| 71 |
VALLE VISTA MANOR |
275021 |
402 SUMMIT AVE |
LEWISTOWN |
MT |
59457 |
2017-10-12 |
281 |
D |
0 |
1 |
BU9C11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to perform physician ordered urinary catheter irrigations for 1 (#4). This failure had the potential to increase the resident's risk of [MEDICAL CONDITION] and urinary tract infection; and the facility failed to monitor a resident for dysphagia symptoms of choking, coughing, and emesis during meals, and failed to monitor lung sounds before and after meals for 1 (#8) resident out of 10 sampled residents. Findings include: 1. A review of resident #4's medical record showed the [DIAGNOSES REDACTED]. He had an indwelling urinary catheter with a [DIAGNOSES REDACTED]. He was readmitted on [DATE]. During an observation and interview with resident #4, on 10/10/17 at 3:45 p.m., it was noted that the resident's urine, as it flowed through his urinary catheter tubing, contained a large amount of white particle sediment in yellow clear urine. A review of resident #4's TARS for (MONTH) and (MONTH) of (YEAR) showed the following: Flush catheter with sterile water and vinegar solution daily and PRN, one time a day related to urinary tract infection, site not specified. Start Date - 08/26/17 0730. Further review of resident #4's TARS, showed that between the dates of 9/1/17 and 10/10/17, the resident received urinary catheter irrigations every day except for 9/1/17, 9/11/17, 9/12/17, 9/13/17, 9/22/17, 9/28/17, 9/29/17, 9/30/17, 10/2/17, 10/5/17, and 10/6/17. Out of a period of 40 days the resident did not receive catheter irrigations as ordered for 11 days, or 27.5 % of the time. It was noted that on 10/7/17 and 10/8/17 the resident received catheter irrigations that were signed off as given on a PRN (as needed basis). During an interview on 10/11/17 at 7:30 a.m., staff member G stated that resident #4 had a history of [REDACTED]. She said that whenever resident #4 received his urinary catheter irrigations, two staff people needed to be present because the resident's behavior can be inappropriate and he makes false accusations. She was unable to explain why resident #4 did not receive catheter irrigations every day, as ordered, for the period between 9/1/17 and 10/10/17. She stated that if a resident refuses a procedure it was supposed to be recorded as a refusal by signing the MARS box with a 2 and there was no documentation present to show the resident had refused treatment. An interview on 10/12/17 at 8:55 a.m., staff member A said resident #4 had a UTI on readmission on 4/14/17 that was treated and resolved. A repeat urine specimen on 4/26/17 showed a repeat UTI that was again treated [MEDICATION NAME] resolved. She said resident #4 had only one UTI since he was readmitted . During an interview on 10/12/17 at 11:10 a.m., staff member I stated she did not know why resident #4 had not received catheter irrigations as ordered by his physician. She stated it was one employee that had not provided the irrigations on her shifts. She also said the employee was no longer employed by the facility and would not be available for survey interview. 2. Review of resident #8's treatment administration record reflected an order to assess the resident's lung sounds before and after meals for seven days. The order start date was 10/5/17. The treatment administration record did not include documentation that the assessment had been done on the following days and times: 10/6/17 at 8:00 a.m., 12:00 p.m. and 6:00 p.m. 10/7/17 at 12:00 p.m. and 6:00 p.m. 10/8/17 at 6:00 p.m. 10/9/17 at 12:00 p.m. and 6:00 p.m. 10/10/17 at 8:00 a.m., 12:00 p.m. and 6:00 p.m. 10/11/17 at 6:00 p.m., and 10/12/17 at 8:00 a.m. Review of resident #8's nursing progress notes did not include documentation of the resident's lung assessments for the dates and times listed above. Review of resident #8's speech therapy progress notes, dated 9/27/17 at 2:29 p.m., reflected, consult with NSG to update on swallow precautions. Printed swallow precautions list for pt (patient) was faxed to B (facility) at 1:00 p.m. Pt will be seen to evaluate tomorrow. Review of a speech therapist progress note, dated 10/4/17 at 12:54 p.m., for resident #8, reflected, Data sheets were provided to NSG staff to document lung sounds and temperatures as well as other comments regarding signs of aspiration during each meal of the day over the next week. During an observation on 10/11/17 at 8:00 a.m., resident #8 was sitting at a table where other residents were assisted to eat. Resident #8's family member was seated next to him and encouraging him to eat. Staff were observed to guide resident #8 in chewing his food and swallowing before he placed more food in his mouth. Resident #8 was eating without noted difficulty at the time of the observation. During an interview on 10/12/17 at 8:50 a.m., staff member G stated the nurses were to check lung sounds after each meal and snacks. Staff member G stated she was not sure where the documentation was in the electronic medical record for the monitoring. During an interview on 10/12/17 at 9:15 a.m., staff member L stated the CNA charts in the medical record have the percent of each meal eaten, but the program did not have an area that CNA staff could document if the resident had symptoms of dysphagia such as choking, coughing, or emesis. Staff member L stated if he was assisting resident #8 and observed symptoms of dysphagia he would report the concern to the nurse. During an interview on 10/12/17 at 10:45 a.m., staff member M stated resident #8 received a soft regular diet and no bread as the bread was causing most of the choking. DeLaune, S. & Ladner, S., Fundamentals of Nursing, Standards and Practice, Albany, NY., (1998), pg. 237. Nurses are obligated to follow the orders of a licensed physician or other designated health care provider unless the orders would result in client harm. |
2020-09-01 |