Rockford, Illinois 2008 Nursing Home Report Card: Provena St. Anne Center
Provena St. Anne Center is a 179 bed nursing home facility located in Rockford, Illinois. The facility is rated as a two star facility in the new rating system instituted by Medicare.gov, indicating that it is a below average facility.
All nursing home facilities are required to advise a resident's family or legal representative when there is a change in condition or an injury. Provena St. Anne Center failed to do this in at least one instance with respect to a resident who sustained a skin tear that required first aid. After state intervention, nurses were in-serviced on the necessity of informing a resident's Power of Attorney timely when a resident sustains a skin tear requiring first aid intervention. The Director of Nursing was also forced to complete an audit of 10% of residents experiencing a skin tear that required first aid on a monthly basis.
All nursing home facilities must use the results of assessments to develop, review, and revise a resident's comprehensive plan of care. Provena St. Anne Center failed to develop a care plan that included objectives and interventions for a resident receiving peritoneal dialysis for the potential for complications arising from renal failure requiring hemodialysis. After state intervention, MDS coordinators and care plan coordinators were educated on assigning a comprehensive care plan for a peritoneal dialysis patients that includes approaches and interventions for peritoneal dialysis. Monthly reviews and audits must be conducted by facility staff and the Director of Nursing.
All nursing home facilities must provide services that meet the professional standards of quality. Provena St. Anne Center failed at least two of its residents in this respect when one resident was given medication after the one week stop date. Another resident received twice the ordered amount of medication on multiple days. Following state intervention, a mandatory in-service was conducted for all nurses regarding transcription, checking medication orders, stop dates for medications. Nurses were to check all transcriptions with another nurse to ensure accuracy. In another 2008 instance, a resident's central venous catheter was cut during a dressing change. The facility had only one rusty hemostat to use to stop the bleeding, so the line was tied off using a piece of string found at the nurses' station. The resident had to be supported by ambulance to a local hospital for replacement. After state intervention, the facility policy for dressing changes to PICC and central lines was changed and licensed staff was trained on the change in policy and the requirement to keep sharp objects away from the PICC and central lines.
All nursing home facilities are to provide pharmaceutical services that ensure accurate acquisition, receiving, dispensing, and administration of all drugs to meet the needs of its residents. Provena St. Anne Center failed at least one of its residents when she did not receive multiple medications on multiple consecutive days as the facility did not have the medications on hand. After state intervention, the nursing staff was in-serviced on giving medications without delay. Nurses were also in-serviced to track instances with pharmacy issues to identify opportunities for improvement.
Medication errors are unacceptable in any medical facility, much less a nursing home facility. Provena St. Anne Center failed to keep its residents free of significant medication errors and placed its residents in immediate jeopardy. A nurse administered Dilaudid instead of Morphine to a patient. Dilaudid is six times more potent than Morphine. The resident became unresponsive and had to be transported by ambulance to the hospital and was admitted with a diagnosis of altered mental status and hypercarbic respiratory failure. The administering nurse was not aware of the error until 44 hours after the event, when it was discovered during a morning drug count. The resident's physician was not notified of the error until eight days after the error. The hospital physician was not advised of the medication error either, thus delaying the appropriate treatment. After state intervention, the pharmacy consultant conducted a mandatory in-service on the 5 "R"s of medication administration - right route, right medication, right patient, right time, and right dose. The facility nursing staff was in-serviced on the facility's medication occurrence policy and focused on identification and reporting of errors as well as appropriate follow up. The in-service also convered the shift narcotic count policy. No nursing staff were allowed to work until they had received this in-service. It does not appear that the nurse involved was terminated.
The Terry Law Firm is experienced in handling cases of nursing home abuse and neglect. Please contact us at 1 (888) 317-2525 or visit us at www.nursinghomejustice.com.
