| 11382 |
CARE HAVEN CENTER |
515178 |
2720 CHARLES TOWN ROAD |
MARTINSBURG |
WV |
25401 |
2010-12-21 |
327 |
D |
|
|
NKSJ11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, review of records from two (2) hospitals, and staff interview, the facility failed, for one (1) of five (5) sampled residents, to: (1) ensure a resident with a gastrostomy feeding tube received all 275 cc free water flushes in accordance with physician orders; (2) monitor the resident to ensure he was having adequate urinary output each shift and irrigate the resident's suprapubic catheter if his urinary output was less than 200 cc in an 8-hour shift in accordance with physician's orders [REDACTED]. Resident identifier: #28. Facility census: 68. Findings include: a) Resident #28 1. Resident Assessment Data Review of Resident #28's electronic medical record revealed a [AGE] year old male who was originally admitted to the facility in 2004. According to his most recent minimum data set assessment (MDS v 3.0) - an abbreviated quarterly MDS with an assessment reference date (ARD) of 10/04/10, his most recent re-entry to the facility as of the ARD occurred on 01/17/10, and his active [DIAGNOSES REDACTED]. Although the assessor noted the resident had infection with a multi-drug resistant organism (MDRO), the assessor did NOT place checkmarks in the assessment to indicate the resident's active [DIAGNOSES REDACTED]. According to the State-specific section of this MDS, the resident had NOT acquired any MDRO infections since his last assessment, to include [MEDICAL CONDITION]-resistant Staphylococcus aureus (MRSA). The assessor noted Resident #28 was alert, rarely / never able to make self understood or to understand others, with impaired short and long term memory and severely impaired cognitive skills for daily decision making. He required the extensive physical assistance of two (2) or more staff members for bed mobility, transferring, locomotion, dressing, toilet use, and personal hygiene, he was totally dependent on one (1) staff member for eating, he did NOT receive any nutrition through tube feeding (although elsewhere in his record was noted that he received feedings through a gastrostomy - "PEG tube" or "[DEVICE]"), and he was frequently incontinent of bowel and had in place an indwelling urinary catheter (elsewhere in his record, it was noted to be a suprapubic catheter). Further review of assessment data revealed he was transferred (with return anticipated) to an acute care hospital on [DATE], and he returned to the facility on [DATE]. -- 2. Hospital #1 Records Review of the resident's hospital records revealed he arrived in the emergency room (ER) of Hospital #1 on 11/17/10. Notes written by the ER nursing staff stated, "2240 (10:40 p.m.) Pt (patient) arrives /c (with) multi layers of Blankets (sic). Hot, moist skin Red (sic) in color. ... 11/17 (sic) 0040 (12:40 a.m. on 11/18/10) [MEDICATION NAME] (L) (left) D/C'd (discontinued) per physician, Blue (sic) tip sent to lab for culture. ..." Review of the form titled "ED Nursing Record - Adult Male - PRIMARY ASSESSMENT", in the section titled "EENT" (ears, eyes, nose, throat) was written: "Dried oral secretions (sic) oral membrane". In the section titled "Skin" were circled the words "diaphoresis" and "hot". In the section titled "Cardiovascular" was written (next to the printed word "[MEDICAL CONDITION]") "mild Bilat(eral) leg & arm". Above the nurse's signature was written: "hands / fingers swelled (sic) ..." Documentation on the form titled "ED Nursing Record - Adult Male - General Documentation", under the heading "I & O" (fluid intake and output), noted the resident received 1000 cc of fluid (elsewhere identified as normal sterile saline - NSS) and voided 50 cc of urine while in the ER of Hospital #1. Documentation by the ER physician on a form titled "Physical Exam" identified the resident was lethargic and "Patient much more alert /p (after) NS (normal saline) Bolus." The resident was transferred from Hospital #1 to Hospital #2 related to the lack of a bed at Hospital #1, and the resident a direct admit into Hospital #2's intensive care unit "because [MEDICAL CONDITION] secondary to urinary tract infection". The resident arrived at Hospital #2 on the early morning of 11/18/10. -- 3. Hospital #2 Records The resident's Hospital #2 "Discharge Summary" revealed the following discharge Diagnoses: [REDACTED]. [MEDICAL CONDITION]. 