| 45 |
WEISER CARE OF CASCADIA |
135010 |
331 EAST PARK STREET |
WEISER |
ID |
83672 |
2018-06-15 |
684 |
E |
0 |
1 |
GRQ011 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, policy review, and resident and staff interview, it was determined the facility failed to ensure professional standards of practice were met related to neuro checks after resident falls, medication management, management of respiratory symptoms and not following physician orders. This was true for 2 of 3 residents (#12 and #16) reviewed for falls when neurological checks were not completed after resident falls, 3 of 12 residents (#2, #20, and #30) whose medications were reviewed when the recommended dose of Tylenol was exceeded and the ordered dose was exceeded for a nasal spray and antacid medication, 1 of 1 resident (#4) reviewed for respiratory symptoms and 1 of 16 residents (#132) where the nurses failed to follow physician orders. This failed practice created the potential for harm should residents experience undetected changes in neurological status after a fall, adverse side effects from excessive doses of medication, and undetected signs and symptoms of worsening respiratory status or [MEDICAL CONDITION]. Findings include: The facility's undated policy and procedure for nasal inhalers, sprays, and aerosols, documented the following: * Verify the physician's order, taking notice of the concentration of the medication and which nostril to treat. * Occlude one of the resident's nostrils, insert the tip into the open nostril and squeeze quickly and firmly one time. * Have the resident hold their breath for a few seconds then exhale through the mouth. * Repeat the ordered number of times in each nostril. The facility's policy and procedure for respiratory care, dated 11/28/17, documented the following: * Depending on the type of respiratory services the resident receives, physician orders and the individualized respiratory care plan, documentation should include, as appropriate: vital signs, respiratory rate, movement of the chest and respiratory effort, abnormal breath sounds, signs of dyspnea (shortness of breath), position change effects of breathing, the nature of sputum (mucous), signs of infection, changes in behavior that may signify [MEDICAL CONDITION] (low oxygen levels), and resident instruction regarding participating in respiratory treatments as appropriate. * The attending practitioner is immediately notified of significant changes in condition, and the medical record reflects the notification, response and interventions implemented to address the resident's condition. The facility's policy and procedure for Neurological Evaluation, dated 11/28/17, directed staff to perform neuro checks every 15 minutes for one hour, then every 30 minutes for one hour, then every hour for two hours, then every 4 hours until (the) physician states it is no longer necessary or in 72 hours if (the) resident's condition is stable and showing no signs and symptoms of neurological injury. The facility's policy and procedure for Fall Response and Management, dated 11/28/17, directed staff to perform neuro checks per the physician's orders, or monitor every 15 minutes for 1 hour, then every 30 minutes for one hour, then every hour for 2 hours or until the resident's status stabilizes if the resident hit their head. According to the Lippincott NursingCenter website, accessed on 6/21/18, and the Nursing (YEAR) Drug Handbook, there are eight Rights of medication administration: 1. Right patient. 2. Right medication. 3. Right dose. 4. Right route. 5. Right time. 6. Right documentation. 7. Right reason. 8. Right response. 1. Resident #2 was admitted to the facility on [DATE] with multiple diagnoses, including [MEDICAL CONDITION] reflux disease and acute sinusitis. Resident #2's physician orders, active as of 6/14/18, documented the following: * [MEDICATION NAME] Proprionate Suspension (a nasal steroid spray) 50 mcg 2 sprays each nostril twice a day for chronic rhinosinusitis. * [MEDICATION NAME] Suspension 200-200-20 mg /5 ml 2 tsp every 6 hours as needed for stomach upset. Resident #2's (MONTH) (YEAR) MAR indicated [REDACTED] * The [MEDICATION NAME] nasal spray was administered each day from 6/1/18-6/14/18. * The [MEDICATION NAME] was administered on 6/8/18, 6/10/18, 6/12/18, and 6/14/18. On 6/14/18 at 9:19 AM, RN #1 administered medications to Resident #2. RN #1 administered two sprays of [MEDICATION NAME] nasal spray to Resident #2's right nostril and left nostril. RN #1 then administered three additional sprays of [MEDICATION NAME] to Resident #2's right nostril and two additional sprays to the left nostril. When asked how many sprays should be administered, RN #1 said it was two sprays in each nostril. When the surveyor brought it to RN #1's attention that she had administered 5 sprays in the right nostril and 4 sprays in the left nostril, RN #1 said Oh. On 6/14/18 at 12:05 PM, RN #1 said sometimes it appeared Resident #2 did not sniff up all the nasal spray, so she gave more sprays. RN #1 said she normally would not give that many sprays. On 6/14/18 at 9:20 AM, RN #1 administered Advanced Antacid (a generic form of [MEDICATION NAME]) 30 ml to Resident #2. On 6/14/18 at 2:50 PM, RN #1 said the order for [MEDICATION NAME] was 2 tsp, which equaled 10 mls. RN #1 said she administered 30 mls of [MEDICATION NAME] to Resident #2 and was thinking it was tablespoons. 2. Resident #4 was admitted to the facility on [DATE] with multiple diagnoses, including heart failure and [MEDICAL CONDITION] (a lung disease). Resident #4's physician orders, active as of 6/15/18, documented the following: * [MEDICATION NAME] sulfate HFA aerosol solution 108 (an inhaled medication to open the resident's breathing tubes) inhale 1 puff every 6 hours as needed for shortness of breath. * [MEDICATION NAME] sulfate nebulization solution 2.5 mg/3 mls inhale 3 mls via nebulizer every 4 hours as needed for shortness of breath and wheezing. * Breo Ellipta 14 dose 100-25 mcg (an inhaled medication to open the resident' breathing tubes plus an inhaled steroid) inhale 1 puff once daily for shortness of breath/wheezing. * [MEDICATION NAME] capsule 18 mcg (an inhaled medication to open the breathing tubes) inhale one capsule once daily for breathing. Resident #4's current care plan directed staff to administer nebulizer treatments as ordered and Check breath sounds and monitor/document for labored breathing. Monitor/document for the use of accessory muscles while breathing. Resident #4's Progress Notes documented the following: * On 6/6/18 at 1:42 PM, he had a cough with expiratory wheezing, thick white to yellow sputum, he was just not feeling good, weak, and with fatigue, and a chest x-ray was ordered by the physician. * On 6/8/18 at 3:42 PM, Resident #4 was improved with a slight cough and some wheezing. The x-ray was done and the report was not back yet. * On 6/13/18 at 3:25 PM, Resident #4 was more confused for the past few days, complained of feeling weaker and needed more help. The chest x-ray was normal. There was no documentation Resident #4's lung sounds were re-assessed after 6/8/18. There was no documentation the oxygen saturation level was checked. Resident #4's MAR indicated [REDACTED] * The [MEDICATION NAME] inhaler was last administered on 6/6/18 and was the only dose administered in (MONTH) (YEAR) and (MONTH) (YEAR). * The [MEDICATION NAME] via nebulizer was not administered in (MONTH) or (MONTH) (YEAR). On 6/12/18 at 9:37 AM, Resident #4 said he recently went to the emergency room due to a cough, he had a chest x-ray, and was still coughing. On 6/15/18 at 11:41 AM, LPN (Licensed Practical Nurse) #1 said Resident #4's lungs were clear with some wheezing. LPN #1 said the last [MEDICATION NAME] nebulizer was given in (MONTH) (YEAR) and the last [MEDICATION NAME] inhaler was given on 6/6/18. LPN #1 said he had not listened to Resident #4's lungs on that morning. LPN #1 said the lung bases were a little diminished and sounded clear. On 6/15/18 at 11:24 AM, RN #2 said Resident #4 had wheezing and coughing on 6/6/18 and was given an antibiotic. RN #2 said the physician may have seen Resident #4 on 6/14/18 at his office and she could call to find out if a note was available. The facility did not provide documentation of Resident #4 being evaluated by the physician on 6/14/18. On 6/15/18 at 12:10 PM, the DON said the staff usually checked oxygen saturation as part of vital signs and did not know why it was not recorded for Resident #4. The DON said she thought the nebulizer and inhaler would have been given when the resident was still complaining of coughing. 