cms_WV: 10741
Data source: Big Local News · About: big-local-datasette
| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 10741 | BISHOP JOSEPH HODGES CONTINUOUS CARE CENTER | 515055 | PO BOX 6316 | WHEELING | WV | 26003 | 2011-08-11 | 224 | G | 1 | 0 | H2M211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on closed medical record review, hospital record review, and staff interview, the facility failed, for one (1) of thirteen (13) residents reviewed, to provide care and services, as determined necessary by a comprehensive assessment and plan of care and/or in accordance with accepted standards of practice, to avoid physical harm. Resident #105 did not receive adequate care related to her diabetes as outlined in her plan of care, and abnormal lab values were not appropriately communicated to her attending physician. This lack of care resulted in a critically high abnormal blood sugar level, rendering the resident unconscious and requiring hospitalization . Facility census: 104. Findings include: a) Resident #105 When reviewed on 08/09/11, the closed medical record of Resident #105 revealed this 89-year ol female had been admitted to the facility' neighboring acute care hospital on [DATE], when she fell at home, where she lived alone, and fractured her left wrist. According to the hospital "history and physical examination [REDACTED]. This document also stated that the resident had additional medical [DIAGNOSES REDACTED]. The resident was admitted to the hospital and underwent a "closed reduction and casting of the left wrist" the following day. A "Progress Notes" document from the acute care hospital, signed by a hospital physician and dated 03/25/11, stated: "Afebrile, doing well, OK for transfer." The resident was admitted to BJHCCC on 03/25/11 at 15:30 (3:30 p.m.). Her [DIAGNOSES REDACTED]. The resident was ordered no diabetic medication or monitoring when admitted to the nursing home. -- Documentation on the admission nursing assessment noted, on Page 4 of 5 in the area that describes level of consciousness, that the resident had clear speech, made her self understood, was able to express ideas and wants, and was able to understand verbal content. Nurses notes at the nursing home immediately began describing the resident as "alert with confusion" or "oriented to person only." - On 03/26/11 at 0400 (4:00 a.m.), a note stated: "Alert /c (with) confusion. ..." - On 03/26/11 at 0900 (9:00 a.m.), a note stated: "Alert & oriented to name only. Confused, easily agitated. ..." - On 03/28/11 at 15:40 (3:40 p.m.), a note stated: "Pt (patient) has been very confused today. She knows her name but isn't sure of much else. ..." - 04/02/11 at 0235 (2:35 a.m.), a note stated: "Alert to name. Reoriented x 2. ..." - On 04/08/11 at 1000 (10:00 a.m.), a note stated: "Pt sitting (arrow pointing up) in cardiac chair in day room. Anxious, wants 'to go home.' Continues to yell 'help me.' Redirecting and 1:1 (one-on-one) attempted /c little success. ..." - On 04/11/11 at 2200 (10:00 p.m.) a note stated: "Pt Alert /c confusion. Was trying to climb out of bed & becoming slightly agitated so [MEDICATION NAME] was given on schedule @ 2100 (9:00 p.m.). ..." - On 04/12/11 at 1530 (3:30 p.m.) a note stated: "Lethargic this AM (morning). Speech difficult to understand. ... Charge nurse aware of pt condition. Dr. (name of attending physician) notified - see new orders." Review of the physician's orders [REDACTED]. (The results of this urinalysis, reported on 04/12/11, revealed no abnormalities, including no finding of glucose in the urine.) - On 04/13/11 at 1600 (4:00 p.m.) a note stated: "... Rash all over back & chest. ..." - On 04/13/11 at 2100 (9:00 p.m.) a note stated: "Rash to trunk and extremities. ... Pt received [MEDICATION NAME] /c [MEDICATION NAME] this PM (evening)." physician's orders [REDACTED]. There was no indication that staff had attempted to determine the cause of the rash. -- On 04/15/11, the resident's physician ordered a complete blood count (CBC), basic metabolic panel (BMP), and urinalysis (U/A) with reflex to be completed on 04/18/11. The results of BMP obtained on 04/18/11 included a blood glucose level of 301 (normal reference range is 74 to 106). There was no evidence in the resident's medical record to reflect staff notified the physician of this significantly elevated blood glucose level. -- A U/A submitted for testing on 04/21/11 revealed glucose in the resident's urine. The level was noted to be 1000 MG/DL, with normal values stated to be 0 MG/DL; this result was identified with "C" indicating this was a critically