2. Urinary tract infection. 3. [MEDICAL CONDITION] surrounding his suprapubic catheter and gastric tube site. 4. Catheter line associated bacteremia with Staphylococcus epidermis, all subsequent cultures negative." Under the heading "Hospital Course" was noted, "The patient was sent to (name of Hospital #1) from his nursing home for high fevers. He was found to have a highly positive urinary tract infection as well as pus surrounding his suprapubic catheter and [DEVICE] as well as some small scattered pressure sores. The patient is a known chronic quadriplegic from end-stage MS and has a history of recurrent urosepsis and ESBL positive organisms. The patient's ultimate infectious sources included a single blood culture positive for staph epidermidis ... He also had both areas of [MEDICAL CONDITION] positive for cultures with [MEDICAL CONDITION]-resistant Staphylococcus aureus as well as pseudomonas and ESBL positive Escherichia coli. Urine culture was positive for [MEDICATION NAME] which was [MEDICATION NAME] sensitive but [MEDICATION NAME] resistant, also positive for the ESBL. Escherichia coli as well. ... The patient resolved with routine treatment of [REDACTED]. -- 4. Record review, including a comparison was made of documentation found in the nursing notes, in the weights and vitals summary report (VSR), and on the November 2010 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] - From 09/25/10 until 11/04/10, the resident had no temperatures recorded in the VSR that exceeded a pre-established threshold that triggered further assessment. - Beginning on the early morning of 11/04/10, the resident had a fever of 100.6 degrees F (axillary) for which he was medicated with Tylenol 650 mg. He continued to have an elevated temperature on 11/05/10, at which time the nurse contacted the physician, who ordered the antibiotic [MEDICATION NAME] 1 gram IM everyday for three (3) days. On the telephone order, the indication for use of the [MEDICATION NAME] was "UTI". - According to the nursing notes, the last dose of this 3-day course of [MEDICATION NAME] was administered on 11/07/10. According to the November 2010 MAR, a nurse administered Tylenol 650 mg for an elevated temperature at 6:00 p.m. on 11/09/10, although there were no corresponding entries in either then nursing notes or the VSR to state what the temperature was. Per documentation on the MAR, additional doses of Tylenol 650 mg were administered for elevated temperatures on 11/11/10 (possibly twice, although one (1) entry was illegible), 11/13/10 (twice), 11/14/10, 11/15/10, and 11/16/10 (twice). - Staff did not notify the physician that Resident #28 continued to have intermittent fevers (beginning on 11/09/10) after completion of the first 3-day course of [MEDICATION NAME] on 11/07/10. Once notified of the resident's elevated temperature on 11/16/10, the physician ordered a second 3-day course of [MEDICATION NAME] 1 gram IM everyday for three (3) days for "UTI". The physician examined the resident on 11/16/10, recorded a [DIAGNOSES REDACTED]. -- 5. Regarding Maintaining Fluid Balance and Monitoring of Urinary Output Review of the physician's orders [REDACTED]. - "[MEDICATION NAME] 1.5 at 85 cc (sic) hour for 20 hour cycle with 4 hours down time (sic) off at 6am (sic) on at 10 am (sic) continue with h2o (sic) flushes of 275cc (sic) every 4 hours for additional 1650ml (sic) a day. Hold if residual (sic) 100ml or over." - "Hand irrigate foley (sic) with 60 cc sterile H2O every 8 hours or as needed for output less than 200cc (sic)." - "Suprapubic cath eter (sic) check every