CONVALESCENT CARE CTR.- MATTOON

Facility I.D. Number: 0036897
1000 Palm
Mattoon, Il 61938

Date of Survey: 10/16/02

Complaint Investigation

"A" VIOLATION(S):

The facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of the resident, in accordance with each resident’s comprehensive assessment and plan of care. 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.

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.

AN OWNER, LICENSEE, ADMINISTRATOR, EMPLOYEE OR AGENT OF A FACILITY SHALL NOT ABUSE OR NEGLECT A RESIDENT. (A, B) (Section 2-107 of the Act)

This REQUIREMENT is not met as evidenced by:

Based on record review and interviews it was determined that the facility failed to identify a significant deterioration in R1's condition and notify R1's physician of the deterioration in condition. The facility failed to provide any personal care or physically monitor and assess R1 from 12:30 a.m. on 9/10/02 until 5:45 a.m. on 9/10/02 when R1 was found dead in bed with pooling of blood in his face, and the body was cold and the extremities were rigid and stiff.

Findings include:

According to the admission face sheet R1 was admitted to the facility on 8/1/02 with diagnoses of dementia, lymphoma, hypothyroidism, MRSA(methicillin resistant staph aureus) of the urine, psychosis, cardiac dysrhythmia, anxiety, dysphasia, and Haldol overdose. According to the current physician's order sheet dated 8/16/02 to 9/15/02 R1 was taking Ativan 1 mg QID (4 times a day),this was increased from TID (three times a day) on 9/5/02, Zyprexa 10 mg BID (2 times a day), increased from 5 mg BID on 9/5/02 for anxiety, Depakote Sprinkles 125 mg BID, started 9/4/02 for anxiety, and on this date, 9/4/02, R1 had an order and was given Ativan 1 mg IM for agitated behavior, Exelon 1.5 mg BID started 8/30/02 for dementia and behavior, and Risperdal 3mg 1/2 tab BID, increased on 8/30/02, an antipsychotic.

In review of the nurses's notes from admission to 9/5/02, physician's notes dated 8/30/02, and telephone interview p.m. with Z5, R1's attending physician on 9/24/02 at 3:42 p.m. , R1 had behaviors described as aggressive, up roaming, hitting doors and setting off alarms, yelling, agitated and up at night out of bed wandering and roaming.

The care plan dated 8/14/02 describes R1's behaviors of wandering with a potential for elopement, walks up and down the halls and pushes on the doors, he resists care and is verbally aggressive and socially inappropriate, has physical aggression with hitting, kicking, biting, and punching. On 8/23/02 new problems were added to the care plan that state R1 disrobes in front of other residents and in public places and is a skin breakdown risk secondary to incontinence.

A significant change assessment was completed on 8/28/02 related to R1 having a deterioration in his mood, an increase in behaviors, and an increase in incontinence. This was confirmed with the care plan coordinator, E10 per interview on 9/20/02 at 12:50 p.m. .

R1's nurses notes from the medical record were reviewed. Chronological documentation of R1's nurses notes beginning on 9/6/02 are as follows:

9/6/02 at 1:45 a.m. describes R1 as restless, intermittent pacing, both sclera somewhat red.

9/6/02 at 1300 (1:00p.m.) the nurses notes state "slept all shift". "Unable to wake enough to give meds (medications) or food".

9/6/02 on the evening shift describes R1 up and wandering with his usual behaviors and ate 75% of his evening meal.

9/7/02 at 1300 (1:00p.m.) "sleeping much of day, roused enough to take meds and eat a small amount of food at each meal".

9/7/02 at 2040 (8:40p.m.) up pacing halls no agitation." Gave resident meds obtained in mouth for a few min.(minutes) then spit them out".

9/8/02 at 1100 (11:00a.m.) "Been awake, alert today. took meds and ate breakfast". On 9/8/02 at 1700 (5:00p.m.) Temp 99 degrees "glassy eyed - confused. Crawling on floor".

9/8/02 at 2100 (9:00p.m.) incontinent of urine.

9/9/02 at 2400 (12:00a.m.) "Res resting quietly in bed. Res. difficult to awaken. Res said a few words after much verbal/tactile stimulation. 2400 (12:00a.m.) Ativan held".

9/9/02 at 0600 (6:00a.m.) "Remains lethargic/difficult to awaken. Slowly says a few words, doesn't open eyes".

9/9/02 1100(11:00a.m.) "Sleeping, but rouses easily for a short time before returning to sleep. Lungs clear, no cough".

9/9/02 at 2015 (8:15p.m.) "Awake and up for evening meal. Refused to stay sitting at the table. MD notified of lack of urination. No call back".

9/10/02 at 12:30 a.m. Ativan held due to resident being somewhat slow to awaken.

