cms_TN: 6649
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| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 6649 | GOOD SAMARITAN HEALTH AND REHAB CENTER | 445170 | 500 HICKORY HOLLOW TERRACE | ANTIOCH | TN | 37013 | 2015-02-11 | 224 | G | 0 | 1 | XIH911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to prevent neglect when staff failed to follow up on dental orders and failed to notify the attending physician of a dental procedure while the resident was on anticoagulation medications; and failed to follow the facility's [MEDICATION NAME] therapy protocol for 1 of 4 (Resident #155) sampled residents reviewed with anticoagulation medication and dental procedures. The facility neglected to notify the physician of a dentist's desire to hold [MEDICATION NAME] for a dental procedure and the facility failed to follow the facility's [MEDICATION NAME] protocol when the physician was not contacted about [MEDICATION NAME] time and international normalized ratio (PT/INR) levels when the resident's [MEDICATION NAME] dose was increased which resulted in actual harm when Resident #155 was hospitalized due to bleeding following tooth extraction. The findings included: Review of the facility's policy entitled [MEDICATION NAME] Protocol effective date 6/1/10 documented, .8. The physician will be informed when residents are taking the following medications while on [MEDICATION NAME] . [MEDICATION NAME]. These medications have the potential to significantly increase the PT/INR ([MEDICATION NAME] time - how quickly blood clots - normal range of 10 to (-) 13) INR - normal range 0.8 - 3.50) value while taking [MEDICATION NAME]. The physician will be encouraged to order a PT/INR every other day while taking one of these meds (medications) with [MEDICATION NAME] due to potential for significant increase in INR and risk for bleeding . Medical record review revealed Resident #155 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of nurses notes dated 12/6/13, documented the resident developed a [MEDICAL CONDITION] of the right thigh and was started on [MEDICATION NAME] (blood thinner) 7.5 milligrams (mg) daily. The resident had received [MEDICATION NAME] with PT/INR levels being done as ordered with physician intervention as needed. The last PT/INR done on 4/2/14 revealed the PT was 26.0 with an INR of 2.24 with the INR being in a subtherapuetic range; [MEDICATION NAME] 7.5 mg was continued. Review of the physician's orders, laboratory results and nurses notes revealed no further orders for PT/INR after 4/2/14. Review of a physician's order dated 4/4/14, documented to increase the [MEDICATION NAME] dose from 300 mg to 400 mg each evening. The facility did not provide documentation the physician was notified of the facility's [MEDICATION NAME] protocol to encourage a PT/INR every other day when Resident #155's [MEDICATION NAME] dose was increased on 4/4/14. Review of a nurses note dated 4/8/14, documented the resident was .crying, indicating a tooth was hurting. Dental assistant was notified. Dentist examined tooth . Review of the dental service note dated 4/8/14 documented, .Hold blood thinner and extract (tooth) . Review of a nurses note from 4/8/14, forward, revealed no documentation the physician was notified of the dentist's statement to hold the [MEDICATION NAME] before extraction nor was there any documentation nursing staff made an appointment for the tooth extraction. Review of a nurses note dated 4/28/14 documented, the .Conservator requested dental eval (evaluation) due to resident c/o (complaining of) tooth pain . The resident was receiving scheduled pain medication of [MEDICATION NAME] 7.5/325 mg three times daily. Review of a nurses note dated 4/29/14 at 11:00 AM, written by Nurse #11, documented .Called (dentist's office) to have dentist to look at resident's mouth to evaluated (evaluate) not to pull teeth. Because resident is on [MEDICATION NAME] talked to conservator aware (teeth) not to be pulled but to evaluate . Review of a nurses note dated 4/30/14 at 2:00 PM, written by Nurse #11 documented, .Dentist arrived talked to assistance (assistant). Said they were only to evaluate not pull because resident was on [MEDICATION NAME] . (the dental assistant) said it was OK (okay) the Dr. (Doctor) is comfortable pulling teeth on [MEDICATION NAME] and then