| 9210 |
EASTBROOK CENTER LLC |
515089 |
3819 CHESTERFIELD AVENUE |
CHARLESTON |
WV |
25304 |
2011-06-08 |
315 |
D |
0 |
1 |
MZQB11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, observation, medical record review, and staff interview, the facility failed to assess each resident's bladder function and develop / implement measures to restore as much normal bladder function as possible. Resident #129 had an indwelling Foley urinary catheter present without a [DIAGNOSES REDACTED]. She had a catheter change followed by a urinary tract infection, and the continued need for the catheter was not re-evaluated. There was no current [DIAGNOSES REDACTED]. Residents #116 and #199 did not receive services to improve their bladder function. There was no evidence to reflect efforts by the facility to ascertain the type of urinary incontinence each was experiencing, nor did the facility implement measures in an effort to improve their urinary incontinence. This deficient practice affected three (3) of thirty-eight (38) Stage II sample residents. Resident identifiers: #129, #116, and #199. Facility census: 144. Findings include: a) Resident #129 During an interview with Resident #129 on 05/25/11 at 1:00 p.m., observation revealed she had an indwelling Foley urinary catheter. When questioned about the presence of the catheter, Resident #129 stated the catheter had been inserted at the facility where she was prior to coming here. Record review revealed Resident #129 was admitted from a hospital to the facility on [DATE] with an order for [REDACTED]. Resident #129's admission minimum data set assessment (MDS), with an assessment reference date (ARD) of 03/11/11, revealed, in Section H, this resident had an indwelling urinary catheter. This triggered the care area Urinary Incontinence and Indwelling Catheter in Section V of the MDS, where the assessor recorded that the location and date of the CAA could be found in the worksheet dated 03/16/11. In Section M of the MDS, the assessor did not identify the presence of any pressure ulcers or open areas. The resident's CAA worksheet for Urinary Incontinence and Indwelling Catheter (dated 03/16/11), when reviewed, stated that there was a potential problem. When describing the nature of the problem / condition, the assessor noted the resident had a Foley indwelling urinary catheter in place and needed assistance with toileting. In the section for discussing the summary and care plan considerations, the assessor recorded: Resident has a Foley catheter in place as evidenced by the order dated 3/5/11. This could place her at risk for problems such as altered urinary output, pain etc. She needs assistance with toileting as evidenced by the documentation in the POC (plan of care). Staff will continue to assist her with toileting and catheter care to help minimize the risk of problems. Any problems noted or reported will be addressed with the MD. Will continue to care plan. There was no discussion of why the catheter was needed and no plan to discontinue the use of this catheter or to have the physician re-evaluate its continued need. There was no information in this resident's medical record discussing why she had this indwelling catheter, when it had been inserted, or whether there was any consideration to remove the catheter. A care plan (dated 03/11/11) contained the following problem statement: Use of indwelling catheter needed due to open area on coccyx. The goals for this problem were: Will have dignity r/t (related to) presence of catheter preserved and Will have no acute complications of the urinary catheter use. The interventions focused caring for and changing of the catheter. There was no plan to discontinue the use of the catheter and no further mention of the open area to the coccyx. Further record review found an order discontinuing the treatment to the resident ' s excoriated area dated 04/04/11, noting the excoriation had resolved. There was no mention of re-evaluating the use of the catheter in view of the resolution of the underlying condition for which the catheter was inserted. On 04/28/11, the nursing notes recorded that this resident ' s catheter was leaking and a new catheter was inserted. There was no evidence there was any continued need for this catheter. On 05/29/11, the nursing notes indicated this resident was complaining of burning on urination. A new order was written for a urinalysis to be completed, and the resident was to start an antibiotic for signs of a urinary tract infection. During an interview on the afternoon of 06/04/11, Employee #88 (assistant director of nursing - ADON) verified the reason for this catheter was excoriation, which was present on admission. This excoriation was resolved on 04/04/11, and there was no evidence of an assessment to determine whether a continued need for this indwelling catheter existed. Employee #35 (a licensed practical nurse - LPN) was questioned about the catheter at 10:45 a.m. on 06/06/11. She reviewed the resident's medical record and stated the reason for the catheter was excoriation. She also verified that, according to the medical record, the excoriation was resolved by 04/04/11. Employee #88, when questioned again on 06/06/11 at 11:00 a.m., verified that she could not find any evidence that this resident ever had any skin open areas besides the excoriation. She was unable to show medical justification for the indwelling catheter. -- b) Resident #116 The resident's annual comprehensive MDS, with an ARD of 02/01/11, indicated the resident was always continent of urine. The quarterly assessment, with an ARD of 04/20/11, indicated she was occasionally incontinent of urine. The physician noted, in a 05/19/11 progress note, the resident had denied dyspnea, did not have dizziness, had no nausea, vomiting, or diarrhea, etc. The note included, C/O (complained of) new onset incontinence - sudden, no urge or control 'I don't know what's wrong (physician quoted the resident).' (The physician noted the resident was alert and oriented.) A urinalysis and culture and sensitivity were ordered. These were completed on 05/20/11. She was found to have a urinary tract infection, and an antibiotic was ordered. There was no evidence found in the nurses' notes of resident having complained for a new onset of incontinence or any other urinary problems. There was no evidence of monitoring to see whether the antibiotic affected resident's complaint of urgency and loss of control. Although the resident's quarterly assessment indicated the resident experienced a slight decline in urinary continence, there was no evidence of an assessment of possible causal factors for the decline. No care plan had been implemented in an attempt to restore her prior continence status, or to prevent further decline. - On 06/03/11 at 9:30 a.m., the resident was interviewed about her bladder function. She stated, Sometimes I need to go when I need