3. Resident #16 was admitted to the facility on [DATE] with multiple diagnoses, including other abnormalities of gait and mobility and muscle wasting and atrophy. Resident #16's current care plan documented the following: * He was at high risk for falls and had a fall on 5/31/18. * Two person assist for transfers with a Hoyer lift. * Anticipate Resident #16's needs. * Ensure the call light was in reach. * Provide non-skid footwear, and the resident was to wear gripper socks while in bed. * PT (physical therapy)/OT (occupational therapy) to evaluate and treat as ordered or as needed. * Place the recliner chair controller in the side pocket of the chair for resident safety. A Fall Risk Assessment Tool, dated 4/3/18 at 6:19 PM, documented Resident #16's fall risk score was 5, which indicated he was at risk for falling. A Progress Note, dated 5/31/18 at 1:39 PM, documented Resident #16 was adjusting his power recliner and could not take his finger off the control button. He was found on the floor, face down, in front of the power recliner. A 5-cm skin tear was present to the left forearm with mild bruising and a small swollen area was noted on the center of his forehead. An A and I Report, dated 5/31/18 at 11:15 AM, documented Resident #16 fell from his chair and was face down on the floor in front of the fully raised recliner. Resident #16's Neurological Assessment sheet, dated 5/31/18-6/1/18, documented neuro checks were performed at the following times: * On 5/31/18: 11:15 AM, 11:30 AM, 12:00 PM, 12:15 PM, 12:45 PM, 1:15 PM, 1:45 PM, 2:15 PM, 3:15 PM, 4:15 PM, 5:15 PM, 6:15 PM, 7:15 PM, and 11:15 PM. * On 6/1/18: 3:15 AM, 7:15 AM, 11:15 AM, and 7:00 PM. * On 6/2/18 at 11:00 AM and 10:00 PM. The neurological checks were not completed through 6/3/18 at 11:15 AM (72 hours). On 6/14/18 at 4:31 PM, the DON said the facility policy indicated neuro checks were for 72 hours, and the physician did not say the neuro checks were no longer necessary prior to that for Resident #16. The DON said there should have been one more day of neuro checks. 4. Resident #30 was admitted to the facility on [DATE] with multiple diagnoses, including gangrene to his left below knee amputation surgical site and [MEDICAL CONDITION]. Resident #30's Admission Physician orders, dated 2/26/18, documented he was to receive [MEDICATION NAME] 10/325 mg ([MEDICATION NAME]/[MEDICATION NAME]) 1 tablet by mouth every 6 hours as needed for pain. It was also noted Resident #30 was not to take Tylenol ([MEDICATION NAME]) while he was taking the medication. The order documented the maximum dose of [MEDICATION NAME] was 4000 mg in 24 hours. Resident #30's Physician order, dated 6/13/18, documented he was to receive [MEDICATION NAME] 10/325 mg 1 tablet by mouth every 6 hours as needed for pain. The order did not include the precaution for the maximum [MEDICATION NAME] dosage in a 24 hour period. The website for the U.S Food and Drug Administration, announced new measures to reduce the risk of severe liver injury with [MEDICATION NAME] on 1/13/11. On 7/28/11, the maker of Tylenol announced new instructions to lower the maximum daily dose from 4000 mg to 3000 mg. On 6/14/18 at 4:38 PM, the DON stated some of the physicians did not reduce the maximum dosage of [MEDICATION NAME] from 4000 mg to 3000 mg. 5. Resident #12 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The USA Food and Drug Administration announced on 1/13/11, new measures to reduce the risk of severe liver injury with [MEDICATION NAME]. On 7/28/11, the maker of Tylenol ([MEDICATION NAME]) announced new instructions to lower the maximum daily dosage from 4000 mg to 3000 mg. A Medication Administration Record [REDACTED]. A physician's order dated 5/9/17, documented Resident #12 was to not to receive more than a maximum dose of 4000 mg, of [MEDICATION NAME] in 24 hours. This was not consistent with the 3000 mg limit recommended by the maker of Tylenol. 