| 4375 |
NORTHEAST ATLANTA HEALTH AND REHABILITATION CENTER |
115504 |
1500 S JOHNSON FERRY ROAD |
ATLANTA |
GA |
30319 |
2016-11-09 |
323 |
G |
1 |
0 |
3P2Y11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to ensure a safe environment for three (3) residents (R15, R28 and R29). Specifically, the facility: a). failed to provide adequate supervision and assistive devices to prevent accidents for R15 who had a history of [REDACTED]. R15 sufferred actual harm when she fell again contributing to an additional hip fracture which led to her ultimate demise, and; b). failed to ensure the environment remained as free from accident hazards as possible for R28 and R29 who required multiple electrical devices when their medical equipment was plugged in to a power strip, this resulted in actual harm when the facility unplugged the pressure prevention mattress used for R28 who had severe pressure sores. (cross refer to F314) The facility census was one-hundred-nine (109) and the sample was seventy-seven (77) residents. Review of the CMS Form 672, signed and dated on [DATE] by the Director of Nursing revealed a total of 10 residents ambulated, 3 ambulated with assistance, 2 are bedfast, and therefore at least a total of 97 residents are at fall risk. Findings include: 1. Review of the Transfer/ Discharge Report revealed R15 was re-admitted to the facility on [DATE] from the hospital after having Open Reduction and Internal Fixation (ORIF) surgery to repair a fractured hip. R15 had [DIAGNOSES REDACTED]. The resident expired on [DATE]. Review of the hospital records [DATE] History and Physical revealed This patient is a very pleasant, [AGE] year-old with a known history of heart failure, chronic pain, neuropathy, spinal stenosis, and generalized debility, who apparently has been having pain in her right lower extremity for the past several days. According to her son, the R15 has not incurred any falls; however, he was informed last Thursday that the R15 had gently slumped to the ground. He states that ever since that time, she has been having severe right lower extremity pain. She has been working with physical therapy with regards to the pain, but it has not gotten any better. He reports that over the last couple of days, the mental status of R15 has somewhat declined and she has become a little bit more confused. This is usually indicative of a urinary tract infection and this prompted the nursing facility to send R15 to the emergency room , R15 underwent a workup, which revealed a distal femur fracture, as well as a urinary tract infection, acute kidney injury and hyperkalemia. Given these issues, the patient has been admitted for further evaluation and treatment. Review of the [DATE] nursing note for R15 documented at 7:25 a.m. revealed, on last rounds at about 6:50 am, assessment the right hip surgical site staples intact, moderate amount dark colored blood was observed sipping out from between the staples. The surgical site surrounding skin was also noted to be warm and tender to touch with slight discoloration. Resident c/o pain to area; Percocet ,[DATE] mg given and she was repositioned with assistance of another nurse for comfort; administered analgesic result pending. BLE (bilateral lower extremity) also remain edematous (non-pitting), both elevated on pillow and heels floated on pillow. No noted acute respiratory distress. O2 (oxygen) via NC (nasal cannula) at 2L/min (2 liters per minute). HOB (head of bed) remains elevated. AM nurse arrived on the unit early and went in the room with writer to assess as well; she took over resident's care at this time - following up with (physician). Unit manager was also made aware/assess site. Review of subsequent nursing notes on [DATE] for R15 revealed a wound culture was taken of the right leg surgical wound. Doppler results were negative for blood clot and the resident was started on an antibiotic to rule out infection. Review of the [DATE] Situation, Background, Assessment and Recommendation Communication Form (SBAR) and Progress Note for R15 revealed documented at 4:23 p.m. revealed, at 11:15 a.m. R15 had to be lowered to the floor today while being transferred from bed to her wheelchair. The operation site on her right hip was bleeding. She also has a skin tear on her right ankle that was bleeding. Vitals are within normal limits. Resident's (son) and (physician) notified. A stat X-ray of right hip and femur has been ordered. Skin tear on right ankle has been cleaned with normal saline and covered with a bandage. Operation site on right hip has been cleaned with normal saline and covered with a bandage. The form did not include evidence of a thorough investigation into the root cause of lowering her