cms_WV: 11383
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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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 11383 | CARE HAVEN CENTER | 515178 | 2720 CHARLES TOWN ROAD | MARTINSBURG | WV | 25401 | 2010-12-21 | 224 | G | NKSJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, review of records from two (2) hospitals, review of facility policies and procedures, review of information published on the Internet related to the topics of "fever" and "axillary temperature", and staff interview, the facility failed to provide goods and services necessary to avoid physical harm to one (1) of five (5) residents (#28). The facility failed to: (1) obtain and consistently record in the same place in the electronic medical record Resident #28's vital signs (e.g., temperature) every shift in accordance with his care plan related to antibiotic administration via his central line for the treatment of [REDACTED]. Tylenol in accordance with physician orders [REDACTED]. line insertion site and ostomy sites for signs of irritation or infection; (6) change the resident's central line dressing weekly in accordance with facility protocol; (7) ensure the resident received all 275 cc free water flushes in accordance with physician orders; (8) 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]. the resident exhibited intermittent elevated temperatures beginning two (2) days after having completed a 3-day course of antibiotic for a UTI. This failure to provide necessary goods and services resulted in physical harm to Resident #28, who was transferred to a hospital on [DATE] and was subsequently diagnosed with [REDACTED]. 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, his abdomen was distended and tympanic, "decubiti" (pressure sores) were present "multi site", and the resident had a [MEDICATION NAME] central line with a dressing labeled "11/9/10". "Patient much more alert /p (after) NS (normal saline) Bolus." In addition to a culture of the [MEDICATION NAME] central line catheter tip, the physician ordered urine and blood cultures. The physician reviewed the results of a urine culture and sensitivity from a previous admission, found the organism previously cultured was E. coli that was positive for extended spectrum beta lactamase (which was resistant to [MEDICATION NAME] and sensitive to Imipenem), and ordered intravenous [MEDICATION NAME] and Imipenem ([MEDICATION NAME]). The [MEDICATION NAME] was started, and the [MEDICATION NAME] was sent with him ("Start [MEDICATION NAME] when [MEDICATION NAME] complete") when he was transferred to Hospital #2 at 0350 (3:50 a.m.) on 11/18/10. -- 3. Hospital #2 Records 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. The resident's Hospital #2 "History and Physical" revealed under the heading "History of Present Illness": "This is a [AGE] year-old Caucasian male with a history of end-stage [MEDICAL CONDITION], depression, chronic [MEDICAL CONDITION], gastroparesis, [MEDICAL CONDITION] bladder, [MEDICAL CONDITION] reflux disease, [MEDICAL CONDITION], and recurