Duty to Report Incidents and to Investigate
The News-Gazette had an article about the state investigation of an incident in which a female patient at Champaign County Nursing Home suffered an injury that went undetected (or covered up) and died several days later. The incident has led to a chain reaction of investigations, reports and findings that have resulted in $50,000 in fines against the nursing home, the loss of some Medicare and Medicaid funding and the potential loss of all Medicare and Medicaid funding.
Two other visits to the nursing home by public health inspectors – one on April 2 and another on April 29 – found more problems at the facility. In the April 2 inspection, it was determined that the nursing home did not follow its own policy in handling an allegation lodged against an employee.
Also that day, the inspector determined that the nursing home staff "failed to provide appropriate treatment and services to maintain or improve abilities in toileting and transfers" for four residents.
The April 29 inspection found that nursing home staff failed to use proper equipment when transferring three patients. In the most serious case a 91-year-old patient suffering from dementia broke her hip after she stood up from her wheelchair and fell. The woman was supposed to have had a personal safety alarm on her wheelchair.
In the incident which set off the series of investigations, a patient identified only as R7 slipped out of a chair while in a lounge area, but apparently was caught by a certified nurse aide.
"CNA slid under (R7) and pulled her onto her lap ... (R7) denied pain .. did not hit head ... did not hit w/c (wheelchair) or w/c pedals. (R7) talking and laughing with staff ... able to move arms and legs without a problem or pain ... Body check done with no areas of redness noted," said a report identified as a "late entry," and dated Jan. 25. It is not clear whether the incident occurred that day or earlier. There was no other documentation of the fall before Jan. 25.
By Jan. 29, however, nurses noticed bruising on the woman's right leg and right hand. A physician ordered the woman be taken to an unidentified hospital. There, an emergency department attendant said the woman's "right leg has progressively increased in size with diffuse ecchymosis (bruising) ... It does appear (R7) struck her head." There was an "incredible amount of blood lost in the leg," an emergency department physician said. It "took a lot of fluid and blood to fix (R7's) anemia/shock which resulted in CHF (congestive heart failure)."
The woman died on Feb. 4. The Public Health investigation of the incident, dated Feb. 25, found the nursing home neglected to properly care for the patient in at least four ways:
– "By failing to implement existing policies on Falls, Lab and Diagnostic Test Results, Laboratory Testing, Orders for Anticoagulants, Anticoagulants and Change in Resident's Condition or Status;"
– "By failing to notify the physician in a timely manner of high laboratory values, neglected to identify a fall, to notify the Physician/Nursing staff of the fall and implement post fall monitoring;"
– "By failing to assess and monitor significant bruising as a side effect of anticoagulant therapy and a fall;" and
– Neglecting "to notify the Physician of the significant bruising in a timely manner, but continued to administer anticoagulants to R7."
The nursing home has allegedly instituted changes in response to the public health findings. For example, training will include special attention to reporting falls. "An episode where a resident lost his or her balance and would have fallen were it not for staff intervention, is a fall. In other words, an intercepted fall is still a fall," said a memo.
And when employees are accused of mistreatment of residents, a memo says they "will be removed from resident contact immediately until the results of the investigation have been reviewed by the administrator or designee. Employees accused of possible mistreatment shall not complete the shift."
