| 37 |
BINGHAM MEMORIAL SKILLED NURSING & REHABILITATION |
135007 |
98 POPLAR STREET |
BLACKFOOT |
ID |
83221 |
2016-06-17 |
309 |
D |
0 |
1 |
J25411 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and resident, family and staff interviews, the facility failed to provide the necessary nursing care and services for 3 of 19 sampled residents (#5, #7 and #9). The facility's protocol to address [DIAGNOSES REDACTED], and physician orders [REDACTED].#5 and Resident #9, creating the potential for adverse health consequences. Resident #7's compression stockings were not applied in accordance with physician orders [REDACTED]. Findings include: 1. Resident #7 was admitted to the facility on [DATE] for rehabilitation following a total knee replacement surgery. She had admission [DIAGNOSES REDACTED]. Resident #7's TKA (total knee arthroplasty) Rehab Hospital Transfer Orders and Instructions, dated 6/3/16, documented thigh high compression stockings were to be to be worn throughout the day for [MEDICAL CONDITION], a stocking could be applied directly over the bandage, and the compression stockings should be removed at night and for showering. No documentation was found indicating compression stockings had been applied during Resident #7's admission to the facility. The Resident #7's Interim ADL (activities of daily living) Care Plan stated she had a self-care deficit related to the [DIAGNOSES REDACTED].#7 with ADLs, as needed, and to encourage her to complete ADLs as independently as possible. Compression stockings were not specifically addressed on the interim care plan. Resident #7 was observed in her room during the survey a total of 4 times. She was not wearing compression stockings during the following observations: * 6/12/16 at 6:50 pm * 6/13/16 at 11:25 am * 6:14;16 at 2:10 pm * 6/16/16 at 3:50 pm LN #1 was interviewed on 6/16/16 at 4:15 pm and stated Resident #7 was to wear compression stockings per physician's orders [REDACTED]. Resident #7 was interviewed on 6/16/16 at 3:50 pm. She stated her physician ordered compression stockings to be worn daily. She stated she was unable to put them on herself and needed staff assistance. She pointed to a towel rack on the wall and stated the compression stockings had been hanging there since the second or third day after admission. Compression stockings were observed hanging on the towel rack at this time. Resident #7 stated the compression stockings had not been applied since staff provided her initial shower, a couple days after she was admitted . Family Member #1 was interviewed on 6/14/16 at 3:00 pm. Family Member #1 stated Resident #7 was admitted to the facility for rehab about a week and a half ago following total knee replacement surgery. Family Member #1 stated he was employed in the medical profession and was concerned that Resident #7 was not wearing the compression stockings. Family Member #1 stated Resident #7 had a small sore under her knee cap on the back of her leg and that may have been why she was not wearing the stockings. He stated, It makes me nervous. I fear more for a blood clot than I do for skin breakdown. 2. Resident #9 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #9 received [MEDICAL TREATMENT] 3 days a week. She was prescribed a pureed diet. Resident #9's 5/3/16 annual MDS assessment noted Resident #9 required extensive assistance of one staff for most ADLs, including eating. The MDS assessment also identified Resident #9 as having long and short term memory problems, disorganized thinking, and receiving insulin injections during each of the 7 days in the assessment period. Resident #9's 2/3/16 quarterly MDS assessment documented her weight as 142 lbs. Resident #9's weight was 134.4 lbs on 6/14/16, which was a 5.3% weight loss since 2/3/16. A Physician order [REDACTED]. The physician also prescribed Humalog insulin 100 unit/ml per sliding scale with blood sugars to be checked twice a day at 6:00 am and 5:00 pm. The sliding scale parameters stated: * If Resident #9's BG was less than 70, the MD was to be called. * If her BG level was 150-199, give 1 unit. * If her BG level was 200-249, give 3 units. * If her BG level was 250-299, give 5 units. * If her BG level was 300-349, give 7 units. * If her BG level was 350-399, give 9 units. * For a BG level greater than 399, call MD. [DIAGNOSES REDACTED] protocol, documented in the Physician order [REDACTED]. * Call MD if BG is less or equal to 70. * Give 4-6 oz of orange juice if resident is able to swallow. * If resident is not able to swallow start IV and give 50 ml D50W. * Recheck blood sugar after 15 minutes of treatment. * If resident is unconscious, cannot swallow, does not have IV access give 1 mg of [MEDICATION NAME] IM or subcutaneous x 1 dose only. * Recheck blood sugar in 15 minutes and notify MD if blood sugar is still less than 70. Resident #9's Medications Flowsheet for (MONTH) (YEAR), indicated she had 8 instances of BG levels of 70 or below recorded at 6:00 am, as follows: * 3/2/16 - 64 * 3/11/16 - 64 * 3/12/16 - 70 * 3/13/16 - 65 * 3/14/16 - 69 * 3/23/16 - 67 * 3/25/16 - 70 * 3/26/16 - 68 There was no documentation on the Medications Flowsheet or in nurses' notes that the physician was notified of the low BGs, whether orange juice or a different carbohydrate source was administered, that BG levels were rechecked, or that potential signs and symptoms of [DIAGNOSES REDACTED] were monitored. [MEDICATION NAME], 5 units scheduled at 7:00 am, was administered on all dates noted above except on 3/13/16. It was not signed off as being administered on that date. Resident #9's Medications Flowsheet for (MONTH) (YEAR), did not include documentation that her BG level was assessed at 5:00 pm on the following 6 dates: 3/10/16, 3/20/16, 3/21/16, 3/24/16, 3/27/16, and 3/31/16. In March, for the dates that Resident #9's BG level was assessed at 5:00 pm, she required administration of sliding scale insulin on 6 occasions. The Medications Flowsheet for (MONTH) (YEAR), documented Resident #9 had 3 instances of a BG level of 70 or below at 6:00 am, that lacked documentation of follow up: * 4/11/16 - 61 * 4/18/16 - 70 * 4/25/16 - 70 There was no documentation on the Medications Flowsheet or in nurses' notes to demonstrate the physician was notified of the low BG levels, whether orange juice or a different carbohydrate source was administered, that BG levels were rechecked, or that potential signs and symptoms of [DIAGNOSES REDACTED] were monitored. [MEDICATION NAME], 5 units scheduled at 7:00 am, was administered on all dates noted above. The Medications Flowsheet for (MONTH) (YEAR), showed Resident #9's BG level was not assessed at 5:00 pm, on the following 10 dates: 4/1/16, 4/3/16, 4/12/16, 4/17/16, 4/19/16, 4/24/16, 4/25/16, 4/26/16, 4/28/16, and 4/29/16. In April, for the dates her BG level was assessed at 5:00 pm, Resident #9 required administration of sliding scale insulin a third of the time (7 occasions). Resident #9's BG on 4/22/16 at 5:00 pm was 179. There was no documentation to indicate 1 unit of insulin was administered in accordance with the sliding scale parameters on that date. The Medications Flowsheet for (MONTH) (YEAR), documented Resident #9 had 1 instance of a BG level of 70 or below when assessed at 6:00 am (BG of 64 on 5/5/16). There was no documentation on the Medications Flowsheet or in nurses' notes to demonstrate the physician was notified of the low BG level, whether orange juice or a different carbohydrate source was administered, that her BG levels were rechecked, or that potential signs and symptoms of [DIAGNOSES REDACTED] were monitored. [MEDICATION NAME], 5 units scheduled at 7:00 am, was administered on 5/5/16. Review of the Medications Flowsheet for (MONTH) (YEAR), indicated Resident #9's BG level was not assessed at 5:00 pm, on the following 4 dates: 4/9/16, 4/12/16, 4/29/16, and 4/31/16. In May, for the dates in which her BG level was assessed at 5:00 pm, Resident #9 required administration of sliding scale insulin 11 times. Resident #9's BG level on 5/26/16 at 5:00 pm, was 239. There was no documentation to indicate 3 units of insulin was administered in accordance with the sliding scale parameters. Resident #9's BG level on 5/27/16 at 5:00 pm, was 164. There was no documentation that 1 unit of insulin was administered in accordance with the sliding scale parameters. LN #1 was interviewed on 6/16/16 at 4:15 pm, and stated Resident #9's food and fluid intake was often poor. Resident #9 was observed in the dining room during breakfast on 6/13/16 from 7:05 am - 8:15 am. She required staff assistance to eat and was not observed to initiate eating independently. The DNS was interviewed on 6/16/16 at 5:00 pm, and referred to the Diabetes Management Protocol noted above in the event of [DIAGNOSES REDACTED]. The DNS stated if blood sugar was less than 70, the physician should be notified. The DNS indicated documentation of physician notification, administration of carbohydrate, and rechecking blood sugar should be found in the Medication Administration Record [REDACTED]. None was provided beyond the nurses' notes which were reviewed above. 