| 22 |
KENTMERE REHABILITATION AND HEALTHCARE CENTER |
85001 |
1900 LOVERING AVENUE |
WILMINGTON |
DE |
19806 |
2018-12-06 |
684 |
G |
1 |
1 |
H65F11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record reviews, interviews, review of facility documentation and hospital records, it was determined that the facility failed to ensure that treatment and services were provided in accordance with professional standards of practice for two (R85 and R99) out of 54 sampled residents. For R85, the facility failed to ensure that treatment and services were provided in accordance with professional standards of practice. The facility failed to have lab (laboratory) results available for physician review and failed to ensure that the physician was notified of abnormal lab results per facility policy. The facility failed to ensure that an H&H ordered to be drawn on 9/21/18 was completed. Additionally, the facility failed to identify that on 9/27/18, R85's episode of chest pain and shortness of breath could be related to low Hgb and failed to notify the physician when R85 exhibited these symptoms. This resulted in harm to R85 when she had to be emergently sent to the ER and subsequently hospitalized requiring emergency transfusion of 2 Units of PRBCs. For R99, the facility failed to ensure that the physician was notified when R99 refused [MEDICATION NAME] doses resulting in lost opportunities for the physician to adjust medication if he/she desired. The facility failed to notify the physician in a timely manner when R99 experienced a significant change in mental status and was deemed unsafe swallowing medications. Findings include: The facility policy titled, Laboratory and Radiologic Services, dated (MONTH) (YEAR), stated, Abnormal labs and x-rays are called to the charge nurse, who in turn, will notify the physician of the results. Physician notification will be documented in the electronic medical record. The facility policy titled, Physician-Notification of Abnormal Test Results, effective (MONTH) (YEAR), stated, .2. Results of laboratory .tests shall be reported in writing to the resident's attending physician from the testing source. 3. Abnormal results will be called and/or faxed to the physician upon receipt. Normal and abnormal test results provided to the facility will not be filed in the resident's chart before the physician reviews and signs the printed results. The results can be placed in a doctor's box for review and signature. The attending physician will initial and date the results when reviewed .5. The Unit Manager/Charge Nurse/Nurse Supervisor receiving abnormal results shall be responsible for notifying the physician of such test results .The nurse will enter date and time, and sign the report as reported to the physician. 6. Signed and dated reports of all diagnostic tests shall be made a part of the resident's electronic medical record. The facility policy titled, Provider Notification of Resident Change in Medical Condition, effective (MONTH) (YEAR), stated, .staff communicates changes in a resident's medical condition to providers in a timely and accurate manner .Changes in Resident Condition Staff will notify the provider .of: .Significant change in condition in physical, mental, or psychosocial status (i.e., deterioration in mental health, mental, or psychosocial status in either life threatening or clinical components) . 1. Review of R85's clinical record revealed: 8/7/16 - R85 was admitted to the facility with [DIAGNOSES REDACTED]. 7/14/17 - R85 was prescribed the medication Xarelto 20 mg daily, used to prevent blood clots in individuals with [MEDICAL CONDITION]. 8/28/17 - R85's care plan was updated and stated that she had the potential for bleeding due to anticoagulation therapy. Interventions included to monitor lab work as ordered, and to assess for signs of abnormal bleeding. 1/29/18 - A lab report revealed R85's hemoglobin (Hgb) was 12.6 (Normal range: 11.8-14.8). 8/17/18 - There was a physician's orders [REDACTED]. There was no documentation in the EMR signifying whether R85 was having any signs or symptoms of bleeding. 8/19/18 - On the day shift, the TAR documented R85 had a guaiac positive stool. 8/20/18 - On the evening shift, the TAR documented R85 had a guaiac positive stool. 8/20/18 - The lab results for the H&H revealed R85's Hgb was 10.5. This was a decrease of 2.1 points when compared to the 1/29/18 result of 12.6. 8/21/18 at 4:25 PM- A physician's progress note stated R85 was seen for [MEDICAL CONDITION] with 2 out of 3 positive stool guaiac tests. The physician noted that R85 had weight loss, never had a colonoscopy, and had a first relative with a [DIAGNOSES REDACTED]. The plan was to consult a GI physician for EGD and colonoscopy, repeat a CBC, check iron study, vitamin B12, and folic acid in 1 week. 8/21/18 - Review of the EMR revealed that R85 was scheduled for a GI consult on 10/1/18 at 2:00 PM for [MEDICAL CONDITION] with positive guaiac stools and a family history of [MEDICAL CONDITION]. 8/22/18 at 3:42 PM - A nurse's progress note stated that R85 had a third guaiac positive stool, and that the physician would review on the next rounds. R85's clinical record lacked evidence that the physician reviewed her chart following this finding. 8/29/18 - The TAR revealed a signature signifying that R85 had a CBC, iron study, vitamin B12 level and folic acid drawn. Review of the EMR revealed there were no results scanned into the record for these blood tests. Upon surveyor request on 12/4/18, the facility provided the blood test results after obtaining them via fax from the lab. Results of R85's Hgb revealed the level was 9.8, a further decrease from the 10/5/18 Hgb result of 10.5 and the iron level was 24 (normal range 35-165). There was no documented evidence stating that the physician was notified of the results, nor was there any evidence showing that the physician had reviewed the results (no physician dated and initialed copy). 9/13/18 - A physician's orders [REDACTED]. 9/15/18 - Lab results revealed R85's Hgb was 7.9, again signifying a decrease from 8/29/18 when it was 9.8. There was no documentation that the physician was notified of this abnormal result per facility policy. 9/17/18 at 12:18 PM - A physician's progress note stated that R85's labs were reviewed and acknowledged that the Hgb was 7.9. The note stated that R85 was asymptomatic (no symptoms), had a prior history of gastritis, and had no abdominal pain or dark/tarry stools. The note stated the plan was to guaiac stools, check CBC and monitor for any GI bleeding. 9/17/18 - A physician's orders [REDACTED]. 9/19/18 - The CBC result revealed R85's Hgb was 7.4, down from 7.9 on 9/17/18. 9/19/18 11:15 PM - A nurse's progress note stated R85's Hgb level was 7.4 and that the NP was notified. The note stated a new order was received to check an H&H on Friday (9/21/18) and that the order was input. 9/21/18 - Review of the TAR revealed it was initialed by nursing staff signifying that the H&H was completed. Review of the Lab Form revealed that nursing staff had written in that R85 was due for an H&H and that it was signed off and dated as completed by the lab technician on 9/21/18. There were no results found for the 9/21/18 H&H. The was no evidence that the facility followed up with the lab to determine why there were no results sent to the facility. 9/22/18 - During the day shift, the TAR documented R85 had a guaiac positive stool. There was no documented evidence that the physician was notified. 9/25/18 - During the day shift, the TAR documented R85 had a guaiac positive stool. There was no documented evidence that the physician was notified. 9/27/18 2:10 PM - A nurse's progress note stated that during lunch time R85 complained of shortness of breath and chest pain. The note stated sublingual [MEDICATION NAME] was administered along with a nebulizer (medicated breathing treatment) and after 5 minutes the resident stated she felt better. There was no evidence that the nursing staff considered these symptoms could be related to R85's low Hgb and there was no evidence that the episode of chest pain and shortness of breath was reported to the physician. 9/28/18 2:27 PM - A nurse's progress note stated that while out at a cardiology appointment, the facility was notified that R85 had a large bloody bowel movement and was being sent to the ER for further evaluation. Review of hospital records revealed that on arrival to the ER, R85's Hgb was 6.7. R85 required transfusion of 2 units of PRBC, was admitted to the hospital and was found during a colonoscopy to have multiple polyps. 12/4/18 at 1:00 PM - During an interview, E2 (DON) stated that the process was for the facility to receive lab results via fax. The evening shift supervisor reviews the lab results and ensures that the physician is notified of any abnormalities. E2 stated it would have been the responsibility of the evening supervisor to inquire about the missing H&H results on 9/21/18. 12/6/18 approximately 8:10 AM - An interview was conducted with E1 (NHA), E2, E3 (ADON) and E4 (Medical Director). E4 stated that the current standard of practice was to transfuse when the Hgb was below 7 and the patient was symptomatic. E4 stated that previously the standard was to transfuse when the Hgb was below 8. E4 stated the facility was monitoring for symptoms and/or if R85's blood pressure dropped the resident would have been sent out to the ER. It was discussed with E4 that the facility failed to identify that results from the 9/21/18 H&H were never received and that the Hgb level might have decreased further. E4 nodded her head. The facility failed to ensure that treatment and services were provided in accordance with professional standards of practice for R85. The facility failed to document what precipitated R85's 8/17/18 H&H and stool guaiac orders, and failed to have lab results available for physician review. The facility failed to ensure that the physician was notified of abnormal lab results per facility policy, failed to document that the physician was notified of an abnormal lab result per facility policy, and failed to provide evidence that an H&H ordered for R85 on 9/21/18 was completed. Additionally, the facility failed to identify that on 9/27/18, R85's episode of chest pain and shortness of breath might be related to the low Hgb and failed to notify the physician when R85 exhibited these symptoms. This resulted in harm to R85 when she had to be emergently sent to the ER and subsequently hospitalized requiring emergency transfusion of 2 Units of PRBCs. Findings were reviewed with E2 (DON) on 12/4/18 at 1:00 PM. Findings were reviewed on 12/6/18 at approximately 7:45 PM during the exit conference with E1 (NHA), E2 (DON), E3 (ADON), and E14 (QA). 2. Review of R99's EMR revealed the following: 5/17/18 - R99 was readmitted to the facility post hospitalization with [DIAGNOSES REDACTED]. 6/16/18 - A quarterly MDS assessment stated R99 was alert and able to make decisions independently. 9/5/18 - A physician's orders [REDACTED]. 9/7/18 - The ammonia level results revealed a value of 93 (normal range: 0-60). 9/7/18 - A physician's orders [REDACTED]. The order further stated to administer [MEDICATION NAME] 45 mls three times a day and [MEDICATION NAME] 30 mls once daily (a total of 4 doses per day) x 3 days and to obtain an ammonia level on 9/14/18. 9/8/18 through 9/10/18 - Review of the MAR indicated [REDACTED] - 9/8/18 - all four doses of [MEDICATION NAME] were administered; - 9/9/18 - two doses of [MEDICATION NAME] were refused by R99 and two doses were administered; - 9/10/18 - one dose of [MEDICATION NAME] not administered due to refusal and one dose documented R99 was LOA (Leave of Absence). Review of the EMR lacked evidence that the facility attempted to administer the missed dose when R99 returned from the LO[NAME] Additionally, there was no documented evidence that the facility notified the physician when R99 refused doses. 9/11/18 - Review of the EMR revealed that the previous orders for [MEDICATION NAME] were resumed (30 mls 3 times a day and 45 mls once a day). 9/11/18 through 9/14/18 - Review of the MAR indicated [REDACTED] - 9/11/18 - all four doses administered; - 9/12/18 - all four doses administered; - 9/13/18 - one dose of [MEDICATION NAME] refused and no evidence of physician notification; - 9/14/18 - all doses administered. 9/14/18 - Review of laboratory results revealed that the ammonia level, ordered on [DATE], was not drawn. Review of the 24 Hour Report for 9/8/18 lacked evidence that a 24 hour chart check was completed. 9/14/18 3:59 pm - A nurse's progress note stated the resident was due for an ammonia level, but the draw was not completed because the test was not ordered. The progress note stated the lab was called and rescheduled the ammonia level for 9/15/18. 9/15/18 - Review of the Lab Form revealed that although an ammonia level was entered for R99, it was not signed off by the lab technician as completed. A notation stated Must be called in for Monday 9/17/18. 9/15/18 - Review of the MAR indicated [REDACTED]. There was no evidence the facility attempted to administer the [MEDICATION NAME] upon R99's return from LOA and there was no evidence of physician notification. 9/16/18 - A quarterly MDS assessment stated R99 was alert and able to make decisions independently. 9/16/18 - Review of the MAR indicated [REDACTED]. 9/17/18 - Review of the MAR indicated [REDACTED]. 9/17/18 - An ammonia level was drawn (ordered to be drawn on 9/14/18) with a value of 133. 9/17/18 8:36 pm - A nurse's progress note stated R99's ammonia level was 133, the physician was notified, there were no new orders, and that the physician would review when in the facility. 9/18/18 - Review of the MAR indicated [REDACTED]. 9/19/18 - Review of physician's orders [REDACTED]. However, [MEDICATION NAME] orders were then changed back to the prior doses. Further review revealed that the consultant pharmacist completed a medication review to determine if R99's medications were causing an increase in the ammonia level. There were no irregularities found by the pharmacist. 