to the floor or any information regarding who was involved, witness statements, what the resident was wearing on her feet, what staff thought happened, whether staff education would be beneficial or what interventions could be put in place to prevent recurrence. Review of nursing notes on [DATE] for R15, revealed the hip wound was monitored, there was no drainage, an X-ray revealed intact hip arthroplasty no change and no new orders. Review of the [DATE] X-ray results for R15 revealed, anatomic alignment is maintained. There is osteopenia noted. There is no acute fracture or dislocation. Prosthesis is noted with no lucency around the hardware. There are no erosive changes seen. Conclusion: Intact bilateral hip prostheses. Review of the nursing notes on [DATE] for R15 revealed the resident was sent to the hospital and returned without new orders. Review of the nursing notes for R15 between [DATE] and [DATE], revealed R15 continued on antibiotic for right thigh surgical site infection, diagnosed with [REDACTED]. ([DATE] CXR right lower lobe infiltrate) Review of the [DATE] nursing note for R15 documented at 2:49 p.m. revealed, resident alert, returned from (orthopedics appointment) during this some discomfort noted - PRN (as needed) medication administered during this time. Resident sutures removed and TX (treatment) to lower right leg is to be d/c (discontinued), also noted resident is to have :no weight bearing until follow-up visit on (MONTH) 4, (YEAR). Review of the [DATE] SBAR Communication Form and Progress Note for R15 documented at 4:39 a.m. revealed, R15 was yelling and found on the floor, resident was re-directed to call for assistance and continuous monitoring; said she wanted to get out of the bed, was very anxious yelling (did) not pay attention at all when (being) directed with what to do, needs more constant monitoring and redirection at all times. Frequent family visits to keep resident accompany. The form did not include evidence of a thorough investigation into the root cause of how she ended up on the floor or any information regarding who was involved, witness statements, what the resident was wearing on her feet, what the resident was doing last time staff checked on her, what staff thought happened, whether staff education would be beneficial or what interventions were put in place to prevent recurrence. Review of the [DATE] nursing note for R15 documented at 8:41 a.m. revealed, R15 was very anxious, yelling and was found on the floor at 4:30 am by the charged nurse and resident care specialist. Assessment was done and vital signs taken. Assisted back to bed with hoyer lift. Denies any pain distress discomfort. Redirected to call for assistance and safety intervention for floor mat to be on the floor while resident in the bed. Will continue with plan of care. Review of the [DATE] X-ray results for R15 revealed, there is prosthetic right femoral head in proper alignment with respect to the acetabulum. There is no fracture or acute dislocation. The prosthesis is properly situated without any loosening. Pubic rami are normal. Conclusion: Intact right hip arthroplasty, unchanged from [DATE]. Review of subsequent nursing notes for R15 on [DATE] revealed the resident was confused, calling out for help throughout the night, received an order for [REDACTED]. Review of the [DATE] nursing note for R15 documented at 12:48 a.m., revealed the physician was called about the resident's complaints of pain and ordered an X-ray of the right hip. Review of the [DATE] nursing note for R15 documented at 11:46 a.m. revealed, R15 continues to c/o pain to her left hip per therapy. This author asked resident if she was having pain now. Resident stated, 'No not when I am sitting down.' This author notified MD and new order was received for an AP and lat (X-ray) of the left hip. Resident continues to yell out when someone goes into her room she is quiet asking them to keep her company. Will continue to monitor. Review of the [DATE] X-ray results for R15 revealed, Hip unilateral w (with) pelvis ,[DATE] V (view) left; comparison: (MONTH) 16/ (YEAR); Findings: Anatomic alignment is maintained. There is osteopenia noted. There is no acute fracture or dislocation. Prosthesis is noted with no lucency around the hardware. There are no erosive changes seen. Review of the [DATE] nursing note for R15 documented at 2:57 p.m. revealed, report of the entire xray was read to (physician). No new orders recd (received) for the UA results which was called to the (physician). This author called the residents granddaughter (name) who said my dad is on a plane and he will not be back for a week. Labs were drawn and she understands that the results will be recd on