Rehab & Care Center- Jackson County
1441 North 14th Street
Incident Report Investigation of 1/19/03
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.
Personal care shall be provided on a 24-hour, seven-day-a-week basis.
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.
AN OWNER, LICENSEE, ADMINISTRATOR EMPLOYEE OR AGENT OF A FACILITY SHALL NOT ABUSE OR NEGLECT A RESIDENT. (Section 2-107 of the Act)
This REQUIREMENT was not met, as evidenced by:
Based on staff interviews, record reviews, and review of incident reports, the facility failed to reassess the use of ½ side rails and failed to initiate interventions to prevent reoccurrence of incidents involving the ½ side rails for one of one sampled resident (R1) from the sample of 5. R1, on two different occasions, had her neck/chin and head area wedged between the half side rails and the mattress. This failure resulted in the death of 1 resident (R1) and resulted in an immediate jeopardy. The past noncompliance occurred from March 12, 2002 to January 19, 2003.
The findings include:
1. R1 was a 88 year old female who was admitted to this facility on 1/11/00 and had diagnoses that included Alzheimer's Disease, Dementia, Organic Brain Syndrome, and Insertion of Gastrostoma.
R1's most recent Minimum Data Set(MDS) was a significant change MDS dated 11/25/02. This MDS documents that R1 had long and short term memory loss, was moderately impaired for making daily decisions, had repetitive physical movements and would resist care. R1 was totally dependent on staff for bed mobility, transfers, dressing, eating, hygiene, and bathing. R1 had partial loss of voluntary movement with limitation on both sides involving the arm, leg, and hand.
The care plan for R1 dated 12/24/02 indicates a problem of "At risk for injury/falls R/T (related to) attempts to self transfer et (and) ambulate...."
A facility incident report dated 01/19/03 documents that E5, Licensed Practical Nurse/charge nurse, was called to resident room D110 by E4, Certified Nurses Aide, and E3, Licensed Practical Nurse at 4:05 A.M. on 01/19/03. R1 was sitting on buttocks with legs bent toward right. R1's head was bent back with chin caught against half side rails and head bent back wedged against the mattress. R1 did not have a pulse, blood pressure, or respirations.
In a written statement dated 01/19/03, E4 stated that at approximately 4:00 A.M., she saw R1 on the floor. E4 checked for a response and noted that R1 was not breathing and immediately ran out of the room to inform E5. After E5 checked the resident, she told E4 to find another aide to help get the resident from the floor and clean her up. This written statement was verified per interview on 01/29/03 with E4.
E-3 stated in a written statement dated 01/19/03, and verified per interview on 01/29/03, that on entering the room she found R1 sitting on buttocks with legs bent to the right with chin caught against half side rail and head bent back wedged against the mattress. There was no pulse, no blood pressure, and no respirations. R1's body was still warm to touch. E3 released R1's head from the side rail. E5 listened for respirations and apical pulse with none noted. E5 stated that R1 was a do not resuscitate. E3 told E4 to put her back in bed.
R1's nurse's notes dated 01/19/03 documented the following: E2, Director of Nurses, was notified of the incident at 4:10 AM; Z1, the physician of record was notified at 4:15 AM; the sheriff"s department was notified of the need to speak with the coroner at 4:20 A.M.; Z2, Deputy Coroner was in the facility to examine the resident; the police department was in the facility and reviewed the information with Z2 at 5:40 AM; and the family was notified at 5:51 AM.
The copy of the Murphysboro Police Department incident report documents, "Officers assisting Jackson County Coroner with accidental strangulation .... Coroner stated death appeared to be accidental."
According to facility incident report review, a similar incident occurred with R1 on 03/12/02 at 12:20 A.M. The facility incident report documents, "Found sitting on buttocks on floor with back against bed holding onto 1/2 SR (side rail) with both hands with neck between 1/2 SR (side rail) and mattress. Res. alert. (no) distress noted." The half side rails were continued and were raised at all times while R1 was in bed, as verified by R1's nurses notes and interviews with E2, DON, E3, LPN, and E4, CNA.
The most recent side rail assessment was dated 02/16/02. This indicates the family requested the side rail and that it is used for safety concerns, assist with bed mobility and assist with bed transfers. E2, Director of Nurses, stated that R1 had half side rails due to the head of the bed being elevated because R1 received a tube feeding. The half side rails were not reassessed after the 03/12/02 incident nor were any interventions initiated to keep this type of incident from reoccurring.
The Immediate Jeopardy was determined to have begun on 01/19/03, when R1 was found sitting on her buttocks on the floor with her head bent back wedged against the mattress and chin caught against the half side rails. E1 and E2 were notified of the Immediate Jeopardy Past Noncompliance on 02/11/03 at 11:20 AM.
Prior to the survey date of 02/18/03, the facility had taken the following Quality Assurance actions which corrected the Immediate Jeopardy and corrected the non-compliance: