| 10788 |
MEADOWVIEW MANOR HEALTH CARE |
515141 |
41 CRESTVIEW TERRACE |
BRIDGEPORT |
WV |
26330 |
2011-08-05 |
224 |
G |
1 |
0 |
PBEB11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to provide goods and services to avoid physical harm, by failing to assess / monitor and obtain timely medical intervention for one (1) of seven (7) sampled residents, resulting in a delay in identification and treatment of [REDACTED]. Resident #14 developed a blister on his left great toe, which was identified in a podiatry consult dated 05/12/11, to which the podiatrist applied a topical antibiotic ([MEDICATION NAME]) and recommended follow-up with the attending physician. The facility did not obtain an order to continue the application of this topical antibiotic to the toe until 05/14/11, and there was no evidence the family was informed of the blister or the topical antibiotic ordered to treat this area. There was no evidence to reflect the nursing staff routinely assessed / monitored the status of this blister after the daily application of a topical antibiotic and a dressing were ordered on [DATE], as evidence by a lack of any nursing progress notes from 04/22/11 until 05/19/11. On 05/19/11, the resident's family member brought to a nurse's attention that his left great toe was red and painful to touch, the left foot was warm to touch, and red streaking was present up to the resident's ankle; however, receipt of the order for a topical antibiotic received on 05/14/11 and an acknowledgement of the family's concerns about the resident's left foot were not recorded in any nursing progress notes until a late entry was made on 07/08/11. On the evening of 05/19/11, the physician ordered a 10-day course of oral antibiotics (Keflex) to be administered four-times-daily (at 6:00 a.m., 12:00 p.m., 6:00 p.m., and 12:00 a.m.). The first dose of Keflex was not administered until 6:00 a.m. on 05/20/11, and the 6:00 p.m. dose on 05/26/11 was skipped due "awaiting delivery from pharmacy". After the Keflex was started, there remained a lack of evidence to reflect that nursing staff was routinely assessing / monitoring the status of this area as well as the resident's response to the treatment, as evidenced by no description of resident's left great toe in any nursing notes until a late entry was recorded by a nurse on 05/22/11 (with only periodic descriptions recorded thereafter) and the absence of any wound assessment and progress review records describing the affected area. When the presence of yellow drainage was identified in a nursing note signed by the author on 05/22/11, there was no evidence to reflect the nursing staff notified the physician or the family of this new finding. The tip of the toe was noted to be "blackish / brownish" in color on 05/26/11, after which the physician discontinued the topical antibiotic to the toe (and ordered the application of skin prep) and discontinued the Keflex for the infection to the toe (and ordered [MEDICATION NAME] for a new upper respiratory infection). There was no evidence to reflect nursing staff notified the resident's family of the change in the status of the resident ' s great toe or of the discontinuation of both the oral and the topical antibiotics to treat the infection. After this discoloration to the tip of the toe was noted, there again remained a lack of evidence to reflect the nursing staff was routinely assessing / monitoring the status of this area, as the documentation began to focus on the resident's respiratory status. On 06/02/11, the physician diagnosed the resident as having gangrene to the left great toe. A subsequent arterial ultrasound revealed impaired circulation to the left lower extremity, and the family elected to place the resident on comfort measures only. On the afternoon of 06/13/11, a 7-day course of Keflex was ordered at the family's request to treat gangrene to the left great toe, which was to be administered four-times-daily (at 6:00 a.m., 12:00 p.m., 6:00 p.m., and 12:00 a.m.). The first dose was not administered until 12:00 p.m. on 06/14/11, with the first three (3) doses having been skipped due to "awaiting delivery from pharmacy". The last dose was administered at 12:00 p.m. on 06/20/11, with no evidence to reflect the resident received all twenty-eight (28) doses of the 7-day course ordered by the physician, and no evidence to reflect the family or the physician was notified of these missed doses. Resident identifier: #14. Facility census: 59. Findings include: a) Resident #14 1. Medical record review revealed this [AGE] year old male was most recently re-admitted to the facility on [DATE]. According to his comprehensive annual minimum data set assessment (MDS) with an assessment reference date (ARD) of 12/16/10, he was alert, but his score of "3" on the Brief Interview for Mental Status indicated his cognitive skills were severely impaired. In Section G, the assessor noted he was totally dependent on staff for the performance