9/19/18 - Review of the MAR indicated [REDACTED]. The 7 PM dose was not administered and documented in the MAR indicated [REDACTED]. Further review of the MAR indicated [REDACTED]. Despite this change in R99's mental status, the facility failed to notify the physician. 9/19/18 3 PM to 11 PM shift - Review revealed there were no nurse's progress notes despite the fact that R99 was too lethargic to be given oral medications. 9/20/18 - The MAR indicated [REDACTED]. 9/20/18 3:23 AM - A nurse's progress note stated to send the resident to the emergency room for further evaluation and management. 9/20/18 3:39 AM - A nurse's progress note stated, Resident noted for increase (sic) lethargy .(Nurse Practitioner) made aware at 3:00am with new order to send resident to hospital for further evaluation and management .Call placed to 911. Transferred to the hospital at 3:30am. Review of the Resident CNA Documentation Record from 9/1/18 through 9/19/18 revealed a total of 10 days on which R99 had no bowel movements. Although R99 was administered a [MEDICATION NAME] suppository on 9/19/18 at 3:25 PM, there was no evidence that it was effective. Review of progress notes lacked evidence of the physician having been notified of R99's lack of bowel movements as was desired with the administration of [MEDICATION NAME]. 12/3/18 12:00 PM - During an interview, E2 (DON) provided a 24 Hour Report which staff are to pull/print to verify and check accuracy of any new orders written in the preceding 24 hours (24 hour chart check). The 24 Hour Report revealed that on 9/8/18, staff failed pull the report to complete the 24 hour chart check. Had the 24 hour chart check been completed it would have identified that the ammonia level ordered on [DATE] to be completed on 9/14/18 was not entered for a lab draw. 12/3/18 3:35 PM - In an interview, E10 (RN) confirmed she was assigned to R99 on 9/19/18 on the day shift. E10 stated that she recalled the resident was quieter and more drowsy than usual. E10 also stated she recalls R99 attended a care plan meeting that day. 12/3/18 5:05 PM - During an interview, E11 (RN) confirmed he was R99's assigned nurse on 9/19/18 on the evening shift. E11 stated that it was evident (R99) was declining. E11 stated the resident had been having intermittent confusion and lethargy over the past several weeks. E11 stated R99 was lethargic but arousable, but he did not feel it was a good idea to give anything by mouth. E11 stated he did not feel there was a need to notify the physician and that vital signs (blood pressure, pulse, respirations, temperature) were within normal range. 12/5/18 9:24 AM - In an interview, E12 confirmed she was R99's assigned nurse on 9/20/18 on the night shift. E12 stated that working night shift most residents are asleep and at times it is difficult to determine if there is a change in mental status. E12 stated she started her rounds at approximately 10:45 PM and R99 was asleep. At 12 AM, E12 stated she went in to administer an [MEDICATION NAME] dose and found R99 lethargic, which was not the residents' usual baseline. E12 stated she had been told in change of shift report that R99's ammonia level was elevated and that the resident was lethargic. E12 stated she held the 12 AM [MEDICATION NAME] dose because she felt it was not safe to give it due to the lethargy. E12 stated she went in again around 3 AM and woke R99, who opened her eyes and then promptly closed them. E12 stated this was not R99's norm, as she would usually smile at her. E12 stated she then called the physician and the resident was sent to the hospital. 12/5/18 approximately 8:10 AM - An interview was conducted with E1 (NHA), E2 (DON), E3 (ADON), and E4 (Medical Director). E4 stated that it is difficult to increase a resident's medication ([MEDICATION NAME]) if they are refusing doses. E4 stated that if resident was refusing doses she would not necessarily have increased the dose. E4 was informed that there was no evidence that the physician was notified about the medication refusals, that ordered labs were not completed timely and that when a change in mental status occurred there was a delay in informing the physician, E4 nodded her head. The facility failed to ensure that the physician was notified when R99 refused [MEDICATION NAME] doses resulting in lost opportunities for the physician to adjust medication if he/she desired. The facility failed to notify the physician in a timely manner when R99 experienced a significant change in mental status and was deemed unsafe swallowing medications. At least an 8 hour delay occurred before the physician was notified and R99 was sent to the emergency room for evaluation. Findings were reviewed on 12/6/18 at approximately 7:45 PM during the exit conference with E1 (NHA), E2 (DON), E3 (ADON), and E14 (QA). |
2020-09-01 |