Marklund Childrens Home
Bloomingdale, Il 60108
Date of Survey: 1/21/03
Incident Report Investigation of 12/13/02
The facilitys governing body shall exercise general direction of the facility and shall establish the broad policies for the facility
related to its purpose, objectives, operation, and the welfare of the residents served.
The facility shall have written policies and procedures governing all services provided by the facility which shall be formulated with the involvement of the administrator. These written policies shall be formulated with the involvement of the medical advisory committee and representatives of nursing and other services in the facility. The policies shall be available to the staff, residents and the public. These written polices shall be followed in operating the facility and shall be reviewed at least annually.
Nursing care (including personal, habilitative and rehabilitative care measures) shall be practiced on a 24 hour, seven day a week basis in the care of residents. Those procedures requiring medical approval shall be ordered by the attending physician.
All necessary precautions shall be taken to assure the safety of residents at all times, such as: nonslip wax on floors; equipment, adaptive equipment and assistive devices properly maintained; and proper use of side rails on beds and restraints.
These Regulations are not met.
Based on observations interviews, file verification, Accident/Incident Reports, Internal Investigation Reports, and review of other pertinent documentation, the facility failed to ensure that nursing services provided adequate monitoring and care for residents health and safety for 1 resident who expired (R11) and 10 additional individuals (R7, R13, R18-R25) who have tracheotomies and pulse oximeter monitors.
Based on observations, interviews, file verification, Accident/Incident Reports, Internal Investigation Reports, the facility Nursing Manual, and review of other pertinent documentation, the facility failed to ensure that R11's pulse oximeter monitor was functioning at optimal performance when R11's tracheotomy (trach) decannulated and he became cyanotic, and he had no pulse or respirations. He expired on 12/13/02. The facility failed to ensure that similar circumstances do not occur for 10 additional individuals (R7, R13, R18-R25) who have tracheotomies and pulse oximeter monitors.
Per his 12/01/02-12/31/02 Physicians Order Sheet, R11 was a 4 year old male, with a gastrostomy tube, whose diagnoses included profound mental retardation, seizure disorder, gastro-esophgeal reflux disease, and respiratory distress. A Respiratory Assessment dated 11/15/02 indicates that R11 had a tracheostomy performed in February 2002.
According to a facility Accident/Incident Report, on 12/13/02 at 6:53 p.m., R11 was found in bed, decannulated and cyanotic, without pulse or respirations. R11's trach stoma was suctioned. 911 was called, and CPR was initiated along with oxygen. The child pinked up and had a pulse of 66. Following his transport to a local hospital via paramedics at 7:03 p.m., R1 expired at 7:23 p.m.
His Medical Certificate of Death reads Acute Airway Obstruction of 5 min (minutes) duration as the primary cause of death.
The facilitys Internal Investigation Report dated 12/16/02, states that on 12/13/02, E10, direct care staff, had her last physical contact with the resident (R11)...at 6:45 p.m. This report continues by stating that, from 6:45 p.m. until 6:53 p.m., E10"...was attending to another resident directly adjacent to this resident, and at 6:53 p.m., E10"...noted the cyanosis, removed the trach collar (of R11) to find that the resident had decannulated. According to the report, trach strings were in place.
Per observations throughout the survey, and per a facility room assignment list, 10 individuals (R7, R13, R18-R25) currently reside in their Exceptional Care Unit (ECU)
During an interview with E10 on 01/06/03 at 5:27 p.m., she stated that the alarm on R11's pulse oximeter monitor did not sound. She said the monitor was quiet, made no noise. She said she did not recall if the monitors green light was flashing or not (green light indicates the monitor is on). E10 said that the probe of R11's pulse oximeter monitor was on R11's toe, and that she disconnected the lead when she picked up R11 (and put him on a mattress on the floor. E10 stated that she has since (the incident of 12/13/02) learned that the machine (pulse oximeter monitor) has to be charged, and that the volume knob is to be turned to full volume. She then demonstrated, with R13 as an example, how there are only 2 outlets in the electrical plate near R13's bed. She said that the number of electrical outlets sometimes presents a problem, as she unplugged R13's nebulizer and plugged her pulse oximeter monitor into that same outlet.
On 01/06/03 at 5:45 p.m., E11, nurse, demonstrated where R13's machines were plugged in, which included the 2 outlets by her bed and 2 additional electrical outlets nearby. E11 explained how, for instance, R13 would have a nebulizer periodically plugged in, an electrical feeding pump on most of the time, and both a pulse oximeter monitor and a compressor plugged in nearly all the time. In addition, E11 stated that at times, R13 may also have a suction machine plugged in and/or a radio. Per observation throughout the survey, as well as E11's input on 01/06/03 at 5:45 p.m., the machines utilized by R13 are typical of those used by all the residents in the ECU, including R11.
On 01/07/03 at 3:14 p.m., E8 was interviewed regarding the incident of 12/13/02, She stated that on that evening, she was outside the door of the room (ECU-1) where R11 and 4 others (R13, R18, R19, R20) resided when she heard E10 say, Oh, my God! She said the time was just before 7 p.m., probably 6:50 something. E8 stated that upon arriving at R11's side, she found him to be blue and limp, the cannula out (and) horizontal across his neck. She further stated that he had no pulse, no apical (pulse), no respirations. She said she herself had seen him playing with a large, yellow toy within the previous 10-15 minutes. E8 stated that E10 said there was no sound from R11's (pulse oximeter) monitor. E8 stated that after R11 left for the hospital that evening, she hooked the monitor up to herself in an effort to find out why no alarm had sounded. E8 said that she found the volume to be turned down to just before off. She stated she then checked the monitors of the other 9 residents on the unit and found 2 others (she did not recall who they were) with volume settings down low. When asked if the volume being turned down has been a problem in the past, E8 replied that one would usually think of the sensor being off or loose (first) rather than the volume (being turned down low). Asked if she was ever aware of R11's trach decannulating prior to 12/13/02, E8 stated that she had heard of it having happened once before, but she herself had not experienced that with R11.
In contrast to what E10 said (interview of 01/06/03 at 5:27 p.m.), E8 said that she (not E10) lifted R11 from a horizontal position across his bed and took him over to R18's bed as there was no suction (machine) by his bed. Also in contrast to E10 saying (01/06/03 interview at 5:27 p.m.) that she disconnected R11's lead, E8 said that E10"found the (montor) connection to be apart...
Per review of the facilitys Nursing Manual, the procedure for Oxygen-Saturation speaks of the attachment of the probe, and that the oxygen-saturation will be checked on all the clients with tracheostomies daily and PRN via standing orders. It will be performed by a nurse. During the interview with E8 on 01/07/03 at 3:14 P.M., she said that E10, direct care staff, would have checked the oxygen-saturation of R11"at about 3P.M. and related the information to her (E8, the nurse). The procedure does not address the monitor and its settings, including volume of the alarm.