| 72 |
BRANDYWINE NURSING & REHABILITATION CENTER |
85004 |
505 GREENBANK ROAD |
WILMINGTON |
DE |
19808 |
2018-04-25 |
692 |
G |
1 |
0 |
81S611 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, interviews, review of facility documentation and hospital records, it was determined that for one (R1) out of 11 sampled residents, the facility failed to ensure that R1 maintained acceptable parameters of nutritional status, specifically electrolyte balance, and failed to offer sufficient fluid intake to maintain proper hydration according to his estimated daily fluid requirements when R1's diet changed on 2/28/18 requiring nursing staff to provide honey-thickened fluids via a spoon for swallowing safety. R1 was hosptalized on [DATE] with [DIAGNOSES REDACTED]. This deficient practice resulted in harm to R1. Findings include: Review of R1's clinical record revealed the following: 6/28/16 - R1 was admitted to the facility with [DIAGNOSES REDACTED]. 1/3/18 - R1's nutritional risk care plan was reviewed with interventions that included the following: monitor food and fluid preferences, provide assistance as needed with food/fluids, and monitor for signs and/or symptoms of diet/supplement intolerance. 1/31/18 - R1 was care planned for being at risk for dehydration with interventions that included: encourage fluid intake from meal tray and between meals; monitor for signs and/or symptoms of dehydration: change in mental status, poor skin turgor, decreased urinary output, dry mucous membranes, dizziness when standing/sitting; monitor labs if ordered; assist with fluid intake as needed; and weight as per protocol. 2/9/18 at 6:36 AM - R1's facility labs revealed the following: - creatinine was 0.6 (normal range was 0.5 - 1.5), - sodium was 142 (normal range was 135-145), - BUN was 17 (normal range was 10-26), and - GFR was 136 (Level 90 or more was Stage 1 - healthy kidneys). 2/16/18 at 8:37 AM - The Nutrition Assessment stated that R1 was on a NAS diet, pureed texture, nectar thick liquids; 75-100% meal intake; received Ensure [MEDICATION NAME] three times a day as a supplement and his intake was 100%; had chewing and swallowing problems; and his estimated nutritional requirements for fluid intake was 2255-2600 mls per day. The nutrition plan stated, .resident continues to lose wt with 4.1% loss this month. BMI underwt for his age. He eats 75-100% of meals and drinks mostly 100% of his Ensure [MEDICATION NAME] .Wt loss may be r/t [MEDICAL CONDITION]. He also receives magic cup at lunch and dinner. Fluids usually 600ml or greater. He receives 8oz of nectar water between all meals for additional fluids r/t thickened liquids. Labs reviewed. Observed resident during lunch meal, ate very well and was able to feed self. Will add double portions with meals to provide additional calories and protein and avoid further weight loss. 2/23/18 at 12:12 AM - R1 was admitted to the hospital for shortness of breath and change in mental status. His admission labs were: - BNP = 500 high (range 0-177), - BUN was 27 high (range 8-22), - creatinine was 0.80 (range 0.70-1.30), and - sodium was 145 (range 136-146). 2/24/18 at 9:58 AM - A hospital progress note stated, .Poor nutrition .seems to have POOR PO intake .Speech did evaluate him yesterday 1) Dysphagia 1 diet with honey thick liquids- ALL PO VIA SPOON 2) Choking precautions 3) 1:1 feeding assist- pt may need verbal cues to swallow due to oral holding 4) Meds crushed in puree . 2/27/18 at 7:38 AM - R1's hospital labs prior to discharge were as follows: - sodium was 145, - BUN was 19, and - creatinine was 0.61 low. 2/27/18 at 3:14 PM - The hospital's Discharge Summary stated that R1 had the following discharge Diagnoses: [REDACTED]. 2/27/18 at 6 PM - R1 was readmitted to the facility. 2/27/18 - R1 was care planned for the Pneumonia [DIAGNOSES REDACTED]. 