| 10209 |
KEARNEY COUNTY HEALTH SERVICES |
2.8e+298 |
727 EAST 1ST STREET |
MINDEN |
NE |
68959 |
2012-08-01 |
309 |
K |
0 |
1 |
NRZX11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER: 175 NAC 12-006.09D Based on record review, staff interview, and observations; the facility failed to assess residents' change in condition, failed to assess residents pain and effectiveness of medications, the facility failed to assess lab results, failed to assess the cause of skin conditions and failed to assess causes and develop nonpharmaceutical interventions for residents anxiety. (Residents 19, 22, and 32). The faciltiy census was 30 and the survey sample size was 26. Findings are: A. Review of the DISCHARGE AND DISCHARGE SUMMARY SHEET revealed the resident was admitted on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Review of Resident 19's MDS (a federally mandated comprehensive assessment tool used for care planning) dated 4/12/2012 revealed the following information about the resident: -the BIMS (Brief Interview for Mental Status) score was 5 of 15 (a score of 0 to 7 indicates severe cognition impairment), -The resident experienced short and long term memory issues, -The MDS addressed no behaviors, -Limited assist of one person physical assist for bed mobility, locomotion on unit and personal hygiene, -The resident required an extensive assist of one person physical assist for transfers, walk in the room, walk in the hall and dressing,, -The resident was dependent on two staff physical assist for toilet use, -The medication review was coded as the resident received an antianxiety one day in the assessment period and an antidepressant every day for the 7 days during the assessment period. Review of the Long Term Care Communication with the Provider, dated 6/28/2012 revealed increased episodes of agitation, biting, hitting, and kicking, wants to go home. PA (Physician Assistant) wrote an order for [REDACTED].>Review of the Laboratory Report dated 6/28/2012 for Resident 19 revealed a hand written note waiting for C & S (culture and sensitivity) along with PA initials. Review of the Physician Telephone Orders dated 7/5/2012 revealed an order to check [MEDICATION NAME] level in 1 week on 7/12/2012. Review of the medical record found no documented evidence of results from a [MEDICATION NAME] level. Interview with the DON and RN-S (Registered Nurse) on 7/25/2012 at 10:30 AM revealed no [MEDICATION NAME] level was available. Also said no culture and sensitivity available for the urinalysis performed on 6/28/2012. Resident received [MEDICATION NAME] (antibiotic) while in the hospital. Review of the UA from the hospital dated 7/4/2012 was sent for culture and sensitivity with final growth of [MEDICATION NAME], faecalis treated with [MEDICATION NAME]. Review of the Initial review and investigation dated 7/3/2012 revealed resident was seen at the clinic for lethargy and sounding gurgly. She was admitted to the hospital . No definite pneumonia was noted. She was treated with [MEDICATION NAME] for possible narcotic overdose. Review of a Clinic Note dated 7/3/2012 revealed resident was brought to the clinic because the resident was lethargic. She had a [MEDICATION NAME] 25 mcg (microgram) patch added by the PA on 6/28/2012 and bumped [MEDICATION NAME] to 150 mg (milligram) daily and added [MEDICATION NAME] 2.5 mg bid (two times a day). Resident basically unresponsive and very lethargic. Resident was gurgling and not able to respond to voice but to pain only. Resident had abnormal lung sounds bilaterally and it sounds like she is not handling her secretions. I suspect the resident may have a narcotic overdose from the [MEDICATION NAME] and maybe aspirated. Review of the admission notes dated 7/3/2012 showed an admission [DIAGNOSES REDACTED]. The reason for admission from long term care was she was not handling her secretions and was non-responsive. [MEDICATION NAME] was administered 2 (two) times and [MEDICATION NAME] was started for low grade fever and bandemia. Review of the nurses notes revealed the following: 6/28/2012 --10:00 AM resident agitated, wanting to ambulate without assistance hitting, kicking, biting unable to redirect the resident. --11:00 AM resident still agitated. Refusing assistance hitting kicking and yelling she wants to go home. --12:00 PM resident out to lunch, calmer but still restless. --2:00 PM resident restless, biting, hitting staff. 