| 6 |
LAURELHURST VILLAGE |
385010 |
3060 SE STARK STREET |
PORTLAND |
OR |
97214 |
2019-02-27 |
684 |
D |
1 |
1 |
71NL11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > 1. Based on interview and record review, it was determined the facility failed to provide alternative care options related to multiple missing medications and treatments for 1 of 1 sampled resident (#199) reviewed for death. This placed residents at risk for medical complications. Findings include: Resident 199 was admitted to the facility in 9/2018, with [DIAGNOSES REDACTED]. On 10/25/18, Resident 199 was sent to the hospital and later passed away. Resident 199's care planned identified she/he was at risk for fluid overload due to end stage [MEDICAL CONDITION] and at risk for hyper/[DIAGNOSES REDACTED] due to diabetes. Interventions included [MEDICAL TREATMENT] and medications per physician orders. Resident 199's 10/1/18 signed physician orders included the following medication and treatment orders: -[MEDICATION NAME] Solution 100 unit/ml (insulin) sliding scale subcutaneously with meals for diabetes; -Aspirin 81 mg every afternoon for heart health; -Nephro-Vit (B Complex-C-Folic Acid) tablet 1 mg every afternoon for supplement; -[MEDICATION NAME] (an antidepressant) 12.5 mg every morning for [MEDICAL CONDITION]; -[MEDICATION NAME] Solution 30 ml TID for hepatic [MEDICAL CONDITION] (a decline in brain function due to liver disease); -Sevelamer (a [MEDICATION NAME] binder) HCL 800 mg TID with meals; -Fluid restriction 1000 ml-1200 ml/day every shift; and -Check CBG (capillary blood glucose) BID. Resident 199's 9/2018 and 10/2018 MAR and DAR (diabetic administration record) documented the following number of missed medications as out of the facility: -[MEDICATION NAME] Solution: 9/2018 - 20 times and 10/2018 - 29 times; -Aspirin: 9/2018 - eight times and 10/2018 - 15 times; -Nephro-Vit: 9/2018 - eight times and 10/2018 - 15 times; -[MEDICATION NAME]: 9/2018 - eight times and 10/2018 - 9 times; -[MEDICATION NAME] Solution: 9/2018 - 16 times and 10/2018 - 23 times; -Sevelamer: 9/2018 - 16 times and 10/2018 - 26 times; and -Check CBG BID: 9/2018 - eight times and 10/2018 - 10 times. Resident 199's 9/2018 and 10/2018 TAR and Fluid Intake Flowsheet recorded 14 days where the resident was over her/his fluid intake of 1200 ml/day. There was no evidence in the resident's clinical record to indicate the facility had attempted alternative care options, such as different medication times or other interventions, to ensure Resident 199 was taking her/his prescribe medications and maintaining fluid restrictions. In an interview on 2/27/19 at 12:38 PM, Staff 10 (Resident Care Manager-LPN) stated she recalled the resident being out of the facility and was on [MEDICAL TREATMENT]. Staff 10 stated if the resident was missing a lot of medications she would expect other interventions, such as changing the resident's medication schedule. Staff 10 was unable to answer why Resident 199 had missed so many medications and treatments. In an interview on 2/27/19 at 1:32 PM, Staff 2 (DNS) stated she expected all medications to be given and treatments provided even when out of the facility. Staff 2 stated she expected other interventions to be provided to ensure the resident received her/his medications and treatments. 2. Based on observation, interview and record review, it was determined the facility failed to assess and perform dressing changes to an intravenous (IV) access line for 1 of 2 sampled residents (#312) reviewed for infections. This placed residents at risk for infection. Findings include: The Centers for Disease Control and Prevention Section VI: Central Venous Catheters outlined the following procedures: B. Peripherally Inserted Central Catheters (PICCs) *Frequency of dressing change: -Transparent dressing: change every five to seven days unless soiled or loose. The Facility's Catheter Insertion and Care Policy and Procedure for central line dressing changes (no date) specified the following: -Change central and midline catheter dressing 24 hours after catheter insertion, every 7 days, or if it is wet, dirty, not intact, or compromised in any way. Resident 312 admitted to the facility in 1/2019 and was discharged at the end of the month with a return to the facility anticipated. Resident 312 returned to the facility in 2/2019 with [DIAGNOSES REDACTED]. The 1/25/19 Admission MDS specified the following: -Section C: Cognitive Patterns revealed a BIMS (brief interview of mental status) score of 15 which indicated Resident 312 was cognitively intact. -Section O: Special Treatments, Procedures and Programs indicated Resident 312 received IV (through the veins) medications. The 2/12/19 Admission Nursing Data Base was inaccurately marked none for IV access. Review of Resident 312's Physician's Orders revealed an order for [REDACTED]. There was no Physician's Order for PICC dressing changes. Review of the 2/2019 TAR indicated no documentation of PICC dressing changes. Review of Resident 312's Progress Notes indicated no documentation related to ongoing assessment and monitoring of the PICC for complications such as bleeding, redness, warmth, tenderness, soilage, drainage, infiltration (leakage of medication into tissue), measurements and displacement. Review of Resident 312's Care Plan indicated IV interventions were created on 2/19/19, seven days after re-admit, for dressing changes per facility protocol and monitor IV site for swelling, redness, infiltration. An observation on 2/19/19 at 10:12 AM, was made of Resident 312's right arm. A PICC with clear dressing dated 2/7/19 was observed on Resident 312's right upper arm. There was no bleeding or redness observed at the PICC insertion site and the dressing was clean, dry and intact. In an interview on 2/19/19 at 10:12 AM, Resident 312 stated she/he received IV medication for a bone infection. She/he stated staff did not change the PICC dressing as often as they should and verified the 2/7/19 date on the dressing. She/he stated this is my lifeline because I have no veins left and denied pain at the PICC site. On 2/20/19 at 12:33 PM, Staff 4 (LPN) was observed to set up and start [MEDICATION NAME] IV medication through the PICC. The PICC dressing was observed and the dressing was clean, dry and intact and dated 2/19/19. In an interview on 2/20/19 at 12:43 PM, Staff 4 (LPN) stated on 2/19/19, she instructed the evening shift nurse to change the PICC dressing because it looked like the PICC dressing was dated 2/7/19. Staff 4 could not locate a physician's order for a PICC dressing change and stated there should have been an order in place. In an interview on 2/20/19 at 12:56 PM, Staff 5 (RNCM) stated she would expect the PICC dressing change order to be on the TAR and confirmed there was no order. She stated the facility PICC protocol was to change the PICC dressing every seven days. Staff 5 stated the facility staff should know the location of a resident's IV access from day one of admit. In an interview on 2/26/19 at 3:51 PM, Staff 2 (DNS) stated IV access should have been noted on the Admission Nursing Data Base Form and confirmed it was missed. She confirmed Resident 312 had a PICC and expected the PICC site to be assessed and monitored and the dressing changed every seven days per protocol. Staff 2 stated education was provided to nursing staff regarding accurate assessments. |
2020-09-01 |