9/10/02 at 2:10 a.m. "Resting quietly in bed. Respirations even, non-labored. 9/10/02 at 5:45 a.m. "Writer entered residents room to take his temp. Lying in bed on his R ( right) side. 0 (no) pulse, B/P, (blood pressure), or respirations. resident expired".

In interview with E1, the director of nurses, on 9/20/02 at about 9:10 a.m., E1 stated that R1 was an aggressive and abusive resident. E1 stated that R1's death was unexpected. E1 stated that R1 was on the Alzheimer's unit and that staff do rounds and check the residents every 2 hours. During the initial tour of the facility E1 stated that they have several residents in the hospital with respiratory infections and problems and some residents have been treated in the facility for respiratory infections. This was confirmed by E2, ADON, (assistant director of nurses), during the resident tour on 9/27/02 at 9:10 a.m. E1 was again interviewed on 9/26/02 at about 3:40 p.m. and was asked that since R1 was admitted with a Haldol overdose if condition may have declined due to his increase in psychotropic medications and E1 stated that she "didn't know".

In interview with E9 on 9/20/02 about 1:50 p.m., the CNA (certified nurse's aide) that usually works the day shift on the Alzheimer's unit, E9 stated she had worked on Monday 9/9/02 the day before R1died. E9 stated that R1 had been "coughing up green phlegm". E9 stated that she knew "R1 was in trouble spitting up that green stuff." E9 stated that she reported this to E1, the director of nurses, and E5, the charge nurse, but this is not documented in the nurses notes or documented as being reported to the physician. E9 continued to say that R1 was not up roaming and wouldn't eat or drink and stated that R1's death was unexpected. E9 also stated that she had worked the weekend and R1 did not eat or drink well over the weekend. E9 repeated that she was "surprised he passed away".

On 9/20/02 at 12:30 p.m. E6, the social service director, was interviewed in her office. E6 stated that she was told that R1 died at 5:45 a.m. when she got to work on 9/10/02. E6 stated that R1 had "dementia, walked up and down halls, was physically aggressive, and had some sexual issues". E6 stated that R1 was "on a lot of psych meds, took way too much medicine". E6 stated that she observed R1 on 9/9/01 and E6 stated that R1 was lethargic all day and not active in the evening. E6 also stated that R1 was not eating or drinking and the staff told her that R1 "did not eat or drink well for the past couple of days". E6 continued to say that on the morning of 9/10/02 E16, the administrator, asked her (E6) to add to R1's care plan that R1 could "wear sweats to bed". E6 stated she wondered "why care plan for in sweats after he died? Why was this an issue?" E6 stated that she "thought the staff were scared to change him" (R1). E6 stated she "added this to the care plan and dated the entry 9/10/02 after he, (R1) had died" E6 stated she felt "very uncomfortable with his (R1's) death". The care plan was reviewed and the entry to wear sweats to bed was on the care plan dated 9/10/02.

On 9/20/02 at 12:50 p.m. E10, the RN Care Plan Coordinator, was questioned regarding R1's care. E10 stated that R1 had Alzheimer's, was (usually) up and about and active. E10 stated that "death was a surprise, sudden, didn't expect death". E10 also stated that E6, the social service director told her that E16, the administrator, had told her to come and add "he can sleep in sweats" to the care plan. E10 stated that this issue had never came up at care plans and that R1 "slept in a gown".

On 9/20/02 at 1:44 p.m. E13, LPN (Licensed Practical Nurse) on duty at time of R1's death, stated he didn't give R1 his Ativan at 12 midnight because R1 was sleeping soundly. E13 stated that about 2:10 a.m. he stepped just inside of R1's room and "thought he was breathing". E13 stated at 5:45 "he was dead, laying on his right side, had pooling of blood in his face, discolored". E13 stated "Could tell it didn't just happen, don't know how long he was dead". On 9/24/02 at 4:50 a.m. E13 was again interviewed by phone and was asked if he gave R1 any care or physically checked or assessed R1's condition he stated "no, the aides do that".

On 9/24/02 at 11:35 a.m., E14, CNA assigned to the unit on the night R1 died, was interviewed by phone. E14 stated she took R1's vitals at 12:30 a.m. but no other care was done. E14 when asked if she gave any care or physically checked R1 after the 12:30 a.m. vitals stated "no, just peeked in the door". E14 stated that the nurse called her to R1's room at 5:45 a.m. on 9/10/02 and informed her that R1 was dead. When asked, E14 stated that R1 was "stiff and cold". E14 was again interviewed on 9/26/02 at 1:53 p.m. and E14 stated that "she just peeked into the room to make sure that he (R1) was still in bed, could not tell if he was breathing or not just assumed that he was".