handed me the papers to sign teeth was (were) already extracted at this time . Review of a nurses note dated on 4/30/14 at 2:00 PM, written by Nurse #4 documented, .Dentist at bedside with resident draped. When asked if . was going to do an extraction today . (Dentist) replied in the affirmative. Dental assistant then entered room and stated, I know we haven't held the blood thinner but we're going to stay here for a little while to make sure (Resident #155) . doesn't bleed or anything. The facility failed to provide documentation the nurse called the resident's attending physician before the dentist preformed teeth extractions while the resident was still receiving [MEDICATION NAME]. Review of the dental progress note dated 4/30/14 documented, .Patient complaining lower right. Patient tolerated tx (treatment) well. Minimum bleeding. Already clotting . There was one tooth surgically removed requiring elevation, and two residual teeth roots were extracted. Review of Resident #155's nurses note dated 4/30/14 documented the following: a. At 4:00 PM - .Resident gauze out blood on face, gown, and linens. Resident cleaned up and gauze replaced clots noted . b. At 5:00 PM - .Resident removal gauze or gauze came out. Gauze in resident's hand. Bleeding continued. MD (Medical Doctor) called. Waiting for answer . c. At 5:30 PM - .No response from MD calls. Continue to monitor resident for bleeding . d. At 6:00 PM - .Resident bleeding continues. Resident unable to keep gauze in mouth . e. At 6:15 PM - .MD called again. All available numbers called. Resident continued monitoring at this time . f. At 6:25 PM - .Order received to transfer to ER (emergency room ) for eval (evaluation) . Review of the emergency department (ED) notes for Resident #155 dated 4/30/14 at 8:19 PM documented, the resident had presented with persistent bleeding from gums since teeth extraction. The resident's PT was greater than (>) 100 while the INR was >14, with oozing blood from the extraction sites. Resident #155 received Vitamin K (medication to enhance clotting of blood) 5 mg to counteract the [MEDICATION NAME]. The resident was admitted to the hospital. Review of the hospital discharge summary dated 5/6/14, documented Resident #155 was admitted for coagulopathy (problem with blood clotting) and acute blood loss [MEDICAL CONDITION]. The resident received two units of fresh frozen plasma as well as two units of packed red blood cells. The PT/INRs were stable after the infusions. Interview with Nurse #11 on 1/15/15 at 7:30 AM, in the chart room, Nurse #11 stated, called the dentist's office to be sure the dentist would be coming to the facility on [DATE]. Nurse #11 spoke with the office nurse and made sure the office nurse knew Resident #155 was on [MEDICATION NAME] and only an evaluation was to be done. The dentist talked to Nurse #4 on 4/30/14. Nurse #11 confirmed the dentist came out of the resident's room with the assistant who said they had extracted three teeth. Nurse #11 stated the dental assistant stated, We are not concerned about [MEDICATION NAME]. We do it all the time (extract teeth on patients receiving [MEDICATION NAME]). Nurse #11 stated she assessed the resident and there was no bleeding noted, but three hours later the resident began bleeding. Interview with the Director of Nursing (DON), on 1/20/15 at 2:00 PM, at the nurses' station, the DON stated, .It is my expectation [MEDICATION NAME] is held prior to a procedure. I would notify the physician of the upcoming procedure and the need to hold the [MEDICATION NAME] . The DON stated, have only been in the DON position for a few months and was really not familiar with the events with Resident #155. Telephone interview with the Medical Director, on 1/22/15 at 1:00 PM, the Medical Director was asked about holding [MEDICATION NAME] before a dental procedure. The Medical Director stated, If [MEDICATION NAME] is to be held before a dental procedure it depends on the type of procedure . three extractions would qualify as a procedure to hold [MEDICATION NAME] before the procedure . would expect a dentist who is doing the procedure to hold the [MEDICATION NAME] . would not pull teeth on any patient unless . knew what medication the resident was on. Interview with Resident #155's attending physician, on 1/22/15 at 3:50 PM, in conference room [ROOM NUMBER], Resident #155's attending physician confirmed [MEDICATION NAME] has a long half life and should be held three to four days before a procedure. Resident #155's attending physician stated, .I expect nursing to notify me of patient scheduled for procedures and ask me if I want the [MEDICATION NAME] held . would have expected a PT/INR to be done before the procedure . Resident #155's attending physician confirmed the staff had called about the resident bleeding and orders were given to send the resident to the hospital. Telephone interview with the dentist, on 1/27/15 at 10:46 AM, the dentist confirmed the dental assistant had an understanding residents have to be off [MEDICATION NAME] so the statement was made on 4/8/15, that extraction was not possible until the [MEDICATION NAME] was stopped. The dentist stated, .That is something I would not do and x-rays showed an infection at the roots of the teeth . would not hold [MEDICATION NAME] for a simple extraction but would hold it ([MEDICATION NAME]) if there was a more extensive procedure. The dentist confirmed he was called back to the facility because the resident still had pain and had been completely evaluated three weeks earlier so there was no sense to come back for an evaluation because the same things would be done . has to schedule the appointment and bring all the equipment so the dentist will go ahead and do the procedure . the dental assistant went out to check with the nurse who said to go ahead. The nurses deny saying to go ahead with the extraction. Interview with Nurse #1 who cared for the resident after the teeth extraction, on 1/27/15 at 2:45 PM, in conference room [ROOM NUMBER], Nurse #1 confirmed she received report from Nurse #11, who said the resident had teeth pulled. Nurse #1 stated she called the resident's physician who stated the extraction should not have been done while the resident was on [MEDICATION NAME]. Nurse #1 stated, .the resident started bleeding and I knew it was not going to stop . Nurse #1 stated, Nurse #4 should have called the resident's physician to notify the physician the resident was having an extraction and the resident was still on [MEDICATION NAME]. Nurse #1 stated, Nurse #4 also should have notified the DON and physician before the procedure started. Nurse #1 denies saying to go ahead with the extraction. Telephone interview with Nurse #4, on 1/28/15 at 9:50 AM, Nurse #4 stated she questioned the dentist's decision to extract teeth because the resident was on [MEDICATION NAME] and the nurse was concerned for bleeding. Nurse #4 stated, .I think I documented in the nursing notes that I questioned the dentist . Nurse #4 stated she could not say whether the resident's physician was notified. Nurse #4 stated, .I did not give the dentist permission to do anything since the dentist had authority over me. The dentist was going to do it whether the resident was on [MEDICATION NAME] or not . Nurse #4 stated, .was certain the DON was notified . (Nurse #4) looked at the resident after the procedure and the resident did not appear to be bleeding . opened the resident's mouth and saw a considerable amount of gauze but did not disturb it . later learned the gauze was full of blood and the resident had to go out to the hospital. Nurse #4 denies saying to go ahead with the extraction. Telephone interview with the Pharmacist on 2/9/15 at 9:45 AM, the Pharmacist stated, the use of [MEDICATION NAME] and [MEDICATION NAME] concurrently can definitely increase the PT/INR. Interview with Nurse #11, on 2/10/15 at 2:30 PM, at the nurses' station Nurse #11 confirmed there was no follow-up on the dental orders dated 4/8/14. Nurse #11 stated, The physician should have been notified of the planned dental extractions; the fact the resident was on [MEDICATION NAME] and [MEDICATION NAME]; and requested blood work. The facility failed to notify the physician of a dentist's desire to hold [MEDICATION NAME] for a dental procedure and the facility failed to follow the facility's [MEDICATION NAME] protocol when the physician was not contacted about [MEDICATION NAME] time and international normalized ratio levels when the resident's [MEDICATION NAME] dose was increased which resulted in actual harm when Resident #155 was hospitalized due to bleeding following tooth extraction. | 2018-05-01 |