2/27/18 at 11:38 PM - A nurse's readmission note stated that R1's oral mucosa moist and pink. 2/28/18 at 7:50 AM - The re-admission Nutrition Assessment stated that R1's estimated nutritional requirements for fluid was 1800 - 2100 mls per day. The nutrition plan stated, s/p hospitalization r/t pneumonia. Continues on ABT and [MEDICATION NAME]. Per previous assessment, resident started on double portions with meals r/t continued weight loss to provide additional calories/protein. Observed resident during lunch today. Ate 100% of meal, does require cueing to slow down .Resident is now being downgraded per SLP to honey thick liquids. Will D/C Ensure [MEDICATION NAME] and instead add super cereal ., super potatoes at lunch and dinner ., and Ensure pudding BID Resident also receives magic cup at lunch and dinner . 2/28/18 to 3/6/18 - R1's clinical record lacked evidence that fluids were encouraged. 2/28/18 at 10:45 AM - A nurse's note stated that R1 had moist oral membrane. 2/28/18 at 3:10 PM - A Speech Therapy note stated, Diet changed to puree diet with honey thick liquids, from nectar thick liquids. Liquids to be given via spoon, for safety. Patient to receive verbal cues and prompts with swallowing; as well as verbal cues to decrease rate of intake. Meds crushed in puree. Spoke with nurse in regards to recommendations . 2/28/18 at 11:17 PM - A nurse's note stated that R1 had moist oral membrane. 3/1/18 at 10:30 AM - A nurse's note stated that R1 had moist oral membrane. 3/1/18 at 11:31 PM - A nurse's note stated that R1 had moist oral membrane. 3/2/18 - R1's ADL care plan was revised and stated that he required supervision with meals after set-up. The facility failed to revise R1's care plan on 2/28/18 when his needs changed requiring facility staff to provide honey-thickened fluids via a spoon for swallowing safety. 3/2/18 at 3:39 AM - A nurse's note stated that R1's mucus membrane was pink and moist. 3/5/18 at 11:20 AM - A nurse's note stated that R1 had a moist oral membrane. 3/5/18 (updated) - The CNA's Resident Profile for R1 under the Fluid section lacked evidence of specific care and services to be provided to R1, specifically it lacked the services to 1) encourage fluids, 2) failed to identify the type of thickened liquid he required with safety precautions, and 3) a hydration program at 10 am, 2 pm and 8 pm for R1. The Meals section stated to See Nurse for diet. 3/6/18 at 2:55 AM - A nurse's note stated that R1's mucous membranes were pink and moist. 3/6/18 at 12:10 PM - A nurse's note stated that R1 was unable to tolerate PO medications and unable to respond to verbal stimuli . The physician ordered STAT labs and to obtain a urine sample by straight cath if necessary. 3/6/18 at 2:33 PM - A nurse's note stated that a urine sample was unable to be obtained. 3/6/18 at 2:58 PM - A nurse's note stated that R1 was .unable to tolerate PO medications and unable to respond to verbal stimuli. MD made aware .Lab lady seen drawing stat labs. 3/6/18 on 3-11 PM shift Late Entry documented on 3/7/18 at 12:05 AM - A facility nurse's note stated, At start of shift, resident was in bed with eyes open. Was not responding or making eye contact. VS were 138/80 (blood pressure), 98.2 (temperature), 90 (heart rate), 18 (respirations), 91% on 4 L via NC. Sat resident up in bed and attempted to give him water. He was not responsive or cooperative with fluid intake, would not make eye contact. Took O2 sat again and it was 88% on 4L. Made MD aware. Sent to (hospital) for evaluation via 911 transport. RP made aware. Review of the (MONTH) and (MONTH) (YEAR) eMARs of R1's fluid intake during meals only and monitored by nursing staff from the 2/27/18 readmission to his 3/6/18 hospitalization at 6 PM revealed the following: - 2/27/18 = 720 mls plus 50 mls from Ensure [MEDICATION NAME] supplement, total fluid intake was 770 mls (accounted for 43% of his minimum 1800 mls estimated fluid requirements for the day). - 2/28/18 = 840 mls plus 480 mls from Ensure [MEDICATION NAME] supplement, total fluid intake was 1320 mls (73%). - 3/1/18 = 960 mls (53%). - 3/2/18 = 960 mls (53%). - 3/3/18 = 840 mls (47%). - 3/4/18 = 960 mls (53%). - 3/5/18 = 720 mls (40%). - 3/6/18 = 120 mls (15%). Despite monitoring R1's fluid intake from his daily meals, the facility failed to identify that R1's fluid intake was not meeting his minimum daily fluid needs (1800 - 2100 mls per day) after his 2/27/18 readmission to the facility when his diet changed requiring staff to provide honey-thickened fluids via a spoon for swallowing safety. The facility lacked evidence that honey-thickened fluids were encouraged and provided between meals. 