| 8254 |
AGAPE REHABILITATION OF ROCK HILL |
425159 |
159 SEDGEWOOD DR |
ROCK HILL |
SC |
29732 |
2013-06-18 |
328 |
G |
1 |
0 |
B96711 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection, based on record review and interviews, the facility failed to ensure that one of one sampled residents reviewed with a [MEDICAL CONDITION] received appropriate care and services. The facility failed to implement interventions timely to prevent dislodgement of the [MEDICAL CONDITION] cannula for Resident #7. The findings included; The facility admitted /readmitted Resident #7 with [DIAGNOSES REDACTED]. Review of the Minimum Data Set assessment dated [DATE] revealed the resident had short and long term memory problems. Review of the hospital Discharge Summary dated 4/23/13 revealed Resident #7 initially was treated at the hospital for a decline in mental status. Imaging on day 2 demonstrated an increase in ventricular size ([DIAGNOSES REDACTED]), and the resident was transferred for neurosurgical care. The resident underwent [REDACTED]. The resident required reintubation within 48 hours for hypoxic [MEDICAL CONDITION] and [DIAGNOSES REDACTED], and subsequently required a [MEDICAL CONDITION] on 4/2/13. According to the summary, On date of discharge, (Resident #7) is alert [MEDICAL CONDITION]. (S/he) is able to speak a few words and follow commands with the LUE (left upper extremity). (S/he) has an old right [MEDICAL CONDITION] as well as facial weakness.[MEDICAL CONDITION] in place with no plans to decannulate given poor functional status and mental status . Review of nursing facility documentation revealed a Daily Skilled Nurse's Note dated 4/26/13 at 10:00 PM, which included information that the suction catheter would not go into [MEDICAL CONDITION] the inner or outer cannula with resistance met at every attempt. Noted [MEDICAL CONDITION] turned to the R(ight) side instead of forward, this was different from 2 days ago. Outer cannula head or neck plate was not flush to the skin and outer cannula was showing protruding out of the [MEDICAL CONDITION] opening in a R(ight) direction instead of straight out. No mucus was found in the inner cannula. (S/he) was coughing mucus into his/her throat and was unable to spit it out easily or swallow it. (S/he) bit the [MEDICATION NAME] suction tube when I attempted to clear his/her throat by suction. I contacted -- NP (Nurse Practitioner) and informed her/him. O2 sats (saturation) 92 % on O2 at 28% . After evaluation of the resident by a Registered Nurse (RN), the NP gave an order to send the resident to the emergency room (ER) for evaluation and treatment for [REDACTED]. Review of the hospital's Admission History and Physical dated 4/27/13 revealed an Admitting [DIAGNOSES REDACTED]. According to the note, vital signs were stable on arrival except for the pulse which was [MEDICAL CONDITION] at 106 with an O2 saturation of 96% with a lot of gurgling and congestion heard in the patient's throat and chest. Respiratory Therapy was called but the catheter could not be advanced more than 4 cm before it hit hard resistance. Review of the CT (Computerized Tomography) scan report and an ENT (Otolaryngology) Consult dated 4/27/13 revealed that the [MEDICAL CONDITION] tip was flat against the anterior wall of the [MEDICAL CONDITION], not positioned well in the trachea. According to the Consult note, the impression was Dislodged [MEDICAL CONDITION]. According to the note, [MEDICAL CONDITION] removed and easily replaced with another. Review of the facility's physician progress notes [REDACTED]. According to the note, the resident's family member was present when the resident had been evaluated by ENT at the hospital. They stated that part of the [MEDICAL CONDITION] apparatus was turned the wrong way inside him. Pt. had pulled out his [MEDICAL CONDITION] set a few times before s/he was readmitted to the hospital. It was thought that floor nursing put it in the wrong way . They mentioned to (the family member) that (the resident) may need a mitten on his/her L(eft) hand . to keep from pulling out his/her [MEDICAL CONDITION] set. According to the Current Plans:, the resident was doing well and [MEDICATION NAME] was ordered to thin secretions. Also noted was- Will see if (facility) is okay with a mitten on L(eft) hand to prevent him/her from pulling out [MEDICAL CONDITION], and future trips to the ER for this. F/U (Follow up) prn (As Needed). Review of the medical record revealed no indication that the possible use of mittens had been discussed or addressed by the facility until 5/11/13. During an interview on 6/18/13, the Director of Nursing (DON) was asked about documentation of an interdisciplinary team meeting relative to any interventions considered for the resident's behavior. The DON stated that they have discussed issues in morning meetings, but stated the facility did not have anything specifically documented for this resident. The surveyor requested to see any documentation in general related to these morning meeting discussions, but the DON did not provide this for review prior to exit. Review of Daily Skilled Nurse's Notes dated 5/1/13 - 5/11/13 revealed the following documentation of continued incidents in which the [MEDICAL CONDITION] was dislodged and/or partially dislodged along with incidents where the resident had removed his/[MEDICAL CONDITION] through which s/he had been receiving Oxygen. There was no evidence that interventions for these behaviors had been implemented by the facility until 5/11/13, when it was documented that orders had been obtained for scheduled [MEDICATION NAME] and hand mitts. 5/1/13 7A-7P .res (resident) takes O2 off + had to be replaced, res reminded to leave it on suctioned several times this shift . Another note dated 5/1/13 at 11:00 PM revealed information that the resident was coughing up a large amount of clear to pink/yellow mucus from trach. Suctioned .S/he removed (trach) collar x 1 . 5/2/13 3:00 PM .suctioned x 2 earlier this shift. ADON (Assistant Director of Nursing) + floor nurse went in to clean trach,[MEDICAL CONDITION] dislodged. ADON able to [MEDICAL CONDITION] obturator .5/2/13 11P- Lethargic but pulling [MEDICAL CONDITION] off periodically .suctioned .Large amount of .phlegm from trach. 5/3/13 9:00 AM .Noted [MEDICAL CONDITION] displaced .Supervisor [MEDICAL CONDITION] in place . 5/3/13 6:00 PM Nurse in to assess pt. Noticed that [MEDICAL CONDITION] lying on his/her chest (with) balloon deflated. Notified Dr. --. New order to send pt to (hospital) for displacement [MEDICAL CONDITION]+ to replace .pt sent to (hospital) via 911 . 5/5/13 3:00 PM Resident pulled [MEDICAL CONDITION] out while sitting (up) in Geri-chair.[MEDICAL CONDITION] (with) obturator .Dr.-- notified. New order refer pt to pulmonologist for [MEDICAL CONDITION] (please try to wean off trach) . 5/6/13 7A-7P .Continues to take O2 mask (off), res reminded to keep mask on, O2 sat (saturation) 96% . 5/6/13 11:00 PM .Takes [MEDICAL CONDITION] off frequently and throws on floor. Found [MEDICAL CONDITION] his abdomen when entered the room . 5/7/13 7A-7P .Continues to pull O2 mask off trach, has to be reminded to leave in place . 11:00 PM .[MEDICAL CONDITION] off and put on floor .O2 [MEDICAL CONDITION] @ 28% . 5/8/13 .No attempt to [MEDICAL CONDITION] continues to [MEDICAL CONDITION] collar .No acute distress . On 5/10/13 Resident #7 had a [MEDICAL CONDITION] consult. Review of the consult note dated 5/10/13 revealed the pulmonologist was asked to give his/her opinion regarding the feasibility for decannulation (removal of the trach). According to the Assessment/Plan, the pulmonologist doubted that the resident could clear secretions or maintain an airway at present and that s/he would not consider downsizing or decannulation of [MEDICAL CONDITION] hospitalized in a facility where immediate emergent airway management was available. A Daily Skilled Nurse's Note dated 5/11/13 at 9:30 AM revealed that at 8:30 AM, the nurse went into the resident's room and found [MEDICAL CONDITION] dislodged laying on the resident's neck. An attempt to put [MEDICAL CONDITION] in was unsuccessful, and 911 was called. EMS was unable to replace [MEDICAL CONDITION] the resident was transported to the hospital. Upon return to the facility at 1:40 PM, it was documented that a size 4 [MEDICAL CONDITION] placed in the ER and the resident was now on 35% Oxygen. At the time of readmission, the DME (durable medical equipment) provider was called to bring in smaller suctioning catheters since the facility only had 14 french catheters. According to the note, the DME provider brought 12 french catheters that the facility was unable to use; and 10 french catheter(s) had been obtained from the hospital's emergency room . Continued review of Nurse's Notes revealed that at 7:00 PM, a sitter was with the resident and at 8:00 PM, s/he had left. The 7:00 PM note documented that a telephone order had been received from the physician for scheduled [MEDICATION NAME] (1 mg every 8 hours) and hand mitts. During an interview on 6/10/13 at 8:00 PM, the DON (Director of Nursing) stated the reason the resident had pulled out [MEDICAL CONDITION] because s/he didn't want it. When asked if any sitters had been provided for the resident, the DON stated that the resident's family member had been referred to a private pay Home Health Agency and had met with them to set up services for a sitter to come at night. According to the DON, since the resident pulled out [MEDICAL CONDITION] the family present, the resident would do the same with a sitter. The DON stated that the family would have to pay for this service, but before it could be started, the resident was sent out to the hospital and [MEDICAL CONDITION] been removed. During an interview on 6/18/13 at 3:10 PM, the DON provided documentation of a contract between Resident #7's RP (Responsible Party) and the home health agency for sitter services (to prevent [MEDICAL CONDITION] being pulled out) to start 5/10/13 at an hourly rate. The DON stated that they had no documentation of when the sitter came or didn't, and that the facility did not have a sign in/sign out sheet for this. The DON stated that the resident was still able to dislodge the [MEDICAL CONDITION] with the mitts on by using hand movements. The DON had been under the impression that [MEDICAL CONDITION] the resident and that s/he would rub it causing it to be dislodged. Further review of Daily Skilled Nurse's Notes revealed the following: 5/12/13 7A-7P .Sitter @ bedside from 4P-8P .Will not keep mitts on hands. Unable to make needs known. 5/15/13 11:00 PM .Continuously removes mittens from hands . 5/16/13 11:00 PM .Continues to take mittens off of hands. No attempts to remove trach/trach collar . 5/17/13 at 10:30 AM stated, Resident pulled [MEDICAL CONDITION]. N.O. (New Order) received to send to (hospital) to [MEDICAL CONDITION]. According to the note, the resident returned to the facility with a 3.5 [MEDICAL CONDITION] place. Review of hospital documentation revealed Resident #7 presented to theER on [DATE] for an evaluation of a dislodged trach. .Patient had a 4.0 Shiley that the patient accidentally pulled out. According to the note, Based on the size of the [MEDICAL CONDITION] opening a 4.0 could not be passed it was replaced with a 3.5 Shiley. Patient will follow up with [MEDICAL CONDITION]. Further review of Nurse's Notes revealed that on 5/17/13 at 3:50 PM, the therapist reported that [MEDICAL CONDITION] out after the resident coughed and that the 3.5 [MEDICAL CONDITION] been reinserted [MEDICAL CONDITION] had been done. At 4:15 PM, it was documented by nursing that the 3.5 [MEDICAL CONDITION] been removed and replaced with a #[MEDICAL CONDITION](with a small amount of blood tinged mucus noted). The note did not indicate why the [MEDICAL CONDITION] been replaced with a #4 trach. At 5:00 PM it was documented that [MEDICATION NAME] 1 mg (milligram) had been given via [DEVICE] (Gastrostomy tube) for increased anxiety and was effective. 