cms_SC: 10163
Data source: Big Local News · About: big-local-datasette
| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 10163 | UNIHEALTH POST-ACUTE CARE - NORTH AUGUSTA | 425296 | 1200 TALISMAN DRIVE | NORTH AUGUSTA | SC | 29841 | 2010-12-15 | 505 | K | Inf | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification and Complaint survey, based on observations, interviews, record reviews, and review of facility policies, it was determined on 12/14/10 at 10:30AM that Immediate Jeopardy and Substandard Quality of Care existed for CFR 483.75 F-505 which was identified at a scope and severity of "K" which began on 9/12/10. The facility failed to assure laboratory test results were returned to the facility in a timely manner and promptly provided to the physician to use for assessment, diagnoses, treatment and initiation of appropriate infection control practice. The systematic failure to provide lab services and notify the physician promptly placed residents at risk for serious harm. The immediate jeopardy was not removed upon exit from the facility. Residents #'s 1,4,5,6,14,15,21 and 29 who were 8 of 22 sampled residents reviewed for Physician notification of lab services were identified with concerns related to physician notification resulting in a delay of treatment. The findings included: The facility admitted Resident #1 on 6-2-10 with [DIAGNOSES REDACTED]. Record review on 12-14-10 at approximately 5 PM revealed that on 9-12-10, Respiratory Therapy noted moderate yellow sputum and a Physician's Interim Order for "Sputum Culture today" was obtained. Further review revealed no laboratory results in the medical record. Review of the Respiratory Therapy notes revealed that the sputum specimen was obtained on 9-15-10. During an interview on 12-14-10 at 6 PM, Registered Nurse (RN) #3 reviewed the medical record and Lab Book and could find no record of the sputum culture having been completed. During an interview on 12-15-10 at 9:20 AM, RN #3 stated that the physician's orders [REDACTED]. She reviewed the Respiratory Therapy Notes with the surveyor and confirmed that the sputum specimen had been obtained on 9-15-10. The lab report was obtained from the computer and RN #3 verified that the lab had received the specimen on 9-16-10 and reported it on 9-20-10. The RN reviewed the Lab Book and confirmed that the lab was entered to be done on 9-13-10 and there was no follow-up to ensure that the results were received and called to the physician in a timely manner. She also reviewed the medical record and could locate no evidence that the physician was ever notified of the results which showed "pseudomonas aeruginosa 2+" and the gram stain with "many" positive rods and "many" white blood cells. Further review revealed that a weekly PT ([MEDICATION NAME])/INR (International Normalization Ratio) was done and the report available to the facility on [DATE] via computer. The lab report noted that the resident was currently "on 2 mg [MEDICATION NAME]" and was faxed to the physician on 11-3-10 (2 days later). The PT was 12.9 seconds with a reference range of 10.0 to 13.0. The INR ratio was 1.0 L(ow) with a reference range of 2.0-3.0. The physician wrote an order on the lab report on 11-4-10 to "Please ^ (increase) to 3 mg". This order was transcribed onto a Physician's Interim Order form on 11-5-10. During an interview on 12-15-10 at 8:50 AM, Licensed Practical Nurse #4 reviewed the medical record and confirmed that the [MEDICATION NAME] was not increased until 11-5-10 based on the 11-1-10 PT/INR results. Resident # 14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the medical record on 12/13/10 revealed the resident had a Urine Culture and Sensitivity obtained on 9/16/10. The resident was started empirically on Bactrim on 9/17/10. Per the lab result, a report of the lab was available on 9/18/10 which indicated the resident had an E-Coli infection which was not sensitive to the Bactrim as ordered. Nurses notes documented on 9/20/10 that the resident expressed to the nursing staff that she thought the Bactrim was "not strong enough to cure UTI" (urinary tract infection). On 9/21/10 the resident complained of burning all over and asked to go to the emergency room . The resident returned from the emergency room with a new order for Keflex for 10 days and a [DIAGNOSES REDACTED]. The lab report filed in the medical record indicated the result was possibly faxed to the facility on [DATE] and clearly faxed on 9/22/10 and faxed to the physician on 9/22/10. There was no documentation that the facility tried to access the lab result after 48 hours, or attempted to access the result once the resident complained of not feeling better. On 12/14/10 during an interview with the ADON (Assistant Director of Nursing) who was also the Unit Manager she stated that just because the lab result was available in the computer did not mean the facility could access the information. She then called the lab and learn that if the report indicated the result was available it would indeed be available in the computer for the facility staff to access. There was no explanation provided by the Assistant Director of Nursing as to why there was a delay in the receipt of the lab result or fax to the physician. The resident was not included on the audit log on the nursing unit for monitoring for the return of the result or physician notification. Resident # 15 was admitted on [DATE]. A PT/INR ([MEDICATION NAME] time/International Normalization Ratio) was