to go and Sometimes I can't make it. She said there had been some improvement since she was given the antibiotic, but she still had times when she needed to go right away. - Shortly before the resident was interviewed, observaiton found a large wet ring on the bottom sheet on the resident's bed. The ring extended almost to the side edges of the bed with the outer edges being slightly brown, as though drying. On 06/03/11 at 10:34 a.m., the wet ring on the resident's sheet was observed with a registered nurse (RN - Employee #95). He said the staff had talked about possibly seeing if the resident would wear a brief at night. He was asked to see whether he could find any documentation regarding the resident's continence status. He later reported the resident had been on [MEDICATION NAME] since 11/2010. Before that, she had been on [MEDICATION NAME] for her bladder. - In a confidential interview, a staff member stated the ring of urine that had been observed on 06/03/11, had to be the result of several episodes of urinary incontinence - the resident did not void much urine at a single time. (This was consistent with the evidence of the light brown drying area at the outer edge of the ring.) - A nursing assistant (Employee #69) was also interviewed on 06/07/11 about the resident's urinary continence. She said she had been reporting the resident's incontinence for about four (4) weeks now. She demonstrated how issues identified by the nursing assistants could be put in the care tracker to alert the nurses. The nursing assistant stated she had asked about whether the resident could have a brief at night. She also said it had also been discussed whether the perimeter mattress kept the resident from getting out of bed at night. - On 06/07/11, the director of nursing (DON - Employee #12) was asked for evidence of an assessment regarding the resident's change in urinary continence status. On the morning of 06/08/11, the DON reported she was unable to locate any assessment for this problem. -- c) Resident #199 The resident's comprehensive admission MDS, with an ARD of 02/11/11, identified the resident was frequently incontinent of urine. He was noted to remain frequently incontinent of urine on the quarterly MDS with an ARD of 04/29/11 and the significant change in status MDS with an ARD of 05/27/11. Initially, the resident was assessed as being non-ambulatory. His quarterly assessment, with an ARD of 04/29/11, indicated he was independently ambulatory in his room, and needed supervision when walking in the halls. During the survey, the resident was observed ambulating independently in his room and in the halls. His assessments indicated he required extensive assistance with toileting, even after his ability to ambulate improved. However, his balance for moving on and off of the toilet continued to be coded as his being unsteady, but able to stabilize without human assistance. None of his MDS assessments indicated he was on a toileting program. The resident was coded as being able to understand and to be understood. His care plan indicated he was incontinent and needed incontinence care, but it did not include any plan for toileting the resident. - On 06/08/11 at 11:10 a.m., the resident was asked if he knew when he needed to void. He replied that he usually knew. - On 06/07/11, in late afternoon, the director of nursing was asked for evidence of an assessment of his urinary continence. She provided a copy of the care area assessment for the significant change in status MDS, with an ARD of 05/27/11, in late morning of 06/08/11. - On 06/08/11, at approximately 1:00 p.m., the CAA for urinary incontinence, completed for the SCSA, was reviewed. The CAA noted the resident required extensive assistance with toilet use and he was frequently incontinent. The form used by the facility for completion of the CAA included a section for the type of incontinence. The choices were stress, urge, mixed, overflow, transient, and functional. None of these were checked. Under the section of the CAA for Care Plan Considerations the assessor had checked to avoid complications, maintain current level of functioning, and to minimize risks as the overall objectives. Improvement and Slow of minimize decline were options, but had not been checked. The narrative for the CAA was Resident is frequently incontinent of urine and needs assist with toileting as evidenced by the documentation in POC. This places him at risk for problems such as skin break down and infections. Staff will continue to asist (sic) him as needed with continent (sic) care to help minimize the risk of problems. Any noted will be addressed with the MD. Will continue to care plan. His [DIAGNOSES REDACTED]. None were indicative of a condition that would prohibit an attempt to improve his urinary continence status. The CAA had a section for diseases and conditions that might affect continence, but none were checked. The CAA verbiage used by the facility was the same as the CAA in Appendix C of CMS's RAI Version 3.0 Manual. The instructions in Appendix C included: Step 4: . provide supporting documentation regarding the basis or reason for checking the item, including the location and date of that information, symptoms, possible causal and contributing factor(s) for that item, etc. Step 5: Obtain and consider input from resident and/or family/resident's representative regarding the care area. Step 6: Analyze the findings in the context of their relationship to the care area. This should include a review of indicators and supporting documentation, including symptoms and causal and contributing factors, related to this care area. Draw conclusions about the causal/contributing factors and effect(s) on the functional ability of the resident, and document this information in the Analysis of Findings section. There was no evidence these steps had been taken in an attempt to assess the resident's potential to have an improvement in his urinary continence status, or to prevent further decline if improvement was not possible. - Also on the afternoon of 06/08/11, the DON provided a copy of the facility's Bladder Patterning and Analysis Worksheet. The purpose stated on the document was: The purpose of the Bladder Patterning and Analysis Worksheet is to provide a space for documentation of a resident's usual bladder pattern and to provide suggested interventions for care plan development. The worksheet covered three (3) days, twenty-four (24) hours for each day, for staff to mark the resident's continence status. Based on the information collected during the three (3) day period, interventions listed on the form were to be reviewed and selected to develop an individualized care plan. This information was not found in the resident's medical records, nor was it provided by the director of nursing when evidence of assessment of the resident's incontinence status was requested. |
2016-01-01 |