5/19/13 at 10:35 PM revealed Resident lying bed, O2 concentrator tubing disconnected (after) looking @ resident [MEDICAL CONDITION] completely out and upside down. Unable to replace trach-911 called and resident sent to ED. Resident had sitter until 9:00 PM . A note timed for 2:00 AM (on 5/20/13) revealed that the resident's family member called the facility to report that they were keeping resident in hospital d/t (due to) swelling [MEDICAL CONDITION] and inability to [MEDICAL CONDITION] consulting pulmonology in am. Review of hospital records revealed a procedure note which documented a [MEDICAL CONDITION], Direct laryngoscopy, and [MEDICATION NAME] through [MEDICAL CONDITION] incision had been completed on 5/23/13. The note stated that The [MEDICAL CONDITION] fell out last week and was not replaced in a timely manner resulting in stenosis of his/her left [MEDICAL CONDITION] site. Since that time, s/he has had intermittent [MEDICAL CONDITION] and replacement of his/her [MEDICAL CONDITION] has been recommended . The note documented a #8 cuffed Shiley [MEDICAL CONDITION] had been inserted into the airway without difficulty. A hospital Progress note dated 5/24/13 documented that the [MEDICAL CONDITION] had been replaced 5/23/13, and that the ENT recommended the patient remain in the hospital until the first [MEDICAL CONDITION] change which would occur after 72 hours. Review of the hospital Discharge Summary dated 5/28/13 (signed 5/31/13) revealed that the resident had been admitted to the hospital after s/he pulled out his/her [MEDICAL CONDITION]. The patient was seen by the ENT who was unable to replace the [MEDICAL CONDITION] at the bedside and it was recommended that the resident be admitted to the hospital for closer monitoring. According to the note, .Patient has been having plenty of airway secretion and is not able to cough adequately to clear his/her secretions. Patient was admitted and had intermittent suctioning. The [MEDICAL CONDITION] was then subsequently changed, but the patient was recommended to be kept in the hospital for reevaluation per the ENT and patient will need another [MEDICAL CONDITION] change within 72 hours. Yesterday, the ENT physician was able to place and change the [MEDICAL CONDITION] to a #6 and s/he has recommended to discharge . The discharge recommendations included, .Recommend closer monitoring of patient to avoid dislodging [MEDICAL CONDITION]. May need continuous sitter or may try an arm immobilizer to see if this reduces the incidence of patient moving to dislodge medical devices, the nursing home to address this and possibly reduce his/her rehospitalization . Review of the nursing facility's medical record documentation from 5/31/13 (when the resident was readmitted ) through 6/6/13 revealed multiple incidents where Resident #7 continued to dislodge his/her trach. Review of Nurse's Notes/Hospice Notes revealed the following: Review of the Hospice notes revealed the following: 5/31/13 (In 11:00 PM, Out 11:59 PM)- .Pt. upon arrival very restless and kicking covers off himself, reaching [MEDICAL CONDITION]. Pt. arrived with wrist restraints which were immediately removed and placed in pt. closet. Verbal cues given to pt. not to place hand [MEDICAL CONDITION].[MEDICAL CONDITION] itching pt. [MEDICATION NAME] applied BID (twice daily).[MEDICAL CONDITION] given by hospice nurse to help alleviate discomfort. Pt. still reaching [MEDICAL CONDITION] 1 mg tid (three times daily) prn (as needed) via g tube . Further documentation in the note stated that the family understood the purpose of hospice but wanted to [MEDICAL CONDITION] g tube and full code status .(Resident) is unable to make sound decisions related to [MEDICAL CONDITION] and stroke in the past . During an interview on 6/18/13 at 1:35 PM, the DON stated that the resident returned from the hospital (readmitted to the facility on [DATE]) on Hospice. The DON stated that s/he told the resident's family member that they didn't do wrist restraints (when it was requested by the resident's family). According to the DON, s/he told the family member that the facility wouldn't take the resident back with restraints. The DON verified when the resident returned to the facility in June there were no restraints ordered. Review of the Nursing Notes for June, 2013 revealed the following related to [MEDICAL CONDITION] care: 6/1/13 Resident [MEDICAL CONDITION]. Res was found by CNA during am care.