March 31, 1995
TWO COOK COUNTY NURSING HOMES DISCIPLINED
SPRINGFIELD, IL -- The Illinois Department of Public Health has taken disciplinary action against two Cook County nursing homes:
Briar Place was fined $10,000 for failure to ensure an employee was trained or experienced to perform an assigned job.
As the result of a complaint, Department surveyors learned a facility nurse mistakenly flushed a resident's Hickman catheter, which is used to administer medications directly into the body, with a drug -- potassium chloride -- instead of salt water (sodium chloride). The resident immediately complained of a tingling sensation, went into respiratory distress and stopped breathing. He was later revived at a local hospital emergency department.
A review of the nurse's personnel records found no training or experience with flushing Hickman catheters and the facility said it relied on the nurse's claim she knew the procedure. Asked about the incident, the nurse said she saw "chloride" and assumed it was sodium chloride.
Mercy Health Care Center was fined $10,000 for improper use of safety devices and restraints.
Responding to a complaint, Department investigators observed a resident restrained in a wheelchair by a safety bar with a combination lock. The resident's physician had prescribed a safety vest while the resident was in a wheelchair; the vest was to be released every two hours for 10 minutes and the resident observed every 30 minutes. State law prohibits the use of safety bars with combination locks.
When asked to remove the lock, the administrator and a certified nurse aid were unable to do so. They were joined by a registered nurse and the three were eventually able to work the combination and get the bar loose.
After reviewing resident files, investigators found other examples of residents restrained with devices not prescribed by their physicians. In addition, facility procedures requiring physicians to specify the type of safety device were not followed.
The Department ordered Mercy Health Care Center to ensure safety devices are used properly and staff is trained in policies, procedures, monitoring, application and release of restraints.
Both facilities have requested hearings on the Department's actions. No hearing dates have been set.
of Public Health
535 West Jefferson Street
Springfield, Illinois 62761
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