cms_UT: 61
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 61 | MT OLYMPUS REHABILITATION CENTER | 465006 | 2200 EAST 3300 SOUTH | SALT LAKE CITY | UT | 84109 | 2019-05-23 | 690 | D | 0 | 1 | PDL911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 of 28 sampled residents, that the facility did not ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections. Specifically, a resident with a suprapubic catheter developed two urinary tract infections. Resident identifier: 25. Findings include: Resident 25 was admitted to the facility on [DATE] and was readmitted on [DATE] and 5/17/19 with [DIAGNOSES REDACTED]. On 5/20/19, an observation was made of resident 25 resting in her room. Resident 25 had contact precautions on the door to her room. Resident 25 stated that she was very sick and [MEDICAL CONDITION]. On 5/23/19, a review was conducted of resident 25's medical record. A physician's orders [REDACTED]. for suprapubic catheter. The order had a hold date from 3/1/19 to 3/4/19, when resident 25 was hospitalized , and a discontinue date of 3/4/19. A physician's orders [REDACTED]. The order was discontinued on 3/4/19. On 12/16/18, resident 25's care plan for recurrent urinary tract infections (UTIs) was updated. The care plan included the following intervention: Suprapubic catheter care Q shift & (and) PRN. Monitor insertion site & provide tx (treatment) to site as directed. Refer to TAR (Treatment Administration Record) for current tx orders & special instructions for daily care of SP (suprapubic) catheter to bladder. A review of resident 25's TAR revealed no orders for catheter cares between 3/4/19 and 5/22/19. A pharmacy review note dated 3/5/19 at 7:49 PM, revealed . Res (resident) readmitted p (with) urosepsis and pneumonia. A review of nursing notes revealed the following: a. On 4/1/19 at 4:50 PM, Resident c/o (complained of) 'urinating through her urethra'. Refused to allow assessment both yesterday and then today, until this afternoon. DON (Director of Nursing) came to room and assisted LN (licensed nurse) in convincing Resident to cooperate with assessment of catheter, replacement and UA (urine analysis), CBC (complete blood count), CMP (complete metabolic panel), which have been ordered. Resident cooperated with sterile placement of new (silicone) catheter, 18Fr/30ml (French, milliliters). It is hoped that the larger lumen will be assistive, and that the larger balloon will also help to prevent infection. UA specimen obtained from new catheter, and sent to lab via facility phlebotomist. Urine cloudy. b. On 4/3/19 at 6:58 PM, Received UA C&S (culture and sensitivity) results Resident is positive for Proteus Vulgaris. Notified NP (nurse practitioner) and receive new orders: [MEDICATION NAME] 500 mg (milligrams) PO (by mouth) BID (twice daily) x (times) 7 days. c. On 4/6/19 at 7:06 PM, [MEDICATION NAME]-UTI Assessment/Observation: decreased burning, increased awareness, pt (patient) reports that she feels better . d. On 4/10/19 at 6:09 AM,Cipro for UTI Interventions: [MEDICATION NAME] for UTI secondary to indwelling catheter Resident Reaction to Interventions: patient tolerating abx (antibiotic), no signs of rxn (reaction) . e. On 4/14/19 at 8:24 PM:, Resident completed PO ABX without Sx (symptoms) of allergic or other adverse effects. Provided patient teaching on the importance of good hydration in good GU ([MEDICAL CONDITION]) health. Particularly, given that she has a suprapubic catheter in. Urine slightly dark colored, but clear/non-sedimented (sic) at present. f. On 4/30/19 at 5:51 AM, Difficult to give pt meds (medications) this morning. Pt was very lethargic. g. On 4/30/19 at 1:13 PM, Resident acting more confused this morning. Held [MEDICATION NAME] D/T (due to) confusion and lethargy. Resident has been perking up, but still displaying some confusion and forgetfulness. She is afebrile. Informed (provider). UA specimen obtained . h. On 5/5/19 at 1:10 AM, The order you have entered [MEDICATION NAME] Inj (injectable) 40 MG/ML (milliliter) Inject 60 mg intramuscularly two times a day for UTI . i. On 5/5/19 at 11:52 PM, Pt continues on new order for [MEDICATION NAME] Inj 40 MG/ML Inject 60 mg intramuscularly for UTI. No adverse reactions noted. Pt has been lethargic this shift. Able to wake up when name called. Meds given in applesauce. Foley running well down to drain. C/o pain and given oxy 5mg with relief. Will continue to monitor. j. On 5/6/19 at 6:37 PM, Resident coop (cooperative) with IM (intramuscular) ABX. No Sx of allergic or other adverse reaction, thus far. She shows notable improvement from prior week, when UA/C&S was obtained. Encouraging hydration . k. On 5/7/19 at 2:18 AM, Pt continues to receive abx for recent UTI. Pt has been lethargic and moody towards staff. Pt has been yelling rather than using call light. Pt has been demanding CNA's (certified nursing assistants) change her when she is dry. Pt has been changed per request and given pain meds for 5/10 pain with relief. No adverse reactions noted to IM injections. Fluids encouraged. l. On 5/11/19 at 11:52 AM, The order you have entered [MEDICATION NAME] Tablet 500 MG ([MEDICATION NAME]) Give 500 mg by mouth one time a day for Indicated for Pneumonia for 10 Days. m. On 5/11/19 at 5:49 PM, X-ray technician arrived to perform x-rays on residents chest. Resident was not responding appropriately to verbal stimuli. Resident would stare off for a while and not speak.no hand grasp noted. when her name was called resident would look at the person that is speaking to her and she would turn away. Resident was pale. SpO2 (oxygen saturation) 91% at 3 liters of oxygen. Temp (temperature) 98.8, pulse 91, BP (blood Pressure) 150/85, respiration 18. Notified NP (resident's provider), received orders to send resident out for further evaluation. Called (local hospital) ED (emergency department) . n. On 5/17/19 at 5:30 PM, Received Nurse to nurse report from Nurse . RN (Registered