[MEDICAL CONDITION] by RN on the floor. 8:00 PM Res pulled out trach. Reinserted by RN on 100 hall. Additional Hospice Notes revealed the following: 6/1/13 (In 8:30 PM, Out 9:00 PM)- .FS (Facility Staff) reports that pt. had [MEDICAL CONDITION] two times since early am .Pt. agitated during assessment. S/he keeps tugging [MEDICAL CONDITIONS] gets irritated when verbally cued to leave area alone. Wash cloth placed in pt. right hand to distract pt. from touching trach. Requested FS to give [MEDICATION NAME] for agitation. 6/2/13 3:00 AM Resident [MEDICAL CONDITION]. Site cleaned,[MEDICAL CONDITION] + Reinserted by RN on the floor. 10:30 AM Resident removed trach. Replaced without incident . 6/2/13 (In 5:15 PM, Out 6:15 PM)- .Pt. face flushed and s/he continues to pull [MEDICAL CONDITION] 2 today. Spoke with FS and ascertain(ed) [MEDICAL CONDITION] may be irritating him/her with the straps. Instructed to check on pt. [MEDICAL CONDITION] and to give [MEDICATION NAME] to see if that will help alleviate site agitation .Pt. [MEDICAL CONDITION] times two today .Also discussed using [MEDICATION NAME] to see if pt would [MEDICAL CONDITION] alone. Site is irritated and pt. is going [MEDICAL CONDITION]. Review of Physician orders/Telephone Orders along with the Medication/Treatment Administration Records for June 2013 revealed no orders for [MEDICATION NAME] and no evidence anything [MEDICAL CONDITION] irritation had been ordered/given. Review of the June 2013 Medication Record revealed [MEDICATION NAME] 1 mg TID (three times daily) PRN (As Needed) had been administered once on 6/1/13 (at 6AM); with no documentation of [MEDICATION NAME] having been administered during the early/morning hours on 6/2/13 around the time frames the resident pulled out his/her trach. Review of a 6/3/13 9:38 AM Physician's Progress Note revealed .Pt. admitted to (the facility) under the hospice GIP (General Inpatient) program for anxiety. S/he had recently been hospitalized after s/he pulled out his/her [MEDICAL CONDITION] again .Agitation under control at this point, will discuss with hospice the next step. If hospice finds that s/he does not require GIP status any further, we can shift pt back to LTC (Long Term Care) at (facility) . Hospice notes for 6/3/13 through 6/7/13 indicated the following: (In 4:00 PM, Out 5:30 PM) .Discussed with facility nurse about pt's agitation and attempting to remove trach. RN verbalized s/he had to give pt his PRN [MEDICATION NAME] Facility nurse -- updated on new order of [MEDICATION NAME] and interventions of OOB (out of bed) to gerichair and [MEDICAL CONDITION] band. (Family member) agreed to try pt on [MEDICATION NAME] 0.5 mg in addition to PRN [MEDICATION NAME] 1 mg . A Physician's Telephone Order dated 6/3/13 at 5:15 PM stated, 1) [MEDICATION NAME] 0.5 mg TID Dx Agitation . 6/(4)/13 1:30 AM Sitter states resident needs to be suctioned. Noted [MEDICAL CONDITION] out. Replace [MEDICAL CONDITION]. (In 2:00 PM, Out 3:30 PM)- Pt is oriented to self mainly. Unable to communicate most needs. Able to follow some directions .Pt is very forgetful and must constantly be reminded to [MEDICAL CONDITION]. Facility nurse --- verbalized that pt has not been attempting to pull [MEDICAL CONDITION] today. S/he stated pt continues [MEDICATION NAME] 0.5 mg TID and only had to have one PRN dose of [MEDICATION NAME] since yesterday .(Family member) and --- notified that if pt's symptoms are resolved tomorrow, pt will discharge (from hospice) to the facility as a LTC (long term care) pt .Facility staff also updated that pt will likely come off (hospice) tomorrow if symptoms are resolved. 6/5/13 (SNF (Skilled Nursing Facility) visit- Pt is calm at this time. Facility nurse --- verbalized pt has been calm and has not been attempting to pull out trach. Pt. is up in geri chair at this time. Pt is discharged off GIP (General Inpatient) (hospice) . (Facility staff member) updated on pt's condition. 