high level. Review of this lab report, with a print date / time of 04/21/11 at 23:55 (11:55 p.m.), found a handwritten notation that was not signed or dated, stating: "Dr. (name) aware. On call for Dr. (name of attending physician)." A nurse's note, dated 04/22/11 at 1700 (5:00 p.m.), stated: "Dr. (name) aware of critical high glucose in urine - on call for Dr. (name of attending physician). - No new orders." When interviewed on 08/09/11 at 2:00 p.m., the facility's director of nursing (Employee #7) confirmed there was no evidence of any further discussion of the abnormal lab results by facility staff or the resident's attending physician. The resident's attending physician, when interviewed via phone on 08/09/11 at 4:10 p.m., stated these elevated findings could have been the beginning of the resident's decline into the unresponsive state, and that the on-call physician could have ordered coverage for the resident with a small dose of insulin. He also stated the facility staff could have made him aware on the following day of the abnormal findings, for possible further treatment. -- Nursing notes continued to document the resident as being alert with confusion. On 04/30/11 a nurse's note stated: "Alert /c confusion. St (straight) cathed (catheterized) for U/A /c reflex. Sent to lab at 1815 (6:15 p.m.). ..." Review of the resident's medical record found no report containing the results of this U/A. When interviewed on 08/10/11 at 8:30 a.m., the DON stated she was not aware that lab results were not on the record. Employee #9 obtained the result from the lab and provided evidence that the test had been completed as ordered. The urinalysis disclosed that the resident again had 1000 MG/DL of glucose in her urine (normal value is 0 MG/DL), and the report stated "C - Critical Result". Employee #9 could not provide evidence that the resident's attending physician had been made aware of the findings of the test, which contained critical level abnormalities. -- On 05/01/11 at 1700 (5:00 p.m.), a nursing note stated: "Alert to name. Difficult to arouse. ... Will continue to monitor." On 05/02/11 at 1130 (11:30 a.m.), a note stated: "Nurse aide taking resident to restroom - states 'residents eyes rolling back of her head and she shook a little.' Only lasted a few seconds - placed back to room. ... Charge nurse notified." On 05/03/11 at 1030 (10:30 a.m.), a note stated: "Dr. (attending physician) office notified of pts (patient's) lethargy. ... blood sugar registered critical high on (illegible). Awaiting call back." On 05/03/11 at 2000 (8:00 p.m.) - nine and one-half (9.5) hours later - a note stated: "Pt unresponsive in AM. Unable to arouse to take meds. ... BS (blood sugar) critical high. Dr. notified & labwork ordered. One time dose of 10 units [MEDICATION NAME] given @ 1200. BS remains critical (arrow pointing up). Dr notified & IV fluids & ATB ordered ..." At 2130 (9:30 p.m.) on 05/03/11, the resident was transferred to the hospital for a direct admission. Results of the lab studies that were ordered that morning were available on the facility record and revealed a blood glucose level of 1051. All other levels on the basic metabolic panel were abnormal as well, with the exception of the potassium and calcium levels (which were within normal limits). -- Review of the resident's plan of care, on 08/10/11, revealed the resident had been identified (on 03/28/11) by the interdisciplinary team to have: "Potential for hyper/[DIAGNOSES REDACTED], other complications related to Diabetes Mellitus." Goals related to this potential problem were: - "Will remain free of s/sx (signs / symptoms) of complications related to diabetes through review date" - "Will maintain blood sugars, other lab values within acceptable range per MD through review date." Approaches determined necessary to achieve these goals included: - "Assess / report to MD prn (as needed): [DIAGNOSES REDACTED] s/sx: Tremors, Shaking, Confusion, Headache, Irritability, Hunger, Nausea / vomiting, Cool, clammy, pale skin, Diaphoresis." - "Obtain and monitor lab / diagnostic work as ordered. Report results to MD and follow-up as indicated." -- The resident was transferred to the hospital prior to the care plan's review date and was admitted with a critically high blood sugar level. There was no evidence that two (2) abnormal lab results related to blood sugar levels and glucose in the urine had been reported to the attending physician. The "history and physical examination [REDACTED]. ... Neurological: Cannot be fully assessed as patient is unresponsive. ..." . | 2014-12-01 |