cms_WV: 11525
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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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 11525 | HEARTLAND OF KEYSER | 515122 | 135 SOUTHERN DRIVE | KEYSER | WV | 26726 | 2010-09-03 | 327 | G | GVP311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, review of hospital records, family interview, staff interview, and interview with the hospital social worker, the facility failed to provide, for one (1) of twelve (12) sampled residents, sufficient fluid intake to maintain proper hydration and health. Resident #115 was admitted to the nursing facility on 07/14/10, following a hospital stay during which she was treated for [REDACTED]. At the insistence of the resident's legal representative, the resident was transferred to the hospital on [DATE], where she was readmitted for urosepsis, an infected pressure sore, and severe dehydration. During her 24-day stay at the nursing facility, there was no evidence to reflect the nursing staff was routinely assessing / monitoring the resident for changes in hydration status / fluid balance, nor was there evidence to reflect the facility identified the need for administration of intravenous (IV) fluids to restore fluid balance, which was not prohibited by the resident's advance directives. Facility census: 114. Findings include: a) Resident #115 1. Record review revealed this [AGE] year old female was admitted to the nursing facility on 07/14/10 following a hospital stay. Prior to this hospitalization , she had been living at the home of her caregiver and medical power of attorney representative (MPOA). According to the hospital history and physical examination was brought to the ER (emergency room ) following (sic) history of generalized weakness, lethargy, not eating or drinking, oliguric (low urine output) with dark foul-smelling urine. In theER on workup, patient was noticed to be dehydrated. Patient was also noticed to have urinary tract infection. Patient was advised (sic) hospitalization for further workup and management of urosepsis and dehydration. ... " According to a Transfer Summary Report hemodynamically stable". Her list of final [DIAGNOSES REDACTED]. - 2. Review of Resident #115's admission orders [REDACTED]. Also present on her chart was a physician orders [REDACTED]. In Section B, the MPOA indicated that, if the resident has a pulse and/or is breathing, staff was to provide limited addition interventions, to include the use of medical treatment, IV fluids and cardiac monitoring as indicated; the resident's MPOA did not select "comfort measures". In Section D, the MPOA specifically indicated the resident was not to receive a feeding tube; while the MPOA did not indicate a preference with respect to the IV fluids, there was no specific prohibition against the administration of IV fluids. Upon admission, the physician ordered a "no added salt", pureed diet with "level II fluids" (honey-thick liquids). According to the resident's weights and vitals summary, her weight on admission (07/14/10) was 130.0# and her height was 63 inches. The diet order was changed to mechanical soft with pureed meats and nectar-thick liquids on 07/20/10. - 3. A nutrition risk assessment, completed by a registered dietitian (RD) on 07/21/10, identified Resident #115 as being at HIGH RISK (score of 8 or higher), with a total score of 16. The RD calculated the resident's total fluid needs as 1737 cc/day. The resident's risk factors included an average intake of 33% at meals during a 7-day observation period, dementia, an [MEDICATION NAME] level of 2.7 (residents with [MEDICATION NAME] of less than 3.0 are at high risk), and one (1) Stage III pressure sore on the coccyx (with Stage I pressure sores also noted on the right hip and left heel). The RD recommended the addition of "Med Pass Supplement 2.0 60 ml 4 x day" on 07/21/10 to provide additional calories and protein for wound healing. On 07/27/10, the physician ordered: "Dietary consult - res(ident) not eating. ..." On 07/28/10, the RD noted, "Consult for res refusing to eat and wt (arrow pointing down) (sic) Res current wt 9-25-10 90.6 (pounds) /s (without) boots verified by re-wt. Boots weighed = 1# each. Res wt 7-23-10 98.2# wt 7-22-10 99.4# wt 7-18-10 127.4#. 130# 7-14-10. (Arrow pointing down) 39.4# / 30% / since adm (admission). Wt quest (questioned) on admit. Res has been refusing to eat per Nsg (nursing). Res current diet NAS mech soft, pureed meats & nectar liquids. Res avg (meal intake) 13% x 7 days (arrow pointing down) from 33% last review 7/21/10. Res currently receiving Med Pass 2.0 60ml 4 x day to supplement diet. Staff stated res consumed ice cream well 7-27-10 Rec (recommend) to add magic cup 1 x day at afternoon snack to provide 300cal/9g protein. Will contact POA to updated likes & dislikes. Will continue to encourage meal intakes." On 07/29/10, the RD noted, "Update (sic) res has started to consume meals better per Nsg (nursing). Nsg stated res will consume bite if presented /c (with) ice cream in between bites. ... D/T (due to) res intakes at meals are improving recommend to add Benical to lunch tray to help meet res needs. No further recommendations at this time. ..." While the RD was addressing the resident's weight loss and nutritional needs on a periodic basis, there was no mention of whether the resident was meeting her daily fluid needs. - 4. Review of the resident's initial acute care plan (developed prior to completion of the comprehensive admission assessment), dated 07/15/10, found no mention of the need to monitor the resident's hydration status, in view of the fact that her final [DIAGNOSES REDACTED]. - 5. The resident's comprehensive admission assessment, with an assessment reference date of 07/21/10, revealed in Section B, the resident's cognitive skills for daily decision-making were severely impaired and she had problems with both short and long term memory. In Section G, she was totally dependent upon staff for bed mobility, transfers, dressing, eating, toilet use, and bathing. In Section I2, the assessor noted the resident had a UTI in the preceding thirty (30) days. None of the "Indicators of Fluid Status" (Items "a" through "d" in Section J1) was marked, indicating the resident did not have any problems with dehydration in the preceding seven (7) days; for example, the assessor did not mark "Dehydrated; output exceeds input" or "Insufficient fluid; did NOT consume all / almost all liquids provided during last 3 days". In Section V, the person completing the care planning decision indicated the interdisciplinary care team would proceed with addressing dehydration / fluid maintenance on the resident's comprehensive care plan. - 6. Review of the resident's comprehensive care plan, with an initiated date of 07/26/10, found no problem statements specifically addressing the resident's recent history of or risk for dehydration. A review of all problems, goals, and interventions identified on the 14-page care plan found no problem, goal, or intervention addressing the need to encourage adequate fluid intake or routinely assess / monitor the resident's hydration status / fluid balance. - 7. Nursing notes indicated, beginning on day of admission, that resident would refuse to eat by refusing to open her mouth. The resident would eat for the MPOA on visit to the facility. A nursing note, dated 07/25/10 at 10:30 a.m., revealed, "... Staff able to get 2 bites of brfast (breakfast) & 60 ml of fluid into resident this am (morning)." On 07/27/10 at 10:00 a.m., a nursing note revealed, "... Res conts (continues) to ref (refuse) to eat / drink ... Res conts to allow food / liq (liquid) to run out of mouth." - 8. On 08/07/10, the facility transferred Resident #115 to the hospital at the request of the resident's MPOA due to a change in the resident's mental status. - 9. According to the hospital history and physical examination ... (Resident #115) was brought to the emergency room with (sic) chief complaint of progressively worsening mental changes with generalized weakness and lethargy. Also patient has stopped eating and drinking for the last four days or more. ... Patient was advised (sic) hospitalization [MEDICAL CONDITION]; possible source is urinary tract infection and necrotic decubitus ulcer with severe dehydration. ... Patient was recently in (name of hospital) in July 2010 for similar urinary tract infection and dehydration, patient was treated, improved and was admitted to the nursing home following her last hospitalization . ..." Under "Clinical Assessment" was noted: "1.[MEDICAL CONDITION] secondary to urinary tract infection. 2. Necrotic sacral decubitus ulcer. 3. Severe dehydration. ..." Under "Plan" was noted: "Is to admit the patient, we will give her IV antibiotics and IV fluids. ..." A review of the hospital's discharge summary, dated 08/19/10, found: "(Resident #115) is an eighty-five year old Caucasian female, a nursing home resident who was hosptalized on [DATE] following history of unresponsiveness associated with generalized weakness, lethargy. On admission, patient was in septic shock. Patient was severely dehydrated ... Patient was hypotensive. Patient was started on IV fluids and was hospitalized for [REDACTED]. ... Clinical Assessment: 1. Infected decubitus ulcer. 2. Urinary tract infection - resolved. 3. [MEDICAL CONDITION]. ... Hospital Course: Patient was given normal saline, IV fluid challenge, followed by 150 cc per hour of IV fluids. ..." The final hospital [DIAGNOSES REDACTED]. E-coli urosepsis. (Escherichia coli are bacteria found in feces.) 2. Infected necrotic sacral decubitus ulcer with staph infection. 3. Septic ulcer disease with GI (gastrointestinal) bleed and [MEDICAL CONDITION]. 4. Acute or [MEDICAL CONDITION]. ..." - 10. An interview with a registered nurse (RN) supervisor (Employee #70), on 09/03/10 at 10:00 a.m., revealed the MPOA wanted Resident #115 to be sent to the hospital on [DATE]. Employee #70 stated, "I offered to call the physician and obtain blood work to determine what was wrong with the resident, and the MPOA stated she wanted the resident sent to the hospital immediately. I called the physician and sent the resident to the hospital." She further stated, "I did not feel that the resident needed to go to the hospital, and she was not exhibiting any signs and symptoms of a urinary tract infection." - 11. There was no evidence to reflect the facility had routinely assessed / monitor Resident #115's hydration status / fluid balance for signs / symptoms of dehydration with the knowledge that the resident was not eating, that her fluid intake was at a minimum, and that, prior to her admission to this facility, she had been treated for [REDACTED]. - 12. In a telephone interview on 08/30/10 at 8:45 p.m., Resident #115's MPOA revealed that, although she did not want a feeding tube inserted, she did want the resident to receive antibiotics and IV fluids if necessary. - 13. In an interview with the social worker at the hospital, on 09/03/10 at 9:00 a.m., she stated, "I did the POST form on her last admission to the hospital in July 2010, and the MPOA did not want a feeding tube inserted but wanted antibiotics and IV fluids if needed. There was never any mention by the MPOA of not wanting IV fluids." . | 2014-01-01 |