cms_WV: 517
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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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 517 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2020-02-04 | 881 | K | 0 | 1 | CN2N11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to implement an antibiotic use protocol, including reporting laboratory results to the facility physician. This resulted in the failure to ensure Resident #57 received appropriate treatment for [REDACTED].) In addition, this placed the resident at risk for developing antibiotic-resistance. This was true for one (1) of five (5) residents reviewed for unnecessary medications. Prior to surveyor intervention, the physician and facility staff, including the infection preventionist, did not identify or attempt to correct this failed practice. Due to the facility's failure to implement an antibiotic stewardship protocol the State Agency (SA) determined there was an immediate jeopardy (IJ) present for more than a limited number of residents residing in the facility. The likelihood of serious harm due to this IJ situation exists because the facility failed to recognize the resident was treated with an inappropriate antibiotic. Being treated with an antibiotic resistant to the organism identified could have resulted in the resident being septic. Due to the system failure to recognize the use of the incorrect antibiotic to treat in antibiotic resistant organism, all residents were potentially at risk for the incorrect antibiotic be prescribed with the negative outcome [MEDICAL CONDITION] being present as well. The following details the timeline of the IJ situation. --The IJ started on 01/04/20. --The facility Nursing Home Administrator (NHA) was notified of the Immediate Jeopardy (IJ) at 12:22 PM on 01/30/20. --The facility submitted their first abatement Plan of Correction (POC) at 1:55 PM on 01/30/20. --The SA requested changes to the abatement POC. --At 2:08 PM and a second abatement POC was submitted by the facility on 01/30/20. --This POC was accepted by the SA at 2:10 PM on 01/30/20. --The IJ was abated at 11:40 AM on 02/03/20 when the SA observed Resident #57's urine culture and sensitivity was received and appropriate antibiotic was ordered by facility's physician/staff. The facility's abatement plan of correction consisted of the following: 1. Resident # 57 was identified as being affected by the alleged deficient practice of failing to implement an antibiotic use protocol, including reporting laboratory results to the facility physician. This resulted in the failure to ensure Resident #57 received appropriate treatment for [REDACTED].#57 physician was notified immediately by the Director of Nurses (DON) on 1/29/2020. Resident #57 physician current course of treatment implemented was to obtain a UA with C & S this was completed on 1/29/2020 by the Unit Charge Nurse (UCN). The Unit Charge Nurse obtained an order for [REDACTED]. Quality Standards Nursing Coordinator educated the Director of Nurses (DON), Clinical Care Supervisor (CCS), and Registered Nursing Assessment Coordinator (RNAC) on antibiotic stewardship data base, documentation expectations, and follow through immediately on 1/30/2020. All Unit Charge Nurses on duty will be educated immediately by a Quality Standards Nursing Coordinator on 1/30/2020 on reading/interrupting a UA with C & S lab results, documentation expectations, communication with physician on lab results, and follow through. Nurse Practitioner examined Resident #57 and reviewed findings with physician in person on 1/30/2020. The CCS or designee will obtain C & S results from the lab by 2/3/2020. The CCS or designee will immediately upon receipt of lab results will report to physician or nurse practitioner for further orders as necessary. 2. DON or designee will educate all nurses at the being of each shift prior to going to the floor until all nurses have been educated starting 1/30/2020 - 2/3/2020. Any nurse on leave of absence will be educated immediately upon return to work prior to going to the floor to provide care. Quality Standards Nursing Coordinator completed an audit of current antibiotic use on 1/29/2020 and no other residents were identified as being affected by the alleged deficient practice. The nurse receiving lab results will review results with the physician or nurse practitioner by the end of the shift. The UCN will document physician or nurse practitioner notification and their response by the end of the shift. The UCN must contact the physician or nurse practitioner and obtain new orders within accordance with antibiotic stewardship. The UCN will document physician or nurse practitioner notification and their response by the end of the shift. The CCS or designee will monitor antibiotic stewardship to ensure diagnostic results have been obtained and the physician or nurse practitioner was made aware and required documentation is completed daily. Antibiotic Stewardship data base will be reviewed daily by the CCS or RNAC or designee daily. 3. The DON will review all findings and report in QAA monthly for follow up to assure POC is effective. Resident identifier: #57. Facility census: 100. Findings included: a) Resident #57 Review of Resident #57's medical records found on 12/31/19, the physician ordered a urinalysis with culture and sensitivity (UA/C&S.) The urinalysis result could not be found in the medical record. On 01/04/20 the facility received the results of the C&S. The Registered Nurse (RN) called the physician to report the results. The registered nurse obtained a verbal order from the physician for the [MEDICATION NAME] milligrams (mg) , two times a day for ten (10) days for greater than 100,000 colony count of the organism Escherichia coli (E. coli.). However, the C&S noted the organism was resistant to [MEDICATION NAME]. ([MEDICATION NAME] is the same as Cipro.) There is no indication the registered nurse reported to the physician that the organism was resistant to [MEDICATION NAME] (Cipro). The C&S report was never signed by the physician to indicate he had reviewed the report. The facility continued to administer this antibiotic for 10 days as ordered. As a result, the resident received an antibiotic that was not appropriate to treat her urinary tract infection. She continued to have signs and symptoms of urinary tract infection, specifically burning upon urination and foul-smelling urine. On 01/29/20, after surveyor intervention, the physician ordered another UA/C&S to be obtained. The physician also ordered the antibiotic [MEDICATION NAME] ([MEDICATION NAME]) intravenously for ten (10) days. The urinalysis obtained on 01/29/20 showed 2+ (large amount) of bacteria. The C&S is pending. On 01/29/20 the Director Of Nursing confirmed the Resident received the wrong antibiotic. At 9:30 AM on 1/30/20, the facility confirmed they did not implement an antibiotic use protocol which included reporting laboratory results to the facility physician. On 01/30/20, the Clinical Care Supervisor (CCS) stated she contacted the laboratory. The CCS stated no UA had been performed by the laboratory on 12/31/19, although it had been ordered. There is no indication the facility had called the laboratory to obtain the UA results prior to surveyor intervention. As a result, the facility did not discover the UA had not been performed as ordered. Prior to surveyor intervention, the physician and facility staff, including the infection preventionist, did not identify or attempt to correct this failed practice. The likelihood of serious harm due to this IJ situation exists because the facility failed to recognize the resident was treated with an inappropriate antibiotic. Being treated with an antibiotic resistant to the organism identified could have resulted in the resident being septic. Due to the system failure to recognize the use of the incorrect antibiotic to treat in antibiotic resistant organism, all residents were potentially at risk for the incorrect antibiotic be prescribed with the negative outcome [MEDICAL CONDITION] being present as well. No further information was provided at the close of the survey at 12:30 PM on [DATE]. | 2020-09-01 |