obtained on 11/29/10. The lab report indicated that the result was available on 11/29/10. The report was faxed to the facility on [DATE] and the physician notified on 12/1/10 who then ordered for the [MEDICATION NAME] to be held one day on 12/1/10. The result of the [MEDICATION NAME] was 27.0 (high) and INR 3.4 (high) Resident # 15 had a urine culture obtained on 11/19/10. The lab report indicated the result was available on on 11/21/10. A physician order [REDACTED]. Further interview with the Director of Nursing (DON) revealed that there had been intermittent problems with accessing lab results on the facility computers. A back up plan was for the lab results to be faxed to the facility. However, the fax was located in the business office which closed at 5:30PM and was not open on weekends. Additionally, the DON stated she had trained new hires on how to access labs but now was aware that the weekend supervisor (who worked a 16 hour shift) and potentially other staff hired prior to her arrival did not know to access the labs. Therefore, any lab result received on the weekend was not currently accessible to the nursing staff. Resident #6 was admitted on [DATE] with a [DIAGNOSES REDACTED]. During record review of laboratory reports it was found that a sputum culture was done on 6/10/10 with a report date of 6/12/10. The results were not faxed to the Physician until 6/15/10 at which time the resident was [MEDICATION NAME] mg PO BID for 5 days for a Pseudomonas infection. A Pro-Time of 10/18/10 with a report date of 10/18/10 was not sent to the Physician until 10/21/10 . The result of the lab test was a [MEDICATION NAME] time 18.6 (high) and 1.8 (low). A Pro-time was drawn on 11/1/10 with a report date of 11/1/10 . The result of the test was 21.3 (high) and 2.3. The physician was faxed the results on 11/3/10. There was no documentation found that nursing identified the delay in treatment. The facility admitted Resident #4 on 7/26/10 with [DIAGNOSES REDACTED]. Record review on 12/13/10 revealed the resident to be on [MEDICATION NAME] Therapy requiring PT/INR's ([MEDICATION NAME] Time/ International Nationalizing Ratio) to be drawn routinely. Further record review revealed the labs to be drawn timely; however, copies of the lab results did not appear to return timely to the facility or to be acted upon timely. Resident #4 had labs drawn: 8/24/10 not called to Doctor until 8/26/10 with an order for [REDACTED]. During an interview with RN #1 (Registered Nurse), the nurse showed an audit form that was being used to track labs. However, check marks were only placed if report faxed, placed in folder, or phone call made to Physician. Some sheets only had dates report received and date report placed in the chart. No follow-up was done by the nurses if a report had been delayed to find out why report delayed or to ask what results were. The lab test for 10/25/10 PT/INR for Resident #4 had not been listed on the audit sheet. This was confirmed by RN #1. Therefore, no one questioned why the result was not faxed until 10/29 and not faxed to doctor until 11/2. The Physician ordered an increase of 1 mg (milligram) to the current [MEDICATION NAME] order on 11/2/10. The facility admitted Resident #5 on 8/26/09 and readmitted on [DATE] with [DIAGNOSES REDACTED]. Record review on 12/13/20 revealed a lab report for a Complete Blood Count (CBC) and a Basic Metabolic Profile (BMP) drawn on 2/08/10. The report was reviewed on 2/14/10 and iron studies ordered. A lab report done on 8/30/10 and sent to facility on 8/30/10 for CBC and BMP had irregularities noted. Note on bottom of report faxed to doctor- fax unsuccessful. There was no documentation of any follow up to refax or call to the doctor. Review of the medical record revealed Resident #21 was admitted to the facility on [DATE] and readmitted on [DATE]. [DIAGNOSES REDACTED]. Review of the Nurses' Progress Notes dated 11/29/2010 indicated Resident #21 "complained of congestion, called (the Attending Physician) new order for sputum C&S (culture and sensitivity). At 3:40 PM, the "sputum culture was obtained from resp(iratory) therapist." On 12/4/2010 at 4 AM, Resident #21 complained of nausea and vomiting and a headache. His temperature was 100.4 degrees, pulse of 112 and blood pressure of 145/95 (significantly higher than the 100's systolic as his baseline). On 12/5/2010, Resident #21 refused care. On 12/6/2010 Resident #21 continued to complain of nausea and vomiting, headache and neck ache. On 12/7/2010 at 12:00 AM, Resident #21's temperature was 102.7 and he stated that he did not feel well. His temperature was rechecked at 3:20 AM, and it was recorded as 103 degrees. The physician was notified and an order was obtained to send him to the emergency room . Resident #21 returned from the emergency roiagnom on [DATE] at 9:15 AM, with orders for intravenous antibiotics (IV) for "[MEDICAL CONDITION]." On 12/8/2010, Resident #21's antibiotics were changed from IV [MEDICATION NAME] to Cipro, [MEDICATION NAME] and intramuscular (IM) [MEDICATION NAME]. On 12/9/2010 at 9:40 AM, "new order airborne precautions move to room [ROOM NUMBER]....MRSA sputum." Review of the Physician's Telephone Orders revealed the following: 11/29/2010, "Sputum C&S"; 12/7/2010 "Send to ER (emergency room ) for increased temperature"; 12/7/2010 " [MEDICATION NAME] 1 gram IV every day for 10 days". 