shift for placement and function. May change cath when dysfunctional." -- Review of his care plan revealed the following problem statement: "I have an enteral feeding tube to meet nutritional needs due to impaired swallowing secondary to [MEDICAL CONDITION] MS." (This problem statement had a "Date Initiated" of 04/30/10, was "Created on" 04/30/10, and was revised on 07/21/10.) Interventions associated with this problem statement included: "Free H2O, 250ml q 4 hrs, as ordered." (This intervention had a "Date Initiated" of 04/30/10 and was "Created on" 04/30/10.) Review of this 13-page care plan found no other problem statements, goals, or interventions addressing the resident's hydration status / fluid balance, although the resident was totally dependent on others to meet his nutrition and hydration needs. There was no acute care plan to address the resident ' s needs for additional free water flushes related to his intermittent fevers. There was also no care plan developed to address the need to hand irrigate the catheter with 60 cc of sterile water if the resident's urinary output was less than 200 cc in an 8-hour shift, although there was a physician's orders [REDACTED]. -- Review of the Enteral Protocol form for November 2010 revealed an order for [REDACTED]. Total Vol: ___ (left blank) ML/24 hours." Beside this order was a series of blocks where the nurse was to initial having provided 275 cc of water at the following intervals daily: 6:00 a.m., 10:00 a.m., 2:00 p.m., 6:00 p.m., 10:00 p.m., and 2:00 a.m. Initials were absent for a total of twenty-one (21) out of one hundred (100) possible flushes between 6:00 a.m. on 11/01/10 and 6:00 p.m. on 11/17/10. There was no evidence to reflect the additional free water flushes of 275 cc were provided as ordered for the following dates and times: - On 11/01/10 at 10:00 a.m., 2:00 p.m., 6:00 p.m., and 10:00 p.m. - On 11/02/10 at 6:00 a.m., 10:00 a.m., 2:00 p.m., 6:00 p.m., 10:00 p.m., and 2:00 a.m. - On 11/03/10 at 10:00 a.m., 2:00 p.m., 6:00 p.m., and 10:00 p.m. - On 11/04/10 at 6:00 a.m., 10:00 a.m., and 2:00 a.m. - On 11/05/10 at 6:00 p.m. and 10:00 p.m. - On 11/15/10 at 6:00 p.m. and 10:00 p.m. -- Review of the treatment administration record (TAR) for November 2010 revealed an order for [REDACTED]. output was less than 200 cc. None of these blocks was initialed, even though one (1) nursing note, dated 11/17/10 at 6:01 p.m., specifically stated, " ...Urinary output >200cc at this time." -- Review of the resident's "Bedside Intake and Output Records" for the period of 11/01/10 through 11/17/10 revealed the following information regarding the resident's urinary output per 8-hour shift for the 11:00 p.m. to 7:00 a.m. (11-7), 7:00 a.m. to 3:00 p.m. (7-3), and 3:00 p.m. to 11:00 p.m. (3-11) shifts: Date - 11-7 - 7-3 - 3-11 = 24-hour total 11/01/10 - 400 cc - (blank) - (blank) = 400 cc 11/02/10 - 350 cc - (blank) - (blank) = 350 cc 11/03/10 - (blank) - (blank) - (blank) = 0 cc 11/04/10 - 450 cc - (blank) - (blank) = 450 cc 11/05/10 - 600 cc - (blank) - (blank) = 600 cc 11/06/10 - 800 cc - (blank) - (blank) = 800 cc 11/07/10 - 700 cc - (blank) - (blank) = 700 cc 11/08/10 - 450 cc - (blank) - (blank) = 450 cc 11/09/10 - no record available 11/10/10 - no record available 11/11/10 - 225 cc - (blank) - (blank) = 225 cc 11/12/10 - 450 cc - (blank) - 325 cc = 775 cc 11/13/10 - no record available 11/14/10 - no record available 11/15/10 - 250 cc - (blank) - (blank) = 250 cc 11/16/10 - no record available 11/17/10 - 350 cc - (blank) - (blank) = 350 cc No additional documentation was found elsewhere in the resident's record to reflect staff was monitoring and recording his urinary output during each 8-hour shift, to identify the need for the 60 cc flushes or to assess the resident's hydration status. -- An interview with the ADON, on 11/21/10 at 9:30 a.m., revealed the resident required more free water added to the gastric tube, because of the intermittent fevers during the month of November. . |
2014-04-01 |