals for seven days. At 2230 (10:30 P.M.) the nurses have documented that R1 had "inspiratory and expiratory wheeze. no cough. Robitussin given". On 3/16/02 at 1400 (2:00 P.M.) the nurses notes state "Res. ate both meals in her room. 75% both meals no audible wheeze, Res. received antibiotics frequent cough". On 3/16/02 at 1500 (3:00 P.M.) the nurses notes state "Found resident yelling for help stated "I can't breathe". According to the notes, nursing staff administered oxygen raising the O2 blood level to 92%. On 3/17/02 at 12:30 P.M the nurses notes state "Very anxious stating, I can't breathe - I can't breathe - I can't stand it". O2..started. Xanax 5 mg. (and) Tylenol 650 mg. given at this time." The subsequent note charted at 0130 (1:30 A.M.) states "Resident sleeping at this time." On 3/17/02 at 1700 (5:00 P.M.) the nurses notes state "Found resident with labored breathing unresponsive diaphoretic."

The subsequent nurses notes document that Z3, the covering physician, ordered R1 to go to the hospital for evaluation and treatment and that Z8, the Health Care Power of Attorney (HCPOA), stated that R1 was a Do Not Resuscitate(DNR) and "wishes for (R1) to stay at Nursing Home". According to the telephone order sheet at 1730 (5:30 P.M.) on 3/17/02, Z3 ordered "Scopolamine patch as directed and MS (Morphine Sulfate) Suppository 5 mg. every four hours as needed or M.S. 2 mg IM (intramuscular) as needed for pain.

According to the nurses notes, R1 received a 2mg injection of M.S. at 1730 (5:30 P.M.) and a scopolamine patch at 1900 (7:00 P.M.). At 1900 (7:00 P.M.) also ordered the diuretic Lasix 40 mg (injection) to be given NOW" and the notes also state "She cont. to breathe heavily audible congestion present." On 3/18/02 at 0835 (8:35 A.M.) the nurses notes state "Resident complaining of SOB (Shortness of Breath) - Audible wheezing. Neb(nebulizer) tx.(treatment) given and M.S. 2 mg IM given...". According to the Medication Administration Record M.S. 2 mg IM was given at 0830 (8:30 A.M.), 1035 (10:35 A.M.) , and at 1245 (12:45 P.M.). According to the Physician's Telephone Orders sheet, on 3/18/02 there was an order to discontinue the MS 2 mg IM PRN (as needed) and an order given for MS (Morphine Sulfate) 5 mg IM every two hours PRN.

According to the Medication Administration Record this 5 mg dose of MS was given on 3/18/02 at 1445 (2:45 P.M.), 1710 (5:10 P.M.), 1910 (7:10 P.M.)and on 3/19/02 at 1010 (10:10 A.M.), 1430 (2:30 P.M.), 1700 (5:00 P.M.) and at 1910 (7:10 P.M.) and on 3/20/02 at 0130 (1:30 A.M.), 0325 (3:25 A.M.), 0600 (6:00 A.M.), 0800 (8:00 A.M.), 1000 (10:00 A.M.), 1200 (12:00 P.M.) and 1800 (6:00 P.M.). The nurses notes document that on 3/19/02 that R1 "has been unresponsive tonight, no oral intake, no voiding, rhonchi remains in both lung fields" and on 3/20/02 at 1400 (2:00 P.M.) nurses document "Res. is unresponsive, blood pressure 102/45 pulse 43 and respirations 12. No void or fluid intake." At 3/20/02 the nurses notes at 1710 (5:10 P.M.) state "Hold medication when resident is lethargic." Do not increase MS., received from Z1, R1's physician. “Resident unresponsive with audible coarse lung sounds. Appears comfortable". And at 3/20/02 at 2000 (8:00 P.M.) the nurses notes state "Resp. remain labored with audible coarse sounds heard". The nurses notes at 2220 (10:20 P.M.) states "Found resident without breath sounds or heart tones. Resident deceased."

In the Transcript of the Evidence presented at the Coroner's Inquest held 10/24/2002, Z5, the Forensic Pathologist, stated: "That the value of morphine in R1's blood was 192 ng/ml." "That a value of 200 or higher is considered fatal. In other words, that level would cause death in any of us healthy persons". R1"had underlying respiratory problems because of her heart failure, but that essentially pushed her over the hill as the final cause of death, with the underlying heart disease we listed as part two on the death certificate". “The morphine was the cause of death on that day at that moment. She would have died perhaps in the next days or weeks. She had severe underlying disease. But the morphine was the cause of death at that moment." “A person getting the dose that she was supposed to be getting, five milligrams every two hours.....should have a level around 14." “So 14, her level is 192 in fluid that's essentially already mixed and diluted with embalming fluid, so probably even much higher than that." "When the toxicologist took that amount of morphine that (R1) had been given starting at 1:30 in the morning, ....that would have been 35 milligrams she was given on the day of death. That still doesn't account for a level of 192 at the time of her death at ten PM. So, it seems that more morphine than is accounted for caused that level. Mathematically that doesn't add up. That's all."

During a telephone interview with Z5 on 12/11/02 at 10:45 A.M., she stated that "mathematically that the blood level of morphine at 192 ng/ml worked out to about 13 times higher than the value of 14 ng/ml." Z5 also stated that R1 "had no kidney or liver disease so that the metabolism would have been normal". Z5 also stated that taking R1's age (94) into account with regard to metabolism "would no more than double the amount of 14 to a blood level of 28 and not 192 ng/ml". Z5 stated that R1 "had serious heart disease and that the heart functioned at about 25%" and said that "R1 was dying but R1 was not in crisis." Z5 stated that "the primary cause of death was respiratory failure in association with high morphine levels". During this telephone interview, Z5 reiterated that "The morphine was the cause of death on that day at that moment."