3. Resident #5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #5 received all food and fluids via a gastrostomy (G) tube, had a [MEDICAL CONDITION], and received 9 liters of oxygen continuously [MEDICAL CONDITION]. Resident #5 was prescribed a total of 4 cans/day of Vital tube feeding formula administered via bolus feedings. Resident #5's 2/21/16 annual MDS documented Resident #5 was in a persistent vegetative state. Resident #5 observed during the survey from 6/12/16 - 6/17/16, to be non-responsive and totally dependent on staff for all cares. When the surveyor introduced herself to Resident #5 on 6/13/16 at 11:30 am, she did not respond in any manner. A Physician order [REDACTED]. The physician's orders [REDACTED]. [DIAGNOSES REDACTED] protocol documented in the Physician order [REDACTED]. * Call MD if BG is less or equal to 70. * Give 4-6 oz of orange juice if resident is able to swallow. * If resident is not able to swallow start IV and give 50 ml D50W. * Recheck blood sugar after 15 minutes of treatment. * If resident is unconscious, cannot swallow, does not have IV access give 1 mg of [MEDICATION NAME] IM or subcutaneous x 1 dose only. * Recheck blood sugar in 15 minutes and notify MD if blood sugar is still less than 70. The Medications Flowsheet for (MONTH) (YEAR), documented Resident #5 had a BG level of 61 on 5/27/16 at 9:00 pm. Documentation on the MAR indicated [REDACTED]. A nurses' note the next day, on 5/28/16 at 4:14 am, stated Resident #5's tube feeding was given in response to the BG of 61, with an improvement to 145 within an hour after the feeding was administered. There was no documentation that the physician was notified of the low BG level. No changes in Resident #5's diabetic medications were made in response to the low B[NAME] Resident #5's [MEDICATION NAME], 20 units, was administered at 10:00 pm on 5/27/16, per the Medications Flowsheet. Blood glucose levels were not consistently taken in accordance with physician's orders [REDACTED].#5's BG level was not assessed at 10:00 am on the following 6 dates: 5/5/16, 5/15/16, 5/23/16, 5/24/16, 5/30/16 and on 5/31/16. The Medications Flowsheet for (MONTH) (YEAR), documented Resident #5 had subsequent [DIAGNOSES REDACTED] incidents on 6/2/16 and 6/3/16, with a BG of 69 recorded at 9:00 pm. The Medications Flowsheet documented Resident #5's insulin scheduled to be given at 10:00 pm, was administered. According to the Medications Flowsheet, Resident #5's BG level was rechecked and was 120. A nurses' note the next day, on 6/3/16 at 6:30 am, documented Resident #5's tube feeding was given in response to the BG of 69 with prompt improvement to 120 noted after the feeding was administered. The nurses' note further documented Resident #5's BG was rechecked prior to the 4:00 am tube feeding and was 59, with an improvement to 124 after feeding. Documentation stated the physician was notified; however, it was not clear if the physician was notified twice for two separate incidents or notified once. It was unclear when the physician was notified. The physician reduced Resident #5's [MEDICATION NAME] to 15 units twice daily on 6/3/16 and again to 10 units twice daily on 6/9/16. Interview with Resident #5's family member (Family Member #3) was conducted on 6/15/16 at 5:30 pm. Family Member #3 stated Resident #5 was dependent on staff for care. She verified Resident #5 was in a persistent vegetative state, all nutrition was provided via a G tube, Resident #5 was a diabetic, and Resident #5 had been experiencing new onset of low blood sugar incidents. The DNS was interviewed on 6/16/16 at 5:00 pm and stated nursing staff should follow the diabetic protocol in the event of [DIAGNOSES REDACTED] incidents. The DNS stated if blood sugar was less than 70, the physician should be notified right away. |
2020-09-01 |