12/8/2010 "DC(discontinue) [MEDICATION NAME] and [MEDICATION NAME] mg (milligrams) BID(twice a day), [MEDICATION NAME] 120 mg IM for 7 days"; 12/9/2010 " airborne precautions, move to room [ROOM NUMBER]". Review of the Respiratory Therapy notes revealed on 11/27/2010, Resident #21's sputum was thin and yellow. Additional notes revealed the sputum was noted to be increasing in quantity and was noted to be thick and yellow. No respiratory distress was documented. Review of the Laboratory data revealed a sputum culture was sent to the lab on 11/30/2010. The lab reported the final results to the facility on [DATE]. The facility notified the the Attending Physician on 12/8/2010, two days after receipt of the report. On 12/8/2010 the antibiotic treatment was altered for Resident #21 because [MEDICAL CONDITION] was not sensitive to the current treatment. There was no documentation noted that the nursing staff followed up to assure the timely receipt of the culture, which resulted in the resident not being place on appropriate transmission based precautions in a timely manner. The resident resided in a room with three other residents at high risk for infection related to cormorbidities. The facility admitted Resident #29 on 1/2/2010 with [DIAGNOSES REDACTED]. Record review revealed a physician's orders [REDACTED]. The results of the culture were made available to the facility on [DATE]. The physician was not notified of the positive culture until 11/15/2010. Further review revealed a PT/INR dated 10/11/2010 was available the same day and the physician was not notified until 10/13/2010. An additional PT/INR was available to the facility on [DATE], with physician notification occurring on the 28th . A PT/INR was dated 11/1/2010 and the results were available to the facility on [DATE] but the physician was not notified until 11/3/2010. During an interview the Nurse Manager from Station II, confirmed the delay in obtaining the culture results from 11/30/2010 for Resident #21 and confirmed the delay in notification for the culture and PT/INR results for Resident #29. She stated that normally cultures take 2-3 days to report. She stated that it was the nurses' responsibility to call and check on the results if they were delayed. The nurse stated that the lab normally faxed over the results when they were available. Lab results were also available through the computer. The Nurse Manager stated that the fax machine was located in the business office or the Admissions office, both of which were locked after 5 PM and on weekends. She/he stated that if a lab was faxed on the weekend, the nurses would not receive the results until the following Monday. If the lab was faxed after 5 PM, the nurses would receive the results the next day. The Nurse Manager confirmed that there had been a two day delay in notifying the physician of [MEDICAL CONDITION] positive culture. She stated that the nurses should have faxed the results to the physician immediately upon receipt of the lab. The Nurse Manager also confirmed that Resident #21 was not placed on isolation precautions for [MEDICAL CONDITION] pneumonia until 12/9/2010, 3 days after the report was made available to the facility. During an interview,a representative from the contract Lab stated that sputum cultures take 1-2 days to report. She/he stated that all cultures were sent to --- Hospital. She stated that if there was a delay in obtaining the results that a lab tech would call the hospital to check on the results. She stated that no documentation of the phone calls were kept. The Lab tech stated that the facility had access to the lab results on the computer and the results were available to the facility on the date reported. She also stated that a fax was automatically generated and sent to the facility upon report of the lab. She stated that there was no confirmation receipt kept for specific lab reports. During an interview, the Director of Nursing confirmed the delay in obtaining the culture report and confirmed the delays in reporting the result to the physician for both Resident #21 and #29. She/he also stated that Resident #21 should have been placed on isolation precautions immediately upon receipt of the lab results on 12/6/2010 and should not have waited 3 days. The facility's policy on Changes in Condition was reviewed. The policy documented that the nurses were to "verbally report resident's status to the physician and provide detailed description of the observed signs and symptoms and any laboratory and or radiology test results. Communication...must occur in a timely manner..." The facility Administrator and two Corporate Nurse Consultants were present on 12/14/10 at 10:30AM when advised by the Team Leader that Immediate Jeopardy and Substandard Quality of Care had been identified by the survey team after conferring with the State Agency. The Immediate Jeopardy was not removed upon exit from the facility and remains ongoing. First Follow-Up Visit During an unannounced onsite visit on 12/30/2010 at 10:30 AM, it was determined based on interviews, observations, review of records, and review of facility policies, that the Allegation of Compliance submitted by the facility on 12/22/2010 had been implemented by the facility and was in practice as of 12/22/2010, removing the immediacy of the deficient practice. The citation at F-505 remained at a lowered scope and severity of " E". The facility will be in compliance at F-505 when an acceptable Plan of Correction is submitted and a follow up visit is conducted to determine that the facility has implemented their Plan of Correction as stated. | 2014-04-01 |