On 9/24/02 at 4:58 a.m. E15, CNA, was interviewed by phone. E15 stated that she did not take care of R1 but was asked to assist E14 to get R1 ready for the mortuary on 9/10/02 about 6:45 a.m. E15 stated that all they did was wash R1's face. E15 stated that they usually wash the entire body and put on a gown but R1 was dressed in street clothes and was already "too stiff" and didn't know if they should cut his clothes to get them off so they just left them on him. E15 stated that R1 was "stiff and cold".

On 9/24/02 at 2:00 p.m. E17, the evening shift CNA, was questioned about R1. E17 had worked the evening shift on 9/9/02 the evening before R1 died. E17 stated that she wondered what was wrong with R1 because he was "unusually tired". E17 stated she did not work the weekend but the staff stated that R1 was "quiet and tired all weekend". E17 stated that R1 slept in the recliner all evening until supper then wouldn't stay at the table to eat and was up and roaming so she changed R1 and put him to bed about 6:45 p.m. E17 stated that she didn't physically check R1 after she put him to bed but just "peeked in at him".

On 9/20/02 about 12 noon E3, CNA, was questioned about R1. E3 stated that R1 was already dead when he came to work on 9/10/01 at 6:00 a.m. E3 stated he went to R1's room about 6:15 a.m. and that R1's left eye was closed, the right eye was open and that R1's left arm was above his head and was stiff. E3 stated that R1 was black, blue and dark purple.

On 9/20/02 at 12:08 p.m. E4, CNA, was questioned regarding R1. E4 stated that he was asked to assist the mortician with R1 at about 7:45 a.m. on 9/10/02. E4 stated that R1 was "in street clothes, his left arm was extended and rigid and his knees were stiff and up at an angle". E4 stated "he was blue and the body was cold". E4 stated that he knew R1 had declined but didn't think he was going to die.

On 9/24/02 at 3:42 p.m. Z5, the attending physician for R1, was called and interviewed. Z5 stated that R1 had Alzheimer's and that he had seen R1 the end of last month (August 2002). In review of R1's record, the progress notes confirmed that Z5 had seen R1 on 8/30/02. Z5 stated when he last saw R1 he was "up roaming, yelling, aggressive and very active". Z5 stated the nursing home called and told him that R1 had died. Z5 stated the death was "sudden and unexpected". When questioned about the cause of death Z5 stated "didn't have any idea, but with his stage of dementia possibly had a stroke". Z5 stated that he was not notified about R1 not eating and drinking well and did not remember any call by the nursing home on 9/9/02 about R1 not urinating. Z5 stated it would be a family decision but if he had been informed that R1 was not eating or drinking he would have sent R1 to the hospital or "pop an IV in at the facility since it is a skilled facility." Z5 stated that he was "not kept abreast of any changes with (R1)". Z5 was again interviewed by phone on 9/26/02 at 1:48 p.m. and Z5 again stated that he had "no call about him (R1) not urinating". Z5 was asked if Z5 felt that R1's change in condition could be due to the increase in his psychotropic medications and Z5 asked surveyor to read the list of his psychotropic medications and then stated "Possibly could be the meds catching up with him - hard to say".

On 9/26/02 at about 9:05 a.m. Z7, agency LPN working on the evening shift before R1 died, 9/9/02) was interviewed by phone. Z7 stated that she was familiar with R1 and he didn't seem any different to her on the night of 9/9/02. Z7 stated that R1 would not stay at the table and going from door to door carrying his food bowl. Z7 when asked did not know if R1 had eaten anything that night. Z7 stated that when they have a problem with a resident they usually fax the doctor the information. Z7 stated that she called the doctor about R1 because he had not urinated on the day shift nor on her shift up to the time she called before Z5's office closed, did not recall the time. Z7 stated that she called Z5's office and talked with the nurse about R1 not urinating. Z7 stated that Z5 did not call her back. Z7 also stated that the CNA's told her that R1 had urinated at the change of shifts. (Previously stated interviews with E17, the PM shift CNA and E14, the night shift CNA confirm that no toileting or incontinence care was provided to R1 by either of them at the change of shifts).

On 9/26/02 at 1:40 p.m. Z8, office nurse for Z5, was called and questioned about receiving a call regarding R1 not urinating. Z8 stated there is nothing in the file about the nursing home calling about R1. Z8 stated that the nursing homes normally correspond with the doctors by fax but if the nursing home calls it is written in the office chart on the resident. Z8 stated that they have not had R1 as a patient very long. Z8 stated again "don't recall anyone calling about him" and said that she "can't say for sure they didn't call and can't say they did call, no way to say but nothing in his (R1's) chart there" (at the office).