3/6/18 at 5:17 PM - 911 was called for a change in R1's mental status and difficulty breathing. 3/6/18 at 6:13 PM - The hospital's ED physician note stated, .History of Present Illness: 63 y/o male with hx of EtOH related dementia presents from (facility) with AMS, [MEDICAL CONDITION] .unable to give a history .Collateral hx - via RN said EMS were unable to get much information from (facility) staff - they were not familiar with the patient and his paperwork does not show much more. Hx of [MEDICAL CONDITION]. Recent [MEDICATION NAME] on MAR from (facility) - not completed course yet .Physical Exam .cachectic .dry tongue .no [MEDICAL CONDITION] .Final Impression: End stage liver disease .Serum sodium elevated. 3/6/18 at 6:21 PM - The hospital's labs revealed the following: - sodium was 163 critical (136-146); - BUN was 60 high (8-22); - creatinine was 1.44 high (0.70-1.30); and - WBC was 15.7 high (3.9-10.6). 3/6/18 at 10:18 PM - The hospital's Goals of Care Discussion with R1's family stated, .The patient has had progressive decline over several months due to progressive dementia. Now presented with severe dehydration in the setting of poor oral intake .discussed that his dementia is progressing and is likely end stage, they do not wish to have aggressive care for him because it will not correct the underlying process. Their focus is to keep him comfortable and are willing to transition him to hospice care . 3/7/18 at 1:02 AM - The hospital's History and Physical stated, .Patient is nonverbal at baseline .referred to the emergency room tonight because of hypoxemia, altered mental status .Patient has been on [MEDICATION NAME] for pneumonia per his outpatient .records. Presents .emergency room where he is noted to have acute kidney injury, lactic acidosis, hypertension, [MEDICAL CONDITION] and [MEDICAL CONDITION], chest x-ray revealing a right lower lobe infiltrate despite outpatient oral antibiotics .Physical Exam .eyes open, looking towards the examiner, not following simple commands .cachectic in appearance, frail, ill-appearing .ENT dry mucosa .Assessment/Plan: Pneumonia .End stage liver disease .Serum Sodium elevated: Hypernateremia related to his acute kidney injury, dehydration, volume depletion .Acute Kidney Injury: .related to .above.[MEDICAL CONDITION], dehydration, volume depletion .Dementia .[MEDICAL CONDITION] . 3/7/18 at 10:31 AM - The facility's STAT labs for R1 (collected on 3/6/18 at 2:21 PM prior to his hospitalization ) were: - creatinine was 1.2, - sodium was 164 High, - BUN was 60 High, - GFR was 61.1 (Level 60 - 89 was Stage 2 - kidney damage and mild decrease in GFR), and - WBC was 14.7 High (range was 4.8-10.8). 4/25/18 at 11:30 AM - During an interview, E20 (RD #2) stated that R1 was on the facility's Nourishment List to receive 8 oz of honey thickened water at 10 AM, 2 PM and 8 PM. When E20 was asked to provide evidence of how much R1 consumed of the honey thickened water three times a day via a spoon as R1 required staff supervision for safety, E20 could not provide further information. While the surveyor was provided with a copy of the facility's Nourishment List, printed with the date of 4/25/18, with R1 listed to receive 8 oz of honey-thickened water between meals, the facility lacked evidence of R1's actual consumption of the fluids to meet his minimum fluid requirement of 1800 mls per day. 4/25/18 at 2:45 PM - Findings were reviewed with E2 (DON). Even with the consideration of R1's comorbidities, decline over the past several months and his current acute illness (pneumonia), the facility failed to identify that R1 was not meeting his minimum daily fluid needs (1800 - 2100 mls per day) after his 2/27/18 readmission to the facility when his diet changed requiring staff to provide honey-thickened fluids via a spoon for swallowing safety. 4/25/18 at 4 PM - Findings were reviewed with E1 (NHA) and E2 during the Exit Conference. |
2020-09-01 |