1:1 with staff unable to redirect. --2:45 PM PA informed of increased agitation, combative, and restless new orders received [MEDICATION NAME] 2.5 mg po bid and urinalysis sent to the Lab urine was cloudy and amber. --(no time of entry) [MEDICATION NAME] and [MEDICATION NAME] started as ordered. --6/29/2012 --1:10 AM drowsy and difficult to arouse. O2 88-92 % loose cough. **No documentation from 6/29/2012 at 1:10 AM until 4 PM on 6/30 approximately 30 hours after documentation of difficult to arouse. 6/30/2012 --4:10 PM resident restless making attempts to stand without assistance intervention 1:1 hitting, biting. --5:30 PM continued behaviors of agitation,yelling , biting, --7:00 PM agitated PA here new orders for [MEDICATION NAME] .5 mg bid. --11:00 PM resting in bed. 7/1/2012 No documentation of behaviors from 6/30/2012 at 11:00 PM until 7/1/2012 --1:45 PM approximately 14 hours . --1:45 PM sleepiness, denies pain hoarse voice. --2:15 PM hitting, scratching staff, wanting to go home. --2:30 PM PA here dc'd (discontinued) [MEDICATION NAME] resident agitated new order for ABH gel 1 ml topical TID --2:50 PM continues combative, biting, hitting. Obtained skin tear left hand. --3:30 PM continues combative, hitting, biting --6:20 PM daughter here less anxious. **No documentation from 7/1/2012 at 6:20 PM to 8:00 AM on 7/2/2012 about 8 hours reference behaviors. 7/2/2012 --8 AM BP (blood pressure) 218/95, pulse 77, respirations 16, temperature 98.4 no O2 (oxygen) saturation drowsy incontinent of urine. [MEDICAL CONDITION] right side of body down arms/face. Accepted meds and drank, no breakfast. --12:00 PM BP 172/88, pulse 60, respiration 17 afebrile no O2 saturation awakens consumes 25 % of meal and medication. verbal report to PA. --1:00 PM [MEDICAL CONDITION] less on right side of body. --6:00 PM lethargic combative with cares ate 50% of meal with much encouragement, being fed. --8:00 PM [MEDICAL CONDITION] less refuses HS (bedtime) meds, in bed. 7/3/2012 --10 PM - 6 AM cooperative with staff 7/3/2012 --9 AM very lethargic no VS documented, drank well at breakfast opens eyes and tries to speak. --2:00 PM OOF (out of facility) to Dr. appointment. --1:30 PM nurse called to the room CNA stated resident hard time coughing and couldn't cough up phlegm assisted with mouth swabs and suctioned. --2:30 PM admitted to acute care --2:45 PM daughter notified of admit to acute care. Review of the Initial review and investigation dated 7/3/2012 revealed resident was seen at the clinic for lethargy and sounding gurgly. She was admitted to the hospital . No definite pneumonia was noted. She was treated with [MEDICATION NAME] for possible narcotic overdose. Review of a Clinic Note dated 7/3/2012 revealed resident was brought to the clinic because the resident was lethargic. She had a [MEDICATION NAME] 25 mcg patch added by the PA on 6/28/2012 and bumped [MEDICATION NAME] to 150 mg daily and added [MEDICATION NAME] 2.5 mg bid. Resident basically unresponsive and very lethargic. Resident was gurgling and not able to respond to voice but to pain only. Resident had abnormal lung sounds bilaterally and it sounds like she is not handling her secretions. I suspect the resident may have a narcotic overdose from the [MEDICATION NAME] and maybe aspirated. Review of the admission notes dated 7/3/2012 showed an admission [DIAGNOSES REDACTED]. The reason for admission from long term care was she was not handling her secretions and was non-responsive. [MEDICATION NAME] was administered 2 times and [MEDICATION NAME] was started for low grade fever and bandemia. Interview with the DON on 7/25/2012 at 11:03 PM stated staff were borrowing medication when the DON started working at the facility and had been told to borrow meds so were re-educated to never borrow medications. Review of the Medication Record dated June 2012 revealed that the staff administered the following medications: [REDACTED] On 6/28/2012 -[MEDICATION NAME] 500 mg daily at 1400 -[MEDICATION NAME] 10 mg every HS -[MEDICATION NAME] 10 mg BID 0800 and 2000 [MEDICATION NAME] 2.5 mg bid started at 1700 [MEDICATION NAME] 25 mcg change every 72 hours for pain applied On 6/29/2012 [MEDICATION NAME] 500 mg daily at 1400 -Harriet 10 mg every HS -[MEDICATION NAME] 10 mg BID 0800 and 2000 [MEDICATION NAME] XR 150 mg daily at 0800 [MEDICATION NAME] 2.5 mg bid 1200 and 1700 [MEDICATION NAME] 25 mcg change every 72 hours for pain On 6/30/2012 [MEDICATION NAME] 500 mg daily at 1400 -[MEDICATION NAME] 10 mg every HS -[MEDICATION NAME] 10 mg BID 0800 and 2000 [MEDICATION NAME] XR 150 mg daily at 0800 [MEDICATION NAME] 2.5 mg bid 1200 and 1700 [MEDICATION NAME] 25 mcg change every 72 hours for pain On 7/1/2012 [MEDICATION NAME] 500 mg daily at 1400 -[MEDICATION NAME] 10 mg every HS -[MEDICATION NAME] 10 mg BID 0800 and 2000 [MEDICATION NAME] XR 150 mg daily at 0800 [MEDICATION NAME] 2.5 mg bid 1200 and 1700 [MEDICATION NAME] 25 mcg change every 72 hours for pain changed [MEDICATION NAME] .5 mg bid at 0800 and 1400 ABH gel PRN applied at 1430 On 7/2/2012 [MEDICATION NAME] 500 mg daily at 1400 -[MEDICATION NAME] 10 mg BID 0800 and 2000 [MEDICATION NAME] XR 150 mg daily at 0800 [MEDICATION NAME] 2.5 mg bid 1200 [MEDICATION NAME] 25 mcg change every 72 hours for pain On 7/3/2012 [MEDICATION NAME] 500 mg daily at 1400 -[MEDICATION NAME] 10 mg BID 0800 and 2000 [MEDICATION NAME] 2.5 mg bid 1200 [MEDICATION NAME] 25 mcg change every 72 hours for pain Review of the medical record for Resident 19 revealed no documented evidence the resident was assessed for pain before the [MEDICATION NAME] Patch was started. Reference Nursing 2012 Drug Handbook revealed the following medication that had possible adverse consequences: --[MEDICATION NAME]--therapeutic class--anticonvulsant--peak time 15 minutes to 6 hours--black box warning--facial [MEDICAL CONDITION], weakness, and lethargy. --[MEDICATION NAME]--therapeutic class--anti-Alzheimer--peak time 3-4 hours--adverse effects--monitor the resident for [MEDICAL CONDITION] because of potential vagotonic effects. --[MEDICATION NAME]--therapeutic class-Anti-Alzheimer--peak time 3-7 hours-- adverse effects--aggressiveness, agitation, anxiety, confusion, [MEDICAL CONDITION], may impair renal function. --[MEDICATION NAME]--therapeutic class---antidepressant--peak time 1-2 hours--adverse effects--monitor blood pressure as drug therapy may cause sustained dose dependent increases in blood pressure. --[MEDICATION NAME]--therapeutic class--antipsychotic--peak time 6 hours--black box warning sedation including coma or [MEDICAL CONDITION], overdose agitation, aggressiveness, reduced level of consciousness, aspiration. --[MEDICATION NAME] Patch--therapeutic class--opiod [MEDICATION NAME]--peak time 1-3 days--black box warning life--threatening hypoventilation between 24 to 72 hours after initial application, overdose signs and symptoms depression , respiratory depression , apnea, [MEDICAL CONDITIONS]. --[MEDICATION NAME]--therapeutic class--antipsychotic--peak time 1 hour--adverse reactions--drowsiness, sedation, [MEDICAL CONDITIONS]. --[MEDICATION NAME]--therapeutic class--anxiolytic--peak time 2 hours--adverse reactions drowsiness, sedation, agitation, weakness, unsteadiness, disorientation. --[MEDICATION NAME]--[MEDICATION NAME]--adverse reactions--peak time 1-4 hours--adverse reaction--drowsiness, sedation, sleepiness, dizziness, confusion, [MEDICAL CONDITION], tachcardia. --[MEDICATION NAME]--therapeutic class--antipsychotic--peak time--3-6 hours--adverse reaction--sedation, drowsiness, lethargy, confusion. --[MEDICATION NAME]--therapeutic class--antidote (may displace opiod [MEDICATION NAME] from their receptors)--adverse effect [MEDICAL CONDITION], tremors. The common adverse reactions the resident experienced were agitation and aggressiveness. Further review found the facility was not tracking behaviors and reviewing the effectiveness of the medication that was being administered to Resident 19. B. Resident 22 was admitted to the facility on [DATE] according to the FACE SHEET on the medical record. The following [DIAGNOSES REDACTED]. Observation on 7/23/2012 at 9:00 AM revealed that Resident 22 had a large purple bruise on the right elbow and another large bruise on the inner side and the outer side of the left elbow. Review of Resident 22's Nurse's Notes dated 7/14/2012 at 7:45 AM revealed that a skin tear was discovered to Resident 22's right elbow. Documentation revealed that the skin tear measured 1.5 cm (centimeter) in length and 0.5 cm in width. Resident 22 stated that the elbow was bumped on the door when exiting the restroom. Further review of Resident 22's Nurse's Notes from 7/14/2012 to 7/24/2012 did not reveal any documentation of bruises to the left elbow. Observation on 7/24/2012 at 2:57 PM of Resident 22 along with the DON (Director of Nursing and LPN (Licensed Practical Nurse) D revealed that they were unaware of the large bruises on both the right and left elbows. Both the DON and LPN D stated that the large purple bruises to both elbows had not been reported so there had not been any assessment as to the cause or to prevent further bruises from occurring. C. Review of an ADMISSION AND DISCHARGE SUMMARY dated 7/10/12 revealed Resident 32 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Review of Resident 32's CARE PLAN dated 7/16/12 revealed (Resident 32) is displaying behaviors of social inappropriateness by arguing with staff and name calling: - 1) Arguing with staff related to anxiety & confusion, 2) Calling staff names; - Approaches were -- 1. Redirect to another activity; -- 2. 1:1 activity; -- 3. change in activity; -- 4. return to room for change of area (do not leave alone); -- 5. take to toilet; -- 6. offer food; -- 7. offer fluid; -- 8. change position; -- 9. adjust temperature of room; -- 10. offer back rub; -- 11. medication intervention (last resort); and -- 12. other. The care plan did not describe behaviors displayed when Resident 32 was anxious or which situations or circumstances caused the anxiety. Interventions did not explain how or where to redirect Resident 32. During an interview on 7/26/12 at 8:30 AM, the Social Service Director (SSD) revealed Resident 32 displayed anxiety by using the call light frequently. The SSD explained Resident 32 would feel the call ling was on for a long time, when it wasn't, then Resident 32 would get more and more anxious. The SSD revealed at times Resident 32 would wake up during the night and want to get up, which added to the resident's anxiety. The SSD stated the staff would try to encourage Resident 32 to go back to sleep, but if the efforts were unsuccessful, staff would assist the resident to get up and sit in the recliner. The SSD revealed this intervention was not on the care plan. The SSD revealed some family dynamics also played a part, as some family members had told said the resident could go home and other had told the resident (gender) could not. The SSD revealed Resident 32 would call staff names and staff were to ignore the behavior and not take it personally. The SSD revealed the family dynamics and the intervention to ignore name calling were not included in the care plan. The SSD revealed there was no documentation that explained what triggered Resident 32's anxiety and interventions on the care plan were not specific in how or where to redirect Resident 32. The SSD stated there was not documentation whether or not interventions tried were successful and 1:1 interventions were not documented. Review of physician's orders [REDACTED]. |
2016-02-01 |