6/6/13 Resident sent to (hospital) after pulling out trach.[MEDICAL CONDITION] was attempted by RN -- + was unsuccessful .Res transported via (ambulance service) via stretcher Per --- @ (hospital), Res is to be returned to (facility) (with) [MEDICAL CONDITION] place. ---stated they do not have his/her sz (size)[MEDICAL CONDITION]+ that s/he is in no distress @ this time . 6/7/13 Returned from hospital @ 1:20 A (with) no trach. Res states s/he does not [MEDICAL CONDITION]. 6/7/13 8:30 PM- Resident restless, removing Oxygen collar from neck. O2 sat 97%, stoma patent . A Physician's Progress Note dated 6/7/13 revealed, .S/he returned to the facility without [MEDICAL CONDITION].(Family member) stated the ER did not have the size s/he needed (which was an 8), that it was not an emergency, and that s/he should be transferred back to the facility without it (trach). They wanted (the resident) to see a pulmonologist other than Dr. ---, but (family member) wants an appt with Dr. -- ASAP (As soon as possible) to [MEDICAL CONDITION] put back in again . A Physician's Telephone Order dated 6/7/13 at 12:16 PM stated, Refer to Dr. --- (pulmonologist) ASAP, Dx [MEDICAL CONDITION] pt (without)[MEDICAL CONDITION] this point. -O2 sat q (every) day, -change [MEDICATION NAME] to scheduled. An Physician's Progress Note signed by Dr. ---(ENT) dated 6/13/13 at 1:15 PM stated, .f/u (follow up) trach. S/he has pulled it - again on 6/7/13 .(No) airway obstruction. D/C (Discontinue trach) . Further review revealed a Physician's Telephone Order had been written 6/13/13 to discontinue [MEDICAL CONDITIONS] Oxygen. During an interview on 6/18/13 at 3:10 PM, the DON reviewed the ENT Progress note dated 6/13/13. When asked if the resident had seen the pulmonologist, the DON stated the pulmonology appt had been scheduled for late June (6/28/13) when the resident had been discharged from the hospital. Review of Social Services Notes revealed a note dated 6/11/13 which stated, SW (Social Worker) will speak to Dr.-- about a referral to a psychiatrist for resident for behaviors of pulling out his/her medical equipment. There was no documentation of a referral having been made prior to this date. A faxed referral dated 6/11/13 for Psychotherapy services stated, pt keeps pulling out his [MEDICAL CONDITION], likely on purpose, please evaluate for possible depression + apply CBT (Cognitive Behavioral Therapy) . During an interview on 6/18/13, the DON was asked about the Life Source referral and stated that the resident had been referred to this Psychology service on 6/11/13 for cognitive behavioral therapy. The DON stated that they only came once a month and had been here on 6/11/13 when the referral had been made, but did not see the resident at that time. Review of the Interim Care Plan dated 5/31/13 revealed the resident had a trach. There was no information included to indicate any interventions had been put into place to prevent the resident from dislodging his/her [MEDICAL CONDITION]. Review on 6/10/13 of the resident's current Care Plan revealed an entry dated 6/6/13 which stated the resident had a trach, and included information that the resident had repeatedly dislodged [MEDICAL CONDITION] required reinsertion of [MEDICAL CONDITION] readmission on 5/31/13. The entry stated the resident was at risk for significant complications. A handwritten entry dated 6/6/13 stated, #8 [MEDICAL CONDITION] cannula, ambu bag +obturator @ bedside. There was no indication from the Care Plan that the resident had returned to the facility without [MEDICAL CONDITION] place on 6/7/13. Another Care Plan entry dated 6/6/13 stated the resident was at risk for altered mood with [DIAGNOSES REDACTED]. Listed approaches included that the resident will likely attempt to [MEDICAL CONDITION]/or PEG tube if s/he becomes anxious without intervention or diversion/ 1:1 supervision. use calm demeanor and positive tone of voice when trying to redirect any behaviors; s/he responds best to calm approach. |
2016-06-01 |