| 8276 |
CAPSTONE HEALTH & REHAB OF EASLEY |
425298 |
1850 CRESTVIEW ROAD |
EASLEY |
SC |
29642 |
2012-07-12 |
514 |
E |
0 |
1 |
PSVU11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record reviews and interviews, the facility failed to maintain clinical records in accordance with accepted professional standards and practice for 3 of 15 residents reviewed for accuracy and completeness of clinical records. (Residents #4, #7, and #13). Resident 4 and 13 had inaccurate cumulative month physician orders. Resident # 7's nursing documentation did not accurately reflect the resident's care. The findings included: The facility admitted Resident #13 with [DIAGNOSES REDACTED]. Record review on 7/12/12 at approximately 1:50 PM revealed a Physician's Telephone Order dated 6/26/12 which stated 1) (Increase) [MEDICATION NAME] to 0.100 mcg (micrograms) . Continued review revealed the order dated 6/26/12 for the increased dosage of [MEDICATION NAME] had not been carried over to the July 2012 cumulative Physician Orders; and the resident was still ordered to receive [MEDICATION NAME] 0.075 mcg daily. This was verified by Licensed Practical Nurse (LPN) #2. When asked how the monthly orders are compiled, LPN #2 stated that once an order is received by the Physician, the order is written, then the yellow copies go to Care Plans where the monthly Physician order [REDACTED]. Review of the July 2012 Medication Administration Record [REDACTED]. During an interview on 7/12/12 at 2:10 PM, the Health Information Manager was told of the concern about the inaccuracy of the cumulative July 2012 Physician order [REDACTED]. When asked how orders are carried over to the next month, she stated that the cumulative orders are printed out 7 days before the changeover (1st of the month). She stated once printed, the night nurse would check these for accuracy. Upon review of Resident #13's July cumulative Physician Orders, the Health Information Manager stated that the nurse checked the orders on 7/1/12 and indicated the signature next to the entry Above Orders Noted by:. She verified there was a blank in the signature/date space for Nurse Review. The facility admitted Resident #4 with [DIAGNOSES REDACTED]. Review of the resident's Cumulative physician's orders [REDACTED]. Review of the Telephone orders on 6/29/12 included the orders for [MEDICATION NAME] 500 mg (milligrams) one po (by mouth) @ HS (hour of sleep) prn (as needed) for cramps. Vitamin B12 1000 mcg (micrograms) po daily. The orders for 6/29/12 were not carried over to the July Cumulative orders. On 6/26/12 telephone orders were received to 1. D/C (discontinue) previous order to clean incision site with wound cleaner and apply a dressing. 2. Clean the area on Rt (right) hip with wound cleanser & apply sure prep & steri strips, check q shift for placement. D/C when steri strips come off. 3. D/C Treatment with [MEDICATION NAME] to Rt. (right) lower buttocks area has healed. 4. Monitor Rt. lower buttocks q (every) shift x (times) 2 weeks for s&s of breakdown. None of the orders for 6/26/12 were carried over to the cumulative orders. A telephone order dated 6/22/12 to D/C [MEDICATION NAME] secondary to [MEDICAL CONDITION]. The [MEDICATION NAME] remained on the July Cumulative Orders, A telephone order dated 6/16/12, stated, Order Clarification: D/C O2. The July Cumulative orders continued to carry orders for Oxygen and Oxygen Equipment. The resident was observed observed on 7/10/12 and 7/11/12 and had no Oxygen equipment in her room. The facility admitted Resident #7 with [DIAGNOSES REDACTED]. Review of the medical record revealed the nurses notes were difficult to follow. Nurses Notes: 6/20/12, 9:30 AM NP (Nurse Practitioner) here & (and) aware of the Hbg (hemoglobin) 7.6. spoke with daughter R/T (related to ) transfusion. 6/20/12, 1:00 PM Spoke with Transfusion Ctr (Center) , order noted and info (information) faxed to schedule transfusion for 6/25/12 (Monday) 6/22/12, 2:20 PM, Residents appt (appointment) for Blood Transfusion is Sunday (6/24/12) 8:30 appt 6/24/12, 7:45 AM, Resident left facility to have blood transfusion 4:00 PM, New orders - Keflex 500 mg (milligrams) bid (twice a day) x 10 days. Urinalysis with C&S (culture and sensitivity) per on call MD. 6/25/12, 11:00 (no am or pm) Resident has appt for blood transfusion on 6/26/12 at 9:30 6/25/12, 2:00 (no am or pm) Blood Transfusion rescheduled for 6/30/12 @ 9:00 (no am or pm) .Resident on ABT (antibiotics) R/T UTI (urinary tract infection) no adverse effects noted no c/o pain/discomfort with urination. T98. 6/25/12, 3:02 (no am or pm) Resident refused BKF (Breakfast) and lunch today but did eat a snack this afternoon. BS (blood sugar) @ 11:30 was 93. 6/26/12, 8:15 (no am or pm) Resident noted to be diaphoretic, breathing labored, O2 sat (oxygen saturation) 83% on 3L/M (liters per minute) increased O@ to 4L/M via n/c . 6/26/12 8:25 (no am or pm) EMS here for resident transporting to hospital . 6/26/12, 300 AM, late entry Resp shallow, lying in bed with eyes closed. Sleeping soundly, hard to arouse. O2 @ 2L NC. 6/26/12, 6:40 AM, late entry, O2 88% increased O2 to 3L, O2 increased to 92% . 6/26/12 1230 AM, late entry UA collected by in & out Cath using sterile technique. Resident tolerated well The nurses notes did not clarify if the resident had/had not received blood when sent out for the blood transfusion. If the resident did not receive the transfusion there was no documentation as to the reason she did not receive it. There was no indication the facility had been observing the resident for possible side effects from a blood transfusion. Nurses notes were written that did not depict the time of the day the note was written, whether in the am or during the pm. The nurses note of 6/26/12 at 8:15, depicted the resident to have an acute change in condition. It was unable to be determined from the notes if the resident did receive the transfusion or if the acute change in condition resulted from the resident having had a reaction to the transfusion. The resident had a urinary tract infection and received an antibiotic. Another transfusion was scheduled for the next day and then rescheduled for the 30th. The resident had an acute change in condition that started at 3:00 AM (late entry) and continued to 8:15 AM when the physician was notified and the resident was sent to the hospital. The late entry nurses notes were not clear as to whether the time they were dated was the time of the event occurrence or the time of the documentation. During an interview with the Director of Nursing (DON) at 11:15AM on 7/12/12, the above nurses notes were reviewed. The DON stated, On 6/24 she went over for blood transfusion. She was very agitated, unable to manage and they sent her back. The family was unable to go on the 26th. They rescheduled for the 30th so the family could go with her. There was no documentation in the medical record the resident was agitated and was unable to receive the transfusion. The DON was further interviewed related to the concerns about the Cumulative Orders. She stated the Medical Records Nurse puts all orders in the system. She uses the yellow copies of the orders. The third shift nurses do the change over. (Check the orders for correctness.) |
2016-06-01 |