tomorrow. Will continue to monitor. Review of the [DATE] nursing note for R15 documented at 7:48 a.m. revealed, R15 is alert, yelling please get me out of bed. Nurse noted resident has legs on the side of the bed, with linen covers off of her. Nurse place resident legs into bed. Nurse returned to find resident had removed her legs to the rt. side of bed. Floor mat is in place, bed is in lowest position for safety precautions. Nurse will continue to monitor. Review of the [DATE] nursing note for R15 documented at 8:24 a.m. revealed, noted left lower leg black bruised. Edema in both lower legs. Resident is very agitated vitals not stable, in bed sleeping legs elevated. Review of the [DATE] nursing note for R15 documented at 8:27 a.m. revealed, upon assessment noted dark purple discoloration noted to left lower extremity. 3+edema noted to bilateral lower extremity. Denies pain/discomfort. Foot of the bed elevated. Called the physician made aware. New order noted venous Doppler done to bilateral lower extremities. Review of the [DATE] nursing note for R15 documented at 6:50 a.m. revealed, called the X-ray provider to receive copy of result from venous Doppler. Awaiting results. Resident rested well throughout the shift. Received results. Passing along to day shift nurse to report results to physician. Review of the [DATE] nursing note for R15 documented at 8:19 a.m. revealed, gave report to (physician) about resident's results from venous Doppler lower bilateral extremities. Made aware that results stated indeterminate for deep vein thrombosis and it recommends for test to be repeated. New order to have test repeated and begin resident on (blood thinners). Review of the [DATE] nursing note for R15 documented at 11:45 a.m. revealed, report was called to the hospital at 11 am and resident left the facility via ambulance accompanied by two emergency medical technicians (EMTs). Review of the [DATE] nursing note for R15 documented at 12:03 p.m. revealed, R15 was admitted to the hospital today. Review of the [DATE] nursing note for R15 documented at 3:55 p.m. revealed, abnormal lab work returned and call placed to physician informed of possible Deep Vein Thrombosis (DVT) per Doppler results study. New order noted to send out to hospital emergency room for evaluation and repeat Doppler study related to left (L) lower extremity. Review of the hospital record's for R15 dated [DATE] documented, history and physical revealed Chief Complaint: leg pain. History of present illness: This is a [AGE] year-old with a history of congestive heart failure, hip fracture, which was apparently atraumatic. The patient had an ORIF performed on [DATE]. The patient had a hospitalization complicated by a urinary tract infection. The patient has a questionable history of diastolic heart failure and was on lasix and the patient was discharged to a rehab facility. At the rehab facility, the patient was sub acutely complaining of pain around the prosthesis. The patient's complaints got worse. The patient had no [DIAGNOSES REDACTED], wound drainage, etc. No shortness of breath, no chest pain, no fever, no chills. She was brought back to the emergency room and a periprosthetic fracture was noted, Past surgical history: ORIF in (MONTH) 2010, right hip fracture and repair in 2008 is status [REDACTED]. Review of the hospital records for R15 on [DATE] physician progress notes [REDACTED]. They have decided on palliative care on left lower extremity (LLE), pain with motion at L hip, right lower extremity (RLE) , incision healed well. RLE; R15 is non-ambulatory at baseline. Proceed (with) palliative care as decided by family. NWB (non-weight bearing) LLE and NWB RLE; (MONTH) work on transfers and pain control. Review of the hospital records for R15 on [DATE] physician progress notes [REDACTED]. NWB status. Palliative care managing pain. Review of the [DATE] nursing note for R15 documented at 8:22 p.m. revealed, return from hospital at this time, Resident was admitted to hospice at this time see new orders in place. Review of nursing notes between [DATE] and [DATE] for R15 revealed the resident was in a lot of pain, medicated for pain with routine and PRN meds, and frequently called out in pain. Review of the [DATE] nursing notes for R15 documented at 9:58 a.m. revealed, Placed a call to physician to verify medication made physician aware that the resident is on scheduled medication, educated physician the resident is yelling help, help, and she is in pain. Family member had concerns resident is in pain was not being controlled. Resident has no labored breathing. Resident is in bed in lowest position with mats in place. Will continue to monitor resident. Review of the [DATE] nursing note