of all activities of daily living (ADLs). In Section I, his active [DIAGNOSES REDACTED]. Other health conditions included pain almost constantly and shortness of breath when lying down. In Section M, the assessor noted he did not have any pressure sores during the assessment reference period, nor did he have any pressure sores during the prior assessment period, by he was at risk for developing pressure sores; the assessor also noted he had no venous or arterial ulcers present during that assessment reference period and no foot problems (including no infections of the foot). According to his abbreviated quarterly MDS with an ARD of 03/10/11, he remained dependent on staff for the performance of all ADLs. In Section I, the assessor did not indicate the presence of any new [DIAGNOSES REDACTED]. In Section M, the assessor noted he did not have any pressure sores during the assessment reference period, nor did he have any pressure sores during the prior assessment period, by he was at risk for developing pressure sores; the assessor also noted he had no venous or arterial ulcers present during that assessment reference period and no foot problems (including no infections of the foot). According to his abbreviated quarterly MDS with an ARD of 06/02/11, he remained dependent on staff for the performance of all ADLs. In Section I, his active [DIAGNOSES REDACTED]. In Section M, he was noted to have one (1) Stage 2 pressure ulcer (with the oldest Stage 2 ulcer having been identified on 05/20/11) and one (1) Stage 3 pressure ulcer (measuring 3.0 cm x 0.8 cm). The assessor also noted the presence of an infection of the foot (e.g., [MEDICAL CONDITION]). Subsequently, the facility completed and electronically submitted a comprehensive MDS for a significant change in status with an ARD of 07/06/11, in which the assessor noted he remained dependent on staff for the performance of all ADLs, his active [DIAGNOSES REDACTED]. -- 2. According to an article about gangrene found on Medline Plus, a service of the U.S. National Library of Medicine, National Institutes of Health: "Gangrene is the death of tissue in part of the body. "Gangrene happens when a body part loses its blood supply. This may happen from injury, an infection, or other causes. You have a higher risk for gangrene if you have: - A serious injury - Blood vessel disease (such as [MEDICAL CONDITION], also called hardening of the arteries, in your arms or legs) - Diabetes - Suppressed immune system (for example, [MEDICAL CONDITIONS]) - Surgery "Symptoms "The symptoms depend on the location and cause of the gangrene. If the skin is involved, or the gangrene is close to the skin, the symptoms may include: - Discoloration (blue or black if skin is affected; red or bronze if the affected area is beneath the skin) - Foul-smelling discharge - Loss of feeling in the area (which may happen after severe pain in the area) "Treatment "Gangrene requires urgent evaluation and treatment. In general, dead tissue should be removed to allow healing of the surrounding living tissue and prevent further infection. Depending on the area that has the gangrene, the person's overall condition, and the cause of the gangrene, treatment may include: - Amputating the body part that has gangrene - An emergency operation to find and remove dead tissue - An operation to improve blood supply to the area - Antibiotics - Repeated operations to remove dead tissue (debridement) - Treatment in the intensive care unit (for severely ill patients) "When to Contact a Medical Professional "Call your doctor immediately if: - A wound does not heal or there are frequent sores in an area - An area of your skin turns blue or black - There is foul-smelling discharge from any wound on your body - You have persistent, unexplained pain in an area - You have persistent, unexplained fever "Prevention "Gangrene may be prevented if it is treated before the tissue damage is irreversible. Wounds should be treated properly and watched carefully for signs of infection (such as spreading redness, swelling, or drainage) or failure to heal." (URL for this article is ) -- 3. Record review revealed a podiatry services progress note date 05/12/11, which noted the presence of a blister on the left great toe, to which the podiatrist applied [MEDICATION NAME]; the podiatrist also recorded the need for follow-up by the facility's physician. ([MEDICATION NAME] is a topical antibiotic.) A box located at the bottom of the form contained a checkmark next to the following statement (quoted as typed): "Based on review of history medical records and exam; this pt (patient) is at medical risk of significant complications and medical care is indicated." -- 4. A review of the resident's physician orders, treatment administration records (TARs), and medication administration records (MARs) found the following: - Order Date: 05/14/11 at 10:00 a.m. (quoted as typed) - "Cleanse lt (left) great toe with dial soap and rinse with NSS (normal sterile saline). Apply [MEDICATION NAME] ointment to toe and cover with a dry dressing." The order was discontinued at 1:50 p.m. on 05/27/11. Nurses' initials on the TAR indicated this treatment was completed daily from 05/14/11 through 05/26/11. Documentation on the physician order [REDACTED]. Reeval (re-evaluate). Area is unstageable." - - Order Date: 05/20/11 at 6:00 a.m. - Keflex Oral Suspension 250 mg / 5 ml ("Instructions: Great toe on left foot"); give 500 mg by mouth four (4) times daily at 6:00 a.m., 12:00 p.m., 6:00 p.m., and 12:00 a.m. The order was discontinued at 1:47 a.m. on 05/27/11. Nurses' initials on the MAR indicated [REDACTED]. Documentation indicated a dose was missed at 6:00 p.m. on 05/26/11 due to "awaiting delivery from pharmacy". According to the physician order [REDACTED]. - - Order Date: 05/27/11 at 3:00 a.m. - [MEDICATION NAME] Oral Tablet 400 mg, give 1 tab once daily at 8:00 a.m. for "UTI" (urinary tract infection). (Note: Elsewhere in the resident's record, documentation indicated this antibiotic was for a "URI" (upper respiratory infection).) The order was discontinued at 1:00 a.m. on 06/03/11. Nurses' initials on the MAR indicated [REDACTED]. - Order Date: 06/02/11 at 5:00 p.m. - "TO (telephone order) Arterial ultrasound to Left lower foot Stat, Call office in AM (morning) to get paper faxed." - Order Date: 06/04/11 - "... D/C Skin prep to tip of (lt) gt (great) toe. ..." - - Order Date: 06/13/11 at 4:00 p.m. - Keflex 250 mg / 5 ml ("Instructions: gangrene grt (great) lt (left) toe); give 10 cc (500 mg) by mouth four (4) times daily at 6:00 a.m., 12:00 p.m., 6:00 p.m., and 12:00 a.m. Nurses' initials on the MAR indicated [REDACTED]. Documentation on the MAR indicated [REDACTED]"awaiting delivery from pharmacy"), but no reason was documented for the skipped dose due at 12:00 a.m. on 06/14/11. The order was discontinued at 4:00 p.m. on 06/20/11, although the resident did not receive all scheduled doses for this course of antibiotics. (Note: There was no evidence in the nursing progress notes for this time period to reflect that nursing staff notified the physician and/or the family that the resident did not receive all twenty-eight (28) doses of this 7-day course of antibiotics.) -- 5. Nursing Progress Notes Review of the nursing notes found no entries from 04/22/11 through 05/19/11, and no entries made on 05/19/11 addressed the status of the resident's left great toe. (Note: There was no contemporaneous entry to correspond with the receipt of an order for [REDACTED]. of this new medication order or the reason for its use.) - An entry, with no date or time recorded but signed by a registered nurse (RN - Employee #11) on 05/20/11, stated (quoted as typed): "Wound assessment: ... He's also on abt (antibiotic therapy) d/t (due to) [MEDICAL CONDITION] to lt (left) grt (great) toe, no odor or drainage noted. Res (resident) did c/o (complain of) pain when area was tx'd (treated), but he's on scheduled [MEDICATION NAME]. ..." - An entry, with no date or time recorded but signed by a licensed practical nurse (LPN - Employee #56) on 05/21/11, stated (quoted as typed): "5/20/11 (Name of attending physician) to see resident this shift, no new orders. Progress note written." - An entry, with no date or time recorded but signed by Employee #56) on 05/21/11, stated (quoted as typed): "5/20/11 Resident alert and verbal w/ (with) intermittent confusion observed, able to make some needs known to staff. Resident started Keflex Oral Suspension 250 MG/ML 500MG PO (by mouth) TID (three-times-daily) related to great toe on left foot. No s/s (signs / symptoms) of adverse reaction to medication observed at this time. ..." (Note: There was no description of the affected area, and the frequency at which the antibiotic Keflex was to be given was four (4) times daily, not three (3) times daily as stated in this note.) - An entry, with no time recorded but signed by Employee #40 (an LPN) on 05/22/11, stated (quoted as typed): "05/21/11 Late entry Vital signs ... Resident remains on Keflex elixer 250mg/5cc 10cc po (by mouth) administered per md orders qid (four-times-daily). No s/s of adverse reaction noted. Keflex administered for left great toe infection. Resident left great toe red and warm with slight [MEDICAL CONDITION] noted. No c/o pain offered. Dsg (dressing) changed per md orders. Call bell within reach." (Note: This was the first description of the resident's left great toe to have been documented in the record since the podiatry consult dated 05/12/11.) - An entry, signed by Employee #40 on 05/22/11, stated (quoted as typed): "05/22/11 1642 (4:42 p.m.) Vital signs ... Resident continues on Keflex elixer 500mg po qid r/t (related to) left great toe infection. No s/s of adverse reaction noted. Left great toe is discolored red with yellow drainage observed. Toe is warm to touch. No c/o pain or discomfort noted. ..." (Note: There was no evidence that nursing staff notified the