Monday, February 9, 2009

Oak Park Healthcare Center Fined for Failing to Provide Emergency Care to Seizure Patient

Oak Park Healthcare Center
Facility I.D. Number 044602
625 North Harlem
Oak Park, Il 60302
Date of Survey: 01/17/02
Complaint Investigation
The advisory physician or medical advisory committee
shall develop policies and procedures to be followed
during the various medical emergencies that occur from
time to time in long-term care facilities. These
medical emergencies include, but are not limited to,
such things as: 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 the
Section, if the staff person meets the specified
certification requirements. 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 resident’s 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. Objective observations of changes in a
resident’s 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 resident’s medical record. AN OWNER,
Based on Interviews with Z1, Z2, Z3, E2, E5 and record
review of nursing home and hospital records, as well
as paramedic transport records, the facility failed to
provide timely assessment and emergency care to one
resident suffering with grand mal seizures from
3:55a.m. until abated by paramedics at 5:10a.m. on
1/11/02. Resident was not transported to a hospital
until 5:40a.m. for care and evaluation.
Facility failed to recognize that emergency services
were needed in a timely manner when seizure
300.1030a)5)activity did not stop and respond to 02.
Seizures did not stop until paramedics administered
Versed IM at 5:10a.m--1 hour and 15 minutes after
symptoms started.
Findings include:
R2 with known history of seizure activity had
previously low Dilantin levels, on 12/10/01 the level
was 0.4mcg/ml and on 12/20/01 the level was 1.3
mcg/ml. Normal levels are 10-20 mcg/ml
(micgrogram/milileter). Per interview with Z3, the
facility had made Z3 aware of the levels and he had
ordered Neurontin and observation to check if R2 was
med compliant. R2 has care plans to monitor for
seizures; medication administration; to monitor labs
and to notify MD (medical doctor) of abnormal levels;
to establish airway and loosen clothing, observe and
record progression of a convulsion and to monitor the
time, intensity and duration of a convulsion. There
was no documentation or interview indicating that any
of this was done.
Computerized medical records from the facility dated
01/11/02 at 7:17a.m, after R2 had already been
transferred to the hospital, stated that R2 had
episode of seizures at 4:00a.m. and M.D. ordered
transfer to hospital, but was refused and R2 was
diverted to another hospital. Surveyor interviewed Z1,
Z2, and E2, who denied that R2 was diverted from one
hospital to another. There was no evidence that R2 was
observed or positioned to maintain the airway as per
care plan. And there was evidence that the facility
failed to differentiate petit mal seizure activity
from grand mal seizure activity that was identified by
the emergency medical team upon arrival to the nursing
Per interview, Z1 stated that on 01/11/02 at
approximately 4:30a.m. at the hospital, he received a
call from E5 stating that R2 has been having seizures
since 3:55a.m. (35 minutes earlier)." I asked the
nurse at the facility what had they done to stop the
seizures. The nurse stated "nothing - we are still
waiting on Superior ambulance. Z1 continued " I then
asked the nurse if this resident was still seizing and
he stated, yes. I told the nurse to call 911 since
they are faster and they can stop the seizing". Per
ambulance records, it was not until after E5 spoke
with Z1 that E5 placed a call to the ambulance service
--even though R2 was having continuous seizure
activity since 3:55a.m.
Per interview with Z2, the facility had placed 02 at 2
liters on R2 and taken minimum vital signs and nothing
else had been done. When Z2 arrived in the room at
4:50a.m., R2 was having grand mal seizures and was
left unattended. Z2 told Surveyor that E5 told Z2 that
R2 was having petit mals but upon observation, R2 was
having tonic/clonic movements indicating severe grand
mal seizures. Z2 also felt that R2 was febrile because
R2 felt extremely hot. Facility had not obtained any
temperature readings from R2 during this time. Z2
responded to the emergency by giving Versed IM,
increasing 02 to 4 liters, and applying ice packs to
both axillas. Z2 left the facility at 5:40a.m. after
stopping the seizures around 5:10a.m. The run time
record indicates that the resident arrived at the
hospital at 5:45 a.m.
Surveyor interviewed E5 on 1/16/02 at approximately
2:40p.m. E5 denied he had waited until 4:41a.m to call
the ambulance and stated that he called 5 minutes
after seizures started for R2 at 4:00a.m. E5 stated
that he administered 02 and never left the room. This
conflicts with the interviews with Z1 and Z2 and the
run sheet for the ambulance company which clearly
states that ambulance was called at 4:41a.m. not
4:00a.m. E5 admitted to talking to Z1 but at 4:00a.m.
instead of 4:30a.m. This is also contradicted in
hospital record review which lists the time of call
clearly at 4:30 to 4:40a.m.
Surveyor requested all nursing notes related to
incident - all notes that were available were received
and read. The nursing notes received concerning the
incident is the 01/11/02 at 7:17a.m entry.
Interview with E7 on 01/17/02 at the facility on
speaker phone with E1 present , E7 stated that R2 was
found unresponsive and with white of eyes showing at
3:55a.m. on 01/11/02. E7 continued "I called E5, who
came in and checked her and gave her oxygen." E7
continued, "I continued to make my rounds on the
floor, but I kept going back to check on her. I went
back at 4:00a.m., and noticed her jerking, her whole
body was jerking, and she was foaming at the mouth. I
got E5 again and he checked on her, took her vital
signs and then left the room to call her doctor. I
left the room to see where E5 was. We both left the

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