Nurse) at (local) Hospital. Resident was admitted to hospital with [MEDICAL CONDITION], and pneumonia. Resident has a central line.currently on [MEDICATION NAME] PO to end in 8 days. Suprapubic catheter in place. dressing is clean dry and intact. o. On 5/17/19 at 7:30 PM, Resident arrived at facility at 1750 (5:50 PM) via medical transport on a stretcher. Resident was diagnosed with [REDACTED]. Resident is Alert and oriented x 2 confused with situation and time. Resident was also exhibiting hallucinations evidenced by resident stating the Ceiling is melting. Resident was agitated by transportation and the move. Resident is currently in contact isolation [MEDICAL CONDITIONS]. Resident has c/o generalized pain administered prn pain medication granting somewhat positive results to resident. lungs diminished at base of lungs no labored breathing nor SOB (shortness of breath) noted. Resident is currently on continuous oxygen 4 liters via NC (nasal cannula). Suprapubic catheter is intact and draining into down drain bag, Catheter size 18fr 30cc. clear yellow urine noted. dressing on suprapubic stoma site is clean dry and intact. 2 person extensive assist with bed mobility, hygiene and toileting. Residents has large bruises noted on BUE (bilateral upper extremities) from previous blood draws. resident has a lumen central venous catheter in place on right chest . p. On 5/17/19 at 11:37 PM, Staff was notified of pts isolation and placed pt in a private room with PPE (personal protective equipment) set up outside the door. Pt was very upset about the change, pt is very confused, possibly due to her UTI. Pt called the cops and stated 'they have just left me.' RN was standing in the room while she called and she could not explain why she was calling them. Police called the main desk, RN explained pts medical condition and assured them that she is rcvng (receiving) all cares. Social Worker called. Social Worker and RN visited with pt to calm her down. q. On 5/18/19 at 6:40 PM, Primary Diagnosis: [REDACTED]. r. On 5/20/19 at 8:46 PM, Notable improvement in the clarity of her speech and expressed thoughts, as well as eye contact during discussions. No difficulty accepting medications or cares (Note: No nursing notes or treatment notes stated that nurses had observed the suprapubic catheter site, cleaned it, or redressed it between 3/4/19 and 5/22/19. The catheter was changed one time on 4/1/19.) A review of laboratory results for resident 25 revealed the following: a. On 4/1/19, Urine culture (UCX) results revealed an infection caused by proteus vulgaris b. On 5/3/19, UCX results revealed that resident 25 had an infection caused by four bacterium: [NAME]ella morganii, Pseudomonas aeruginosa, Staphylococcus aureus, and [MEDICATION NAME] faecalis. On 5/23/19 at 9:05 AM, an interview was conducted with RN 3. RN 3 stated that resident 25 had experienced some confusion with her urinary tract infections. RN 3 stated that the protocol had been to clean the suprapubic catheter site with normal saline and cover with a drain sponge. RN 3 stated that the nurse should clean the site every shift and document the cleaning. RN 3 stated that orders for catheter cleaning should be in the TAR. RN 3 was unable to locate physician's orders [REDACTED]. On 5/23/19 at 9:27 AM, an interview was conducted with the DON. The DON stated that resident 25 also had a [DIAGNOSES REDACTED]. The DON stated that resident 25 was lethargic and very sick. The DON stated that staff had been putting a silver alginate over the stoma site a few months back to control bacterium. The DON stated that CNAs were performing catheter cares. The DON stated that resident 25 had been referred to an infectious disease doctor. On 5/23/19 at 9:47 AM, an interview was conducted with CNA 4. CNA 4 stated that catheter cares for CNAs meant that they wiped the catheter and resident's perineal area. CNA 4 stated that she also cleaned the tubing down to the drain bag. CNA 4 stated that if there was a dressing on the suprapubic catheter stoma site, the CNA would contact the nurse for cares. CNA 4 stated that she did not apply dressings to stoma sites. On 5/23/19 at 9:50 AM, a follow-up interview was conducted with RN 3. RN 3 stated that if there was not an order to perform catheter cares on the TAR, any nursing cares would have been documented in a progress note. RN 3 stated that the wound nurse was also responsible for cares, and would document in a nursing note if cares had been performed. RN 3 stated that CNAs would not perform the dressing change for resident 25's suprapubic catheter. On 5/23/19 10:05 AM, a follow-up interview was conducted with the DON. The DON stated that there was documentation stating that one nurse had changed resident 25's suprapubic catheter one time between 3/4/19 and 5/1/19. The DON stated that there was no documentation that any of the nurses cleaned and dressed resident 25's suprapubic catheter site between 3/4/19 and 5/22/19. The DON submitted Suprapubic Catheter Care instructions as part of the facility's Nursing Services Policy and Procedure Manual. Cares for suprapubic catheters included the following: a.Observe the resident for signs and symptoms of urinary tract infection and [MEDICAL CONDITION]. Report findings to your supervisor . b. Wash around the catheter site with soap and water. (Note: If the resident has a drainage sponge around the stoma site, remove the drainage sponge before washing with soap and water.) Wash the outer part of the catheter tube with soap and water. c.Inspect the stoma site and skin around the stoma for any redness or skin breakdown. d.Documentation: The following information should be recorded in the resident's medical record: .all assessment data obtained during the procedure. How the resident tolerated the procedure. If the resident refused the procedure, the reason(s) why and the intervention taken. Results of skin assessment around the stoma site | 2020-09-01 |