Kankakee Nursing & Rehab Center
Kankakee, IL 60901
Date of Survey: 12/18/2002
The facility shall have written policies and procedures, governing all services provided by the facility which shall be formulated by a Resident Care Policy Committee consisting of at least the administrator, the advisory physician or the medical advisory committee and representatives of nursing and other services in the facility. These written policies shall be followed in operating the facility and shall be reviewed at least annually by this committee, as evidenced by written, signed and dated minutes of such
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 residents 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.
General nursing care shall include at a minimum the following and shall be practiced on a 24-hour, seven-day-a-week basis:
Objective observations of changes in a residents 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 residents medical record.
All necessary precautions shall be taken to assure that the residents environment remains as free of accident hazards as possible. All nursing personnel shall evaluate residents to see that each resident receives adequate supervision and assistance to prevent accidents.
The advisory physician or medical advisory committee shall develop policies and procedures to be followed during the various medical emergencies that may occur from time to time in long-term care facilities. These medical emergencies include, but are not limited to, such things as:
1) Pulmonary emergencies (for example, airway obstruction, foreign body aspiration, and acute respiratory distress, failure, or arrest).
2) Cardiac emergencies (for example, ischemic pain, cardiac failure, or cardiac arrest).
3) Traumatic injuries (for example, fractures, burns, and lacerations).
4) Toxicologic emergencies (for example, untoward drug reactions and overdoses).
5) Other medical emergencies (for example, convulsions and shock).
There shall be at least one staff person on duty at all times who has been properly trained to handle the medical emergencies listed in subsection (a) of this Section. This staff person may also be counted in fulfilling the requirement of subsection (d) of this Section, if the staff person meets the specified certification requirements.
These regulations are not met as evidenced by:
Based on record review and interviews the facility failed to:
The resident sustained a subdural hematoma and expired at a local hospital on 10/15/2002.
Review of R2's face sheet shows that R2 was admitted to the facility on 10/11/1993, with diagnoses including Dementia, Osteoarthritis, Osteoporosis and Cataracts. Review of R2's assessment dated 07/03/2002 shows that R2 had cognitive impairment, ambulated independently and required supervision only with dressing and personal hygiene.
A review of R2's 10/14/2002, nurses note at 3:15 P.M. showed, "seen per staff in entry way, going to the floor with head to floor, eyes closed." The facility investigation report read: "seen per staff collapsing to the floor with eyes closed hitting her head to the floor. Doctor ordered to observe and send the resident to the hospital when condition changes." In an interview with E8 (receptionist) on 10/25/2002, at approximately 10:30 P.M., E8 claimed "when she fell, it sounded so loud, chills went through me. She fell so hard that her head bounced twice on the floor. In an interview on 10/17/2002, at approximately 2:10 P.M. R1 stated that when R2 fell, "it was so loud, it sounded like a brick fell on the floor."
In an interview with E1(Administrator) and E2 (Director of Nursing) on 10/17/2002, at approximately
1:15 P.M. E2 stated that for all incidents of falls that involve a head injury, a neuro check will be initiated and completed within the first 40 hours. The facility procedure review shows that neurological check should be done as follows:
Every 15 minutes for the first 2 hours
Every 30 minutes second 2 hours
Every 1 hour for 4 hours
Every 2 hours for 8 hours
Every 8 hours for 24 hours.
A review of the facility's neurologic assessment procedure # 11 read: "Documentation will be done on flow sheet with additional information on the nurses notes." A review of the neurological signs observation sheet for R2 indicated no documentation of neurological signs after 7:15 P.M. on 10/14/2002 (only four hours after observed fall).
On 10/22/2002, at approximately 12:30 P.M. per phone interview, E7 (LPN, evening shift) stated that she started the neurological signs check at 3:15 P.M. because R2 hit her head. E7 claimed R2's vitals were okay. During a phone conversation with E7 on 10/22/02, R7 claimed she was not aware that she failed to assess R2 hourly for any changes in neurological signs after 7:15 P.M. on 10/14/2002. E7 stated that she left early that night.
Review of the nurses notes show no documentation or assessment on the status of R2's condition from
11:00 P.M. to 7:00 A.M.. There was no documentation of neurological signs after 7:15 P.M. on 10/14/2002.
On 12/05/2002, at approximately 2:25 P.M. per phone interview with E5 (LPN, night shift) stated that she was aware of R2's incident. E5 claimed that R2 was in "deep sleep" that night and couldn't get any verbal response from R2. E5 also stated that she remembered (the Certified Nurse Aides) saying that R2 was very hard to be aroused. E5 admitted that she didn't assess R2 and she did not document anything in R2's clinical record because she had a lot of things to do that night. E5 stated that she cannot even remember if a neuro check was started.
E6 (restorative nurse aide) was interviewed by phone on 10/18/2002, at approximately 11:35 A.M. E6 indicated on 10/15/2002, she went to R2's room at approximately 8:00 A.M. and found that R2 was not verbally responding and would not open her eyes.
In an interview with E4 (LPN, morning shift) on 10/17/2002, at approximately 1:00 P.M. said, "On 10/15/2002, at 7:00 A.M. I went to the patient's room; she was non responsive, I thought she was just tired so I left her. At 9:30 A.M., I went to the room to give her medication but she was still not responding. I shook her and I took her hand up in the air and it just fell, she did not respond and her eyes were closed. I went out to look for the CNA (Certified Nurses Aide) to know if she ate for breakfast. The CNA stated she didn't eat at all. At 9:45 A.M., I went and asked an R.N. to help me assess her and she said 'send her to the hospital.'" When E4 was shown the neurologic assessment sheet, E4 stated that she did not do any neurological assessment of R2 and did not know how to conduct the neurological signs assessment.
Per phone interview on 10/22/2002, at approximately 2:30 P.M., the attending physician (Z1) stated that a CAT Scan was done in the hospital on 10/15/2002, and revealed that R2 expired with a diagnosis of intra cerebral hemorrhage. Z1 stated that he ordered the staff to monitor R2, conduct neurological assessments and if her condition declines to send the patient out to the hospital. This order was verified on the physician order sheet dated 10/14/2002. Z1 stated he was unaware that the neurological assessments were done only for four hours instead for 40 hours. Z1 also stated "that is a problem, they should have monitored her closely and followed their protocol."
Review of R2's hospital emergency room physical examination dated 10/15/2002, indicated that upon admission R2 was comatose (non responsive to verbal and painful stimuli) with pupils dilated. R2 was diagnosed with Subdural Hematoma, Coma, Aspiration Pneumonia and was pronounced dead at approximately 3:24 P.M. on 10/15/2002.