6. Resident #20 was readmitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Resident #20's admission MDS assessment dated [DATE], documented she was moderately cognitively impaired. a) A Post Fall Investigation dated 4/3/18 at 12:35 AM, documented Resident #20 was in bed under a weighted blanket. Resident #20 was out of bed when the floor alarm sounded. Resident #20 fell and hit her head on the corner of her night stand. Resident #20 was transported to a hospital emergency roiagnom on [DATE] at 1:00 AM and returned to the facility at 3:30 AM. Documentation of neurological checks for the fall dated 4/3/18 were not found in Resident #20's medical record. b) A Post Fall Investigation, dated 4/21/18 at 9:45 PM, documented Resident #20 stood up from her wheelchair and fell on her right side. She hit her head on the door frame. She sustained a bump on her right forehead and two small skin lacerations on her arm. Resident #20's Neurological Check form, dated 4/21/18, documented completed neurological assessments performed by nursing on 19 of 24 opportunities. The other 5 neuro checks lacked each the following: * Pupil Response * Eye Response * Level of Consciousness * Motor Response c) A Post Fall Investigation, dated 4/30/18 at 7:30 PM, documented Resident #20 was found on the floor in her room. She was on her right side and found to have a cut over her right eye. She stated she hurt her head. A Neurological Check form, dated 4/30/18, documented neurological assessments were completed nursing staff from 4/30/18 at 7:45 PM through 5/1/18 at 7:45 AM. Resident #20 did not receive neurological checks for 72 hours. There was no physician order to stop the neurological checks earlier than 72 hours. On 6/15/18 at 11:36 AM, the DON stated she was aware that some neurological checks were incomplete. The facility's policy and procedure for Diabetes Mellitus, dated 10/31/17, documented the following: * Notify the physician for blood sugar levels below or above the established ranges and carry out any new orders. * Monitor the resident and notify the physician if the blood sugar level is above 240 despite extra insulin being administered. * Document in the chart the physician was notified of the change in condition and/or the diagnostic results, and any new orders. 7. Resident #132 was admitted to the facility on [DATE] with multiple diagnoses, including Type 2 diabetes mellitus. Resident #132's physician orders, active as of 6/14/18, documented the following: * Blood sugar checks four times a day and as needed. * Basaglar KwikPen (Insulin [MEDICATION NAME]) inject 30 units at bedtime. * Insulin [MEDICATION NAME] inject 14 units with meals. * Insulin [MEDICATION NAME] inject per sliding scale: if blood sugar Greater than 350 give 5 units and call MD . Resident #132's current care plan directed staff to administer diabetes medication as ordered and monitor/document/report to the physician for signs/symptoms of [MEDICAL CONDITION] (elevated blood sugar). Resident #132's Weights and Vitals Summary documented blood sugar readings as follows: * 6/6/18 at 10:14 PM = 359 * 6/7/18 at 7:55 AM = 307 * 6/7/18 at 12:06 = 324 * 6/7/18 at 4:49 PM = 413 * 6/7/18 at 5:03 PM = 413 Resident #132's (MONTH) (YEAR) MAR indicated [REDACTED] * On 6/6/18 at 5:00 PM, Insulin [MEDICATION NAME] inject per sliding scale: if blood sugar Greater than 350 give 5 units and call MD . was initialed NN, DPQ, and R. There was no documentation of units administered. * On 6/7/18 at 8:00 AM, the blood sugar was 307 and 4 units of insulin were administered. * On 6/7/18 at 12:00, the blood sugar was 324 and 4 units of insulin were administered. * On 6/7/18 at 5:00 PM, the blood sugar was 413 and 5 units of insulin were administered. Resident #132's Progress Notes documented the following: * On 6/6/18 at 9:35 PM: He arrived at the facility at approximately 7:10 PM via facility van. He was very hungry and a meal was provided. * On 6/7/18 at 12:18 PM: Blood sugars since admission were 304-359. * On 6/7/18 at 10:00 PM: His blood sugar was 413, insulin was administered, and the physician was notified. An order was received to increase the Basaglar insulin to 30 units at bedtime. *There was no documentation the physician was notified when the blood sugar was 359 on 6/6/18 at 10:14 PM. On 6/14/18 at 10:29 AM, the DON said she did not see it documented that the physician was notified of the blood sugar of 359 on 6/6/18 at 10:14 PM, and the nurse should have notified the doctor. |
2020-09-01 |