resident's family or physician of the yellow drainage from the left great toe, which was a new finding.) - Subsequent entries stated the following: - 05/22/11 at 2317 (11:17 p.m.) by Employee #61 (an RN) - "... continues to receive Keflex ..." (No description of the affected toe was provided.) - 05/23/11 at 0318 (3:18 a.m.) by Employee #61 - "... Resident continues to receive Keflex ..." (No description of the affected toe was provided.) - 05/23/11 at 1024 (10:24 a.m.) by Employee #40 - "... Resident continues on Keflex ... Left great toe is discolored red with small amount of yellow drainage noted ..." - 05/24/11 (no time recorded) by Employee #51 (an LPN) - "... He is currently on Keflex related to infected toe ..." (No description of the affected toe was provided.) - An entry, with no date or time recorded but signed by Employee #62 (an RN) on 05/24/11 - "... Resident taking Keflex for [MEDICAL CONDITION] in L foot and L great toe. ..." (No description of the affected foot or toe was provided.) - Further entries reiterated that Resident #14 was receiving Keflex for an infected left great toe, with no descriptions of the affected area provided. - The next entry that provided a description of the affected area, which had no date or time recorded but was signed by Employee #11 on 05/26/11, stated (quoted as typed): "... Res (resident) is on keflex d/t infection to lt grt toe, the tip of toe is blackish / brownish. It's measuring 2.5cmx2.5cm, no odor or drainage, periwound is a pinkish color. Res does yell out in pain when toe is dressed but was already med. (medicated) with a prn (as needed) [MEDICATION NAME]. Once tx (treatment) is finished, res no longer yells out. ..." (Note: There was no evidence the nursing staff notified the resident's family of this change in the color of the affected area.) - On 05/26/11, the physician discontinued the Keflex for the infected left great toe and ordered [MEDICATION NAME] to treat an upper respiratory infection. On 05/27/11, the topical antibiotic treatment to the toe was also discontinued, and the twice daily application of skin prep for fourteen (14) days was ordered. (Note: There were no entries in the nursing progress notes to reflect the resident's family was notified of the change in the status of the resident's great toe or that both the topical antibiotic ([MEDICATION NAME]) and the oral antibiotic (Keflex), which had been ordered to treat the infection toe, had been discontinued.) - After the [MEDICATION NAME] was started, nursing documentation began to focus on the resident's respiratory status, and documentation of the status of the resident's left great toe diminished in frequency with the following entries noted (all quoted as typed): - 05/28/11 at 11:52 a.m. by Employee #62 - "... Wound to left great toe, skin prep every day applied. ..." - 05/29/11 at 3:17 p.m. by Employee #11 - "... Res has [MEDICAL CONDITIONS], and the area to lt grt toe could be d/t (due to) that disorder. The area is measuring 0.8cmx2cm and is a dark purplish/brownish area. No odor or drainage noted. The tx of skin prep continues as ordered. ..." - 06/03/11 at 2:30 a.m. by Employee #30 (an LPN) - "... resident has new order for arterial ultrasound of left lower leg stat. ..." - 06/03/11 at 6:21 p.m. by Employee #11 - "Res is on abt d/t infection to lt grt toe, the area is black, no odor or drainage. The outer part of the wound is slightly reddened and a little warm to touch. The area is measuring 2.5cmx2.5cm. He c/ pain when area is touched. He went for ultrasound and per MD and mpoa (medical power of attorney representative) is aware res will be cmo (comfort measures only). ..." (Note: The resident was receiving [MEDICATION NAME] to treat an upper respiratory infection; contrary to what was stated in this note, the resident was not on any antibiotics at this time to treat the infection of his left great toe.) - 06/04/11 at 12:02 a.m. by Employee #51 - "... He, Finished his [MEDICATION NAME] for the URI. His right Great toe is black in color and no drainage at this time. ..." (Note: This entry identified his right (not his left) great toe as the site of the infection.) - 06/04/11 at 6:35 p.m. by Employee #11 - "Res is on [MEDICATION NAME] d/t an infiltrate ... The wound to his lt grt toe remains black and is warm to touch, no odor or drainage noted. It is slightly reddened around the outside of the nail bed. ..." (Note: This entry identified that he was still receiving [MEDICATION NAME] when the previous entry stated he had taken his last dose of this antibiotic.) - 06/05/11 at 8:23 a.m. by Employee #11 - "Weekly summary: late charting ... Per (name of attending physician) he has gangrene to the lt grt toe, and the family has decided that surgery is not an option for him d/t his overall condition. ..." - After the resident was placed on comfort measures only, the family requested another course of antibiotics to treat the infection to the left great toe. On 06/13/11 at 