| 847 |
MONUMENT REHABILITATION AND CARE CENTER |
285095 |
111 WEST 36TH STREET |
SCOTTSBLUFF |
NE |
69361 |
2019-05-28 |
684 |
G |
1 |
1 |
3V0011 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.09D Based on observations, record reviews and interviews; the facility failed to ensure that 1) abnormal bleeding was assessed and follow up was completed to ensure care was provided promptly for one current sampled resident (Resident 41) on blood thinning medication, 2) low blood sugar readings were assessed and follow up care provided to ensure needs were met for one current sampled resident (Resident 42, 3) [MEDICAL CONDITION] were assessed and follow up completed to ensure healing without complications for one current sampled resident (Resident 48) and 4) a PICC (Peripherally Inserted Central Venous Catheter) line was monitored every shift and a heart monitor present on re-admission was monitored as indicated for one current sampled resident (Resident 73). The facility census was 85 with 24 current sampled residents. Findings are: [NAME] Review of the Admission Record, printed 5/21/19, revealed that Resident 41 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review revealed that the resident was readmitted from the hospital on [DATE] with a [DIAGNOSES REDACTED]. Review of the Care Plan, goal date 6/3/19, revealed that the resident was at risk for bruising and bleeding related to the use of blood thinning medication. Interventions included that the staff were to inspect the resident's skin for bruising or unusual bleeding daily during care and report to the charge nurse and provider for further interventions. Further review revealed that the resident had both short term and long term cognitive deficits and had difficulty making self understood and understanding others. Review of the Progress Notes revealed the following including: - 2/25/19 at 4:30 AM This nurse noted a large bruise to the left side of the hip, bruise area was hardened, the resident grimaced when the area was touched, no reports of injury from the previous nurse, resident was unable to state the source of the injury due to cognitive impairment, will pass report to coming nurse to notify the primary care physician for evaluation; - 2/25/19 at 1:29 PM Nursing Late Entry Note: Was told in morning report that the resident had a bruise. Later in the day, during the skin assessment in the bath house, the bruise was assessed and appeared dark purple and spanned approximately 29 cm. (centimeters) across and 9 cm. wide. The resident was assessed by a Nurse Practitioner and orders were received to send the resident to the Emergency Department; - 2/25/19 at 9:23 PM Update from the hospital showed that the the resident's INR (International Normalized Ratio), a blood laboratory test for bleeding time, showed a critically high level at 6.16 ( a range of 2.0 - 3.0 generally considered a therapeutic range for people taking blood thinning medication such as [MEDICATION NAME]). Further review revealed that the resident was to be admitted to the Intensive Care Unit at least overnight. Interview with the DON (Director of Nursing) on 5/23/19 at 8:15 AM confirmed that the night shift nurse should have identified the resident's high risk for abnormal bleeding due to the use of blood thinning medication and completed a skin assessment including the size and characteristics of the bruising. Further interview confirmed that the nurse should have notified the provider right away to determine the need for further evaluation and treatment. The DON confirmed that the day shift nurse should also have identified the resident's high risk for abnormal bleeding, should have assessed and documented the bruise and followed up with the resident's provider for further evaluation and treatment to ensure that the resident's needs were met. B. Interview with Resident 42 on 5/20/19 at 9:40 AM revealed had a low blood sugar this morning and had to drink orange juice. Further interview revealed no follow up blood sugar was done. Review of the Care Plan, goal date 6/18/19, revealed that the resident had a [DIAGNOSES REDACTED]. Interventions included that the nursing staff would observe the resident for low blood sugar symptoms including flushed face, sweating, change in usual mental status, lethargy, irritability, fruity breath odor, nervousness, trembling and light headedness. Review of the Medication Administration Record, [REDACTED]. Further review revealed that the resident's blood sugar was 64 on 5/16/19 at 6:59 AM and at 11:30 AM and the blood sugar on 5/1/19 at 7:30 AM was 61. Review of the Progress Notes, dated 5/20/19 and and 5/1/19 revealed no assessment of the resident, including symptoms of hypogylcemia (low blood sugar), treatment provided or a follow up assessment of symptoms or blood sugar obtained. Further review revealed that on 5/16/19 at 6:59 AM, the resident was given glucose for low sugar with no assessment of the resident's symptoms or follow up blood sugar. Interview with the DON on 5/23/19 at 9:20 AM confirmed that the blood sugar levels listed above were abnormally low for the resident. Further interview confirmed that the nurses were to assess and document the resident's symptoms of low blood sugar, interventions provided and the resident's response to the interventions, including a follow up blood sugar in about an hour, to ensure that the resident was stable and needs were met. C. Observations of Resident 48 on 5/20/19 at 3:50 PM revealed dried [MEDICAL CONDITION] and redness on face and arms and a bandage on the right outer neck area. Further observations at 1:30 PM revealed MA (Medication Aide) - C and MA - D provided skin care and applied [MEDICATION NAME] to excoriated areas on the coccyx and gluteal folds. Review of the Care Plan, goal date 7/2/19, revealed that the resident had altered skin integrity related to incontinent [MEDICAL CONDITION] and excoriation. Interventions included weekly skin inspection, thorough skin care and apply barrier cream after incontinent episodes. Review of the Weekly Skin Review, dated 5/16/19, revealed no assessment of the multiple [MEDICAL CONDITION], area covered with a bandage on the neck or the excoriation on the coccyx and gluteal folds. Interview with the DON on 5/23/19 at 10:10 AM confirmed that there was no documentation on weekly summaries or progress notes of the resident's current skin injuries including the [MEDICAL CONDITION] on the face and arms, area on the neck or excoriation. Further interview confirmed that these areas needed to be routinely assessed and documented to ensure healing without complications. D. Record review of Resident 73's MDS (Minimum Data Set, a federally mandated assessment tool utilized to develop resident care plans and tracking for admissions and discharges) records revealed the resident was initially admitted to the facility on [DATE]. The tracking MDS records indicated the resident was admitted to an acute care hospital on [DATE] and re-admitted to the facility on [DATE]. A Significant change in status MDS was completed on 4/29/19. The assessment revealed the was receiving IV (intravenous) therapy both during the hospital stay and during the reference period of the MDS (4/23/-4/29/19). Interview on 5/20/19 at 10:30 a.m. with MA (Medication Aide)-E revealed the unit where Resident 73 now resided was a unit designed for residents with minimal care needs. MA-E stated there was no charge nurse routinely staffed on the unit. Observation of Resident 73's PICC line dressing change on 5/20/19 at 2:40 p.m. revealed RN (Registered Nurse)-F and the facility DON assisting the resident during the dressing change. RN-F and the DON discovered the resident's surrounding area to the PICC line was bright red measuring 7 x 12 cm with some blistering areas alongside the insertion site. Both RN-F and the DON stated this was not present at the last changes. Also, during the observation, a heart monitor was observed in place. Interview with the DON following the observation 5/20/19 at 3:00 p.m. revealed Resident 73's PICC line was scheduled for weekly dressing changes and as needed. The DON also verified there was no licensed nurse assigned as a charge nurse on the 300 unit, but that licensed nurses from other halls come over and do the dressing changes when scheduled and LPN (Licensed Practical Nurse)-I (A restorative nurse) is on the unit some days. The DON was unaware of any orders or monitoring that should be done regarding the resident's heart monitor. Interview with LPN-I on 5/20/19 at 3:30 p.m. revealed LPN-I is not involved in the PICC line care and treatment for [REDACTED]. Interviews and observations of the night shift staff on 5/22/19 between 4:45 a.m. and 5:30 a.m. revealed MA-X was assigned to the unit where Resident 73 resided. MA-X described being the only staff member on the unit during from 6 p.m. to 6 a.m. and if needing a licensed nurse, the Alzheimer's unit charge nurse would come down to the unit. RN-T described working on the locked Alzheimer's units from 6 p.m. to 6 a.m. and confirmed there was no licensed charge nurse on the 300 unit where Resident 73 resided. RN-T described assisting with PICC line dressing changes for Resident 73 on the days scheduled for change, but does not make routine rounds or check the dressing on other days. Record review of Resident 73's current physician orders [REDACTED]. An order dated 4/22/19 for Change central Line dressing weekly and PRN (as needed) as needed for dislodgement or soiled. There were no instructions or orders related to the resident's heart monitor. Record review of Resident 73's Treatment Administration Record for (MONTH) 2019 revealed the facility was documenting weekly central line dressing changes every Monday. There was no documentation the line was changed on 5/13/19. There was no documentation on the resident's treatment records for (MONTH) 2019 that licensed nurses were monitoring the PICC line site other than on dressing change days. Record review of Resident 73's electronic progress notes revealed no documentation by licensed nurses that the PICC line site and heart monitor sites were being monitored except on days when the PICC line dressing was changed. Interviews with the DON and ADON (Assistant Director of Nursing) on 5/28/19 at 10:30 a.m. verified there was no supportive documentation that Resident 73's PICC line dressing was being monitored on every shift and there was no documentation or orders pertaining to the resident's heart monitor placed during the hospitalization in April. Source: University of Michigan Serious risks from common IV (intravenous) devices (MONTH) (YEAR). These (PICC lines) are not innocuous devices. The time has come to stop thinking of them as a device of convenience, and rather one with clear risks and benefits. Many studies and patient safety efforts have worked to reduce another clear risk associated with PICCs: infections often called CLABSIs, for central line associated bloodstream infections. But the risks of [MEDICAL CONDITION]'s ([MEDICAL CONDITION] clotting_ and the potentially lethal risk of a [MEDICAL CONDITION] embolism if the PICC clot breaks away, haven't gotten the kind of attention that a common device would warrant. |
2020-09-01 |