for R15 documented at 4:58 a.m. revealed, Resident was yelling throughout the night. Upon entering resident's room she stated I don't know what's wrong with me. Stated she was in pain, gave PRN methadone, also gave Ativan 1 mg due to anxiety. Bed in lowest position with mats in place. Resident is on 3L of O2 via nasal cannula. No shortness of breath noted. Respirations even and unlabored. Will continue to monitor resident. An anonymous interested party (AIP) was interviewed on [DATE] at 9:00 a.m., by the State Survey Agency complaint intake staff. The AIP said the facility was responsible for R15's recent hip fracture, due to gross negligence and the resident was subsequently put on hospice services. Review of the [DATE] nursing note for R15 documented at 11:36 p.m. revealed, Resident and family members invited to 72 hr (hour) care conference meeting today, discussed in details hospice procedure and services that will be provided for resident. Also discussed pain and agitation medication that's will be provided by hospice. Social Worker requested that family provide personal sitter for resident for so many hours throughout the day according to their preference, (family member) stated that it's very hard to see his mother decline and he's unable to do more for her, he latter stated that he will sit down with his family and discuss issues and concerns that was discussed in this meeting. Review of the [DATE] nursing note for R15 documented at 9:58 a.m. revealed, Resident is in coma state at this time, hospice nurse at bedside, son at bedside. Review of the [DATE] nursing note for R15 documented at 7:52 p.m. revealed, On arrival today to 2nd shift, resident was unresponsive, (about 5:45 p.m.) Resident began moving around and yelling as usual. She received her afternoon meds as requested per (family). For now her vitals look ok and she is alert and stable. Review of the [DATE] nursing note documented at 2:52 p.m. revealed, Resident has eyes open-glossy and fixated, respirations labored. Resident has family at bedside during this time. Review of the [DATE] nursing note for R15 documented at 11:32 p.m. revealed, Resident alert new orders in place. Resident condition changed hospice notified. resident pain meds administered tolerated well, family members at bedside will continue to monitor. Review of the [DATE] nursing note for R15 documented at 6:20 a.m. revealed, Resident was alert and speaking out hello. Family member at bedside. Review of the [DATE] nursing note for R15 documented at 11:44 a.m. revealed, Resident is on Hospice. Moaning and body movements noted . Resident is resting peacefully . Family at bedside. Will continue to monitor. Review of the [DATE] nursing note for R15 documented at 4:24 p.m. revealed, Resident awake and alert at intervals. Total care provided per nursing and hospice care in all aspects of daily living. Resident turned and repositioned for comfort q (every) 2 hrs and as requested. Pain medication administered as scheduled, to include break thru pain relief. Medication effective. Review of the [DATE] nursing note for R15 documented at 2:45 p.m. revealed, resident in comatose state . labored breathing upon assessment wet. (R15) has family member at bedside at this time. Review of the [DATE] nursing note for R15 documented at 5:47 p.m. revealed, no pulse no respiration no blood pressure. (Hospice) notified to come to facility to pronounce patient at this time. Hospice nurse arrived at 6:00 pm. to assess patient and to do pronouncing of patient family at bedside. The Corporate Clinical Auditor (CCA), who was also a registered nurse, was interviewed on [DATE] at approximately 11:30 a.m. She said the SBARs are investigations into the falls and there were no other investigations. She said the process was to discuss the previous day's falls at the daily clinical meeting and weekly at the At Risk meeting. The CCA said, generally, they discussed where the resident was, what happened, was there any injury, what can we do, have interventions worked, some will fall, prevent injuries. She said she was not there when R15's falls were discussed. When asked for evidence of what was discussed at the daily clinical meetings and weekly At Risk meetings regarding R15, the CCA said she could provide fall protocols, but did not have documented evidence of the meetings. Review of the August, 2012 Fall Management, Overview, Practice Guidelines revealed: Each resident is assisted in attaining maintaining his or her highest practicable level of function by providing the resident adequate supervision, assistive devices and/or functional programs as appropriate to minimize the risk for falls. The Interdisciplinary Team (IDT) evaluates each resident's