4:53 p.m., Employee #11 recorded the following entry (quoted as typed): "... Res is also to start keflex 250mg/ml 10cc po qid x 7 days per Dr. (name) at mpoa's request. This is d/t gangrene to lt grt toe at this time area remains black but is dry. No odor noted, area is warm to touch. ... " As noted above, documentation on the MAR for June 2011 indicated the first three (3) scheduled doses of Keflex were missed; "awaiting delivery from pharmacy" was noted as the reason for two (2) of these skipped doses. There were no entries in the nursing progress notes to reflect that staff notified either the family member (who had requested this course of antibiotics) or the physician that the resident did not receive all twenty-eight (28) scheduled of the Keflex. - Further review of the nursing notes found an entry, dated 07/08/11 at 5:11 p.m., stating (quoted as typed): "Late entry: On 05/14/11 evaluation of the left great toe revealed red area on tip of the toe, that was warm to touch. Also some dried blood was on the left great toe around the toenail. After reading the consult form from (name of podiatry service), Dr. (name of attending physician) was notified of the findings. [MEDICATION NAME] external topical ointment was ordered for 14 days. On 05/19/11 residents daughter approached the nurses station and asked for a nurse to evaluate the residents left foot. On assessment, the left great toe was very red, and painful to touch. Also, the left foot was warm and red streaked covering foot up to the ankle. At this time, the resident stated the foot was painful to touch, even with the blankets. Dr. (name) was notified of the reassessment on the residents foot. Keflex liquid 500mg 4 times a day for 10 days was ordered. First dose was given on 5/20/11." -- 6. physician progress notes [REDACTED]. Review of the physician's progress notes revealed an entry dated 04/14/11 which contained no mention of any problems with the resident's feet. The next consecutive entry, dated 05/20/11, also made no mention of any problems with the resident's feet. The next consecutive entry, dated 05/26/11, noted the resident was on Keflex for [MEDICAL CONDITION] of the left great toe and identified a plan to change the Keflex to [MEDICATION NAME] to treat an upper respiratory infection. The next consecutive entry, dated 06/02/11, noted the physician had been asked to re-evaluate the resident's left great toe. The tip of the toe was black. The physician noted, "... Gangrene (L) great toe - failed antibiotics. ..." -- 7. Review of the wound assessment and progress review forms on Resident #14's medical record found no such records were initiated to track the status of the blister, which was intact when identified by the podiatrist on the resident's left great toe on 05/12/11. -- 8. Care Plans Review of the resident's care plans found an episodic care plan, dated 05/20/11, stating (quoted as written): Problem: "Infection great left toe. Goal: "Will resolve during the next 14 days." Approaches: "(1) Antibiotic as ordered. (2) Treatment as ordered. (3) Monitor for improvement or decline of area. Notify MD as needed." This care plan has a "D/C (Discontinuation) Date" of 05/27/11. - There was no evidence that an episodic care plan was developed to address the resident's left great toe on 05/12/11, when the podiatrist identified and treated the blister, or on 05/14/11, when the attending physician ordered the daily application of a topical antibiotic and a dry dressing to the resident's left great toe. The facility also failed to review / revise the resident's care plan to address the need for on-going monitoring of the resident's left great toe and left foot between the date the 05/20/11 episodic care plan was discontinued on 05/27/11 and when the comprehensive care plan was updated on 06/14/11, to note the presence of gangrene and the initiation of comfort measures only. -- 9. In interviews with the administrator, the director of nursing, and the owner on the morning of 08/05/11, they were asked for any additional information to demonstrate the facility's nursing staff had been routinely assessing / monitoring the resident's left great toe from 05/12/11 until gangrene was diagnosed on [DATE], as well as any additional information to reflect the nursing staff had contemporaneously notified the resident's family of changes in the condition of his left foot and when changes were made with medication and treatment orders. The administrator provided evidence of an internal investigation that confirmed a lack of documentation to reflect changes in his left great toe / foot were being routinely assessed / monitored and that staff had failed to notify the family as changes occurred in his left great toe / foot, as well as when changes were made to medication and treatment orders related to the infection. No additional information to the contrary was provided prior to this surveyor's exit on the early afternoon of 08/05/11. . |
2014-12-01 |