IDPH has cited and fined Parker Nursing & Rehabilitation Center in Streator after a resident there developed sepsis from aspiration pneumonia due after vomiting because his orders for administering nutrition through his feeding tube were not followed, leading to him be admitted to hospice for end of life care.
One of the basic truisms in the nursing home industry is that a nursing home should not accept the admission of a resident when they are not able to meet the care needs of the resident. This is what happens when that fundamental is not followed.
When a resident is admitted to a nursing home from a hospital, the discharge planner from the hospital forwards information to the nursing home regarding the medical history and care needs of the resident. Those records are reviewed by a senior member of the nursing staff to determine whether or not the resident is suitable for admission to the nursing home. If so (and the financial portion of the admission is worked out), then the resident can be admitted to the nursing home.
The resident at issue was admitted to the nursing home for rehabilitation after experiencing a stroke. He had a tracheostomy and a feeding tube. However, the admission screening information from the hospital stated that he was a “short stay” admission. The discharge orders included continuous infusion of the solution for the feeding tube at 75 mg per hour. Delivery of the solution would ordinarily require use of a pump to ensure that the resident received the solution at the desired rate.
The decision to accept a resident at this nursing home would ordinarily be made the quality assurance nurse, who at this facility was a LPN. However, she was gone on vacation at the time that the admission was being considered and her role was being covered by another nurse, the MDS Coordinator. This nurse okayed accepting the resident into the facility, apparently unaware that they did not have a pump for use for this resident.
There were other members of the staff who were aware that there was no pump available for this resident. However, no one called the resident’s doctor to notify him that they could not carry out the doctors’ orders due to the lack of a feeding pump. The resident’s doctor told the state surveyor that he should have been notified and that had the staff done so, he would have changed the orders.
Without a pump to regulate the flow of feeding tube solution to the resident, the rate of the feeding tube was left to gravity – in other words, the bag with solution was left to hang on an IV pole and simply empty out. The problem with this is that the rate at which the solution was delivered to the resident was not controlled, which in this case meant that the solution was delivered to the resident far too quickly. The net result of this is that the resident was badly overfed and began to vomit, with vomit coming from the resident’s mouth and out of the tracheostomy.
Vomiting from a resident represents a change in condition which requires physician notification. However, the doctor was not notified. Further, the nurse did not shut off the tube feeding, resulting in the resident continuing to be overfed. As the resident continued to receive more and more solution, he continued to vomit.
The nurse reported to the state surveyor that she did not suction the resident initially, but did so later. Even then, it was a superficial suctioning, not a deep suctioning which would have been necessary to clear the airway. Suctioning was necessary to clear the airway because when a person inhales foreign substances into the lungs, this causes aspiration pneumonia.
Aides assigned to care for the resident reported to the state surveyor that throughout the night they advised the nurse on duty that the resident was continuing to vomit and that the resident did not look good. Despite this, the nurse did not go to check on the resident and did not suction the resident’s airway.
Some 5 hours after the resident began to vomit, the nurse called for an ambulance to take the resident to the hospital. There, the resident was diagnosed with severe sepsis due to aspiration pneumonia caused by overfeeding. The resident was admitted to hospice to receive end-of-life care.
There were multiple failures in the care that this resident received:
- The nursing home accepted the resident for admission when it did not have the equipment necessary to treat him consistent with physician orders;
- They did not advise the doctor that they did not have the pump necessary to control the delivery of feeding tube solution to the resident, precluding the doctor from issuing other orders for the feeding of the resident;
- They failed to advised the doctor that the resident was receiving far more feeding solution than was ordered;
- They failed to advise the doctor of the onset of vomiting by the resident;
- Once the resident began to vomit, they failed to stop the delivery of the feeding tube solution;
- The nurse on duty failed to suction the resident’s airway once he began to vomit, setting the stage for him to develop aspiration pneumonia;
- The nurse on duty failed to assess the condition of the resident despite being advised by aides that the resident was continuing to vomit and did not look good.
All of these failures set the stage for the resident to be admitted to hospice to receive end-of-life care. This is a resident who despite his recent medical issues, was admitted to the nursing home as a rehabilitation patient – in other words, there was an expectation that he would eventually return home. This was not be be due to the failures in the care that this resident received.
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