fall risks. A Plan of Care is developed and implemented, based on this evaluation, with ongoing review. If a fall occurs, the IDT conducts an evaluation to ensure appropriate measures are in place to minimize the risk of future falls. The Director of Nursing/designee is responsible for coordination of an interdisciplinary approach to managing the processes for prediction, risk assessment, treatment, evaluation, monitoring, and calculation of resident falls. Each facility will take a proactive approach for new residents admitted and will consider all residents to be at risk for falls until reviewed by the IDT. A fall Care Plan will be initiated upon admission for each resident. When a fall occurs, assess resident for injury. The Licensed Nurse will complete: Incident/ Accident Report (Briggs); 24 Hour Report (Briggs); and Initiate the Interdisciplinary Post Fall Review. Communicate all resident falls to the attending physician and the resident's family and document on the Interdisciplinary Post Fall Review form . The licensed nurse documents family/responsible party and physician notification on the Interdisciplinary Post-Fall Review form and places the completed form in the Nurse's Notes section of the Medical Record. The nurse will communicate the resident fall to the IDT via the 24 Hour Report (Briggs). The IDT will review all resident falls within ,[DATE] hours at the morning Interdisciplinary Team meeting to evaluate circumstances and probable cause for the fall. OPTIONAL: Fall information may be added to the Electronic Care Management Board (ECMB) if so desired for tracking purposes. The IDT modifies and implements a Care Plan and treatment approach to minimize repeat falls. The Care Plan will be reviewed/revised as indicated. The RCS (certified nurse aide) Assignment Sheets/ Care Kardex are updated as appropriate. The IDT will complete the Interdisciplinary Post Fall Review (see forms tab). The In-House Communicator form (Briggs) should be used to make referrals to appropriate IDT members. IMPORTANT: A Change of Condition form must be completed, if indicated by resident assessment. The Director of Nursing or designee will document falls on the Incident/Accident Report QA&A (Quality Assurance & Assessment) Log and the Individual Resident Fall QA&A Log (see forms tab) as they occur and submit reports to risk management system as indicated. Risk management system reports may be used, if desired, to complete tracking/trending reports for QAPI (Quality Assurance Performance Improvement). The NHA was interviewed on [DATE] at approximately 4:00 p.m. He said the facility was already cited deficient practice for R15 on a previous complaint ending on [DATE]. 2. R28 was observed on [DATE] at 1:35 p.m. with the wound care nurse. The wound care nurse said R28 was admitted with both of his pressure ulcers, a stage 4 on his sacrum and a stage 2 on his right posterior thigh. The wound care nurse confirmed there was an 8 outlet yellow surge protector power strip taped to the floor between R28 and his roommate - plugged in to the power strip were R28's suction machine, R28's humidifier and the roommate's oxygen concentrator. The NHA was interviewed on [DATE] at approximately 3:36 p.m. The NHA said there were not enough outlets for R28 or R29, who were roommates, to accommodate their medically necessary, physician ordered, equipment. He stated when R28 was admitted they realized they did not have enough outlets and directed the Maintenance Director to install a power strip in R28's room. The NHA said both R28 and R29 had more medical equipment than they had outlets in the room. The NHA stated that a decision was made to unplug the bed of R28 for a few days. The NHA stated he checked with the Fire Marshall and based on the amperage of the power strips, felt the need was met. He said he was not aware a power strip could not be used for medical equipment. The NHA and the Maintenance Director were interviewed on [DATE] at approximately 10:30 a.m. The NHA confirmed R28's family member (F1) talked to him about the power strip, and he told the Maintenance Director to install a power strip in R28's room. However, the Maintenance Director said he got the power strip right away and left it at the nurses' station for the nurses to install in the room because R28 was receiving care at that time and he did not want to interrupt and a few days went by before it was discovered the power strip had not been installed. The NHA also confirmed a few days went by before he became aware the power strip was not installed. The NHA said as soon as he found out the power strip had not been installed, he took immediate action to have the power strip put in place. |
2019-11-01 |