cms_SD: 121
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| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 121 | JENKIN'S LIVING CENTER | 435036 | 215 SOUTH MAPLE STREET | WATERTOWN | SD | 57201 | 2018-12-12 | 658 | D | 0 | 1 | L4X311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the provider failed to complete a comprehensive nursing assessment, document the assessment, and notify the physicians' of the findings of those assessments for two for two sampled residents (10 and 93). Findings include: 1. Review of resident 93's medical record revealed: *He was admitted on [DATE]. *His [DIAGNOSES REDACTED].>-Malignant neoplasm of bladder. -Retention of urine. -Other specified disorder of kidney and ureter. Review of resident 93's 11/6/18 Minimum Data Set (MDS) assessment revealed: *He needed extensive physical assistance of one person in the following areas: -Personal Hygiene. -Toileting. *He had an indwelling catheter. *He had not had a significant weight loss or weight gain. Surveyor: Observation and interview on 12/11/18 at 4:33 p.m. with medication assistant P during resident 93's medication administration revealed:*He had an indwelling catheter. *The urine in his leg bag appeared to be a dark brownish-orange color. *The medication assistant stated he had blood in his catheter recently. -Sometimes the resident would pull at the catheter. *Staff documented the resident's urine output and the color of the urine on the report sheet for the next shift. -The nurse reviewed that report sheet every day. Surveyor: Review of the following Reflection's Unit reports for resident 93 indicated: *12/8/18 urine was dark amber during the day shift, and blood was present in his urine during the afternoon shift. *12/9/18 blood was noted in his urine on the night shift, and it was noted an amber color on the day shift. There was no urine appearance documentation of urine for the afternoon shift. *12/10/18 there was no urine appearance documentation. *12/11/18 Orange colored urine was documented on the night shift, dark red/brown color was documented on the day shift, and dark brown was documented on the afternoon shift. Interview with licensed practical nurse (LPN)/unit coordinator B on 12/12/18 at 8:10 a.m. regarding resident 93 revealed: *The physician would have been contacted when there was blood noted in his urine for over twenty-four hours. -The blood was not always noted in his urine for longer than twenty-four hours. *She planned to contact the physician today following due to the blood being present since 12/8/18. Surveyor: Observation, interview, and record review on 12/12/18 at 12:32 p.m. with LPN/unit coordinator B during resident 93's catheter irrigation revealed:*They had an order for [REDACTED]. *The resident had blood in his urine in the past. -Usually that resolved itself within twenty-four hours or so. *His urine was now yellow colored. -She was aware his urine was a dark orange/brown color on 12/11/18. *She confirmed a few days before that he had blood in his urine. -There had been no follow-up nursing assessments and documentation related to that in his record. 2a. Review of resident 10's interdisciplinary progress notes revealed on: *7/13/18 at 10:52 a.m. Nurses Note: Note Text: Urine obtained d/t (due to) resident does not feel well, frequent voiding with burning. *7/17/18 at 10:38 a.m. COMMUNICATION - with Family/NOK (next of kin)/POA (power of attorney). Note Text: Spoke with (son) about new orders: started on antibiotics for UTI (urinary tract infection). *7/17/18 at 10:40 a.m. Physician Visit Orders: Dr. (name) here. [MEDICATION NAME] 500mg (milligram) 1 PO (by mouth) QOD (every other day) starting tonight at 1800 (6:00 p.m.). [MEDICATION NAME] 1 gram IM (intramuscularly) today. Family notified: Spoke with son (name). *There was no further documentation of any nursing assessments, interventions, vital signs, or the effectiveness of the antibiotic. b. 11/19/18 at 12:35 a.m. Resident Incident Report Date/Time of Incident: (MONTH) 19th-2017 @ 0035 (12:35 a.m.). Description of Events: Resident was found laying on the floor in her room with her head positioned right in front of the door making entry difficult. Writer squeezed through doorway to assist The Resident. Resident stated she had just finished using the bathroom and was attempted to locate a clean pad when her legs became weak and buckled. She stated that she fell to her knees, then backwards onto her bottom, then to her back. Resident denied hitting her head, but neurological observations were implemented anyway. Resident was evaluated and her only complaints were of back pain and bilateral hip pain, but stated this pain was present prior to fall. Resident assisted up and assessed for further injury with none apparent. Resident was assisted back to her bed and attempt for a cath (catheter) U/A was attempted (due to following observations: fever, back pain, lethargy, weakness, fall, and complaints of burning with urination.) Cath U/A (urinalysis) was unsuccessful due to [DIAGNOSES REDACTED]. Resident then assisted to stand to obtain clean catch U/A (due to incontinence.) Small amount of concentrated/cloudy yellow urine returned and placed in fridge to be taken to PLH (hospital) Lab (laboratory) Mental State: Normal for Resident. Alert/Oriented. Some confusion. Injury: None apparent.Vitals: T:99.8 P:69 RR:18 02:90% Room Air BP: 145/67 PERRL (pupils equal, round, and equally reactive to light), hand grasps strong bilaterally. Actions: Resident assessed, incontinence product changed, U/A obtained, and assisted back to bed. Teaching: Encouraged Resident to call for help due to weakness/lethargy. Family Notification: Will pass on to have dayshift notify family during daytime hours. *11/19/18 at 3:03 a.m. Nurses Note, Note Text: Clean-Catch U/A obtained on Resident after attempting to straight cath U/A under sterile technique with no success. Resident complains of burning with urination, back pain, weakness, lethargy, and falls. Obtained clean-catch U/A with cloudy concentrated return. Sent to first floor fridge to be taken to PLH Lab in the AM. *11/19/18 at 3:38 a.m. COMMUNICATION - with Physician Situation: FYI (for your information).Fax sent to Dr. (physician's name) notifying that U/A was obtained due to complaints of burning with urination, lethargy, weakness, fever, and back pain. Fall scene report also faxed to Dr. (physician's name) as an FYI. Background: Assessment (RN)/Appearance (LPN): Recommendations. *11/19/18 at 6:34 a.m.Nurses Note, Note Text: resident sleeping, neuros remain stable. *11/19/18 at 9:34 a.m. Nurses Note Note Text: Resident c/o some knee pain (denies that this is new or r/t (related to) the fall). Son was notified.Nurses Note Note Text: Fax sent to PCP (primary care provider) with UA results from today and med list. *11/19/18 at 5:32 p.m. Behavior Note, Note Text: When entering residents room the writer asked if she was going to go down to supper and the resident stated Well I fell this morning and I'll never be able to walk again so I'm eating in here from now on *11/19/18 at 6:14 p.m. Nurses Note, Note Text: Follow up to fall 11/19/18 0035 (12:35 a.m.). Resident remained in bed all day today, when writer asked if she was sore from her fall, she said no my legs just hurt like normal. *11/20/18 at 6:38 a.m. Nurses Note, Note Text: FOLLOW UP: neuros remain within normal limits; easily aroused, continues to feel that she can't get up and walk since 'I fell '; repositioned often, found with feet to the knees hanging out of bed x (times) 3. *11/20/18 at 11:30 a.m. Order Note, Note Text: Received fax from Dr. (physician name) with orders [MEDICATION NAME] PO BID (two times a day) x 1 week for UTI. Rx (prescription). notified. *There was no further documentation of any nursing assessments regarding her fall or UTI. c. 11/25/18 at 8:55 p.m. Nurses Note, Note Text: residents blood sugar before supper was 62 gave resident a rice crispie bar and a glass of orange juice 20 minutes later blood sugar was 104 waited until after supper to administer insulin. Resident did not show signs of [DIAGNOSES REDACTED]. *11/26/18 at 8:59 a.m. Nurses Note, Note Text: Resident felt weak,and tired checked blood sugar 108 assisted to lay down. *No further documentation of any more blood sugar tests and what the blood sugar was before the insulin had been administered or if it had been administrated. d. 11/13/18 at 2:36 p.m. Physician Visit Orders: Dr. (physician name) here on rounds. Orders for CBC (complete blood count) and UA (urinalysis). Family notified: Message left for (son's name). *11/15/18 at 9:24 a.m. Order Note, Note Text: Dr. (physician name) called in an order to [MEDICATION NAME] 1 PO BID x 7 days for a UTI. Repeat UA in 10 days. Rx. and son, (name) notified. *Nothing had been documented on how the resident had been feeling after she had started the antibiotic for a UTI until: -11/17/18 at 7:09 a.m., 11/18/18 at 7:09 a.m., 11/19/18 at 6:39 a.m., 11/21/18 at 6:34 a.m., and 11/24/18 at 6:27 a.m. e. 11/25/18 at 10:13 p.m. Nurses Note, Note Text: No c/o (complaints of) of urinary sx.(symptoms) this evening. (R) (right) eye is slightly reddened and itchy this evening. resident c/o feels like sand in it Medicated eyes with eye drops per orders. *No further documentation on her complaints of: -What her urinary symptoms were and if they had continued. -If her right eye was still red and if she still had itching and pain. f. 11/29/18 at 1:05 p.m. Nurses Note, Note Text: urine obtained for repeat per MD sent to Brown Clinic lab. *11/29/18 at 3:54 p.m. Infection Note, Note Text: Keflex started for UTI. *11/29/18 at 3:58 p.m. Order Note Note Text: Received order for Keflex 500mg. Pharmacy and (son) notified. *No documentation on why the u/a had been ordered, her signs or symptoms, vital signs, and physician contact. The next nurses notes regarding any complaints or temperatures were on: -12/1/18 at 6:40 a.m.,12/2/18 at 6:57 a.m., and 12/6/18 at 6:44 a.m. g. 12/7/18 at 9:21 p.m.Nurses Note, Note Text: Resident complained of chest pain at 1945 (7:45 p.m.), resident typically has tums in her room which she can self administer but she was out, writer gave her 2 tums because she requested them. Writer checked resident's BP at the time and it was 146/70 with a pulse of 63. Writer checked back 20 mins later and resident was still having chest pain, rechecked her BP and it had gone up to 159/67 with a pulse of 80. Resident asked if she could have one of her chest pain pills. Writer did administer nitro at (YEAR) (8:15 p.m.), after about 20 mins resident stated her chest pain had gone away. Resident laying in bed now. Will continue to monitor. *The next documentation was on 12/8/18 at 6:34 a.m., Nurses Note, Note Text: no c/o pain or discomfort thru the night; skin warm and dry. 3. Interview on 12/12/18 at 1:30 p.m. with the director of nursing revealed: *There was no policy for documentation in the residents' records. *She was aware some of the documentation had not been completed in regards to the above residents' conditions. *She had discussed it in a nurse's meeting and had followed-up with some chart reviews. *She had not documented those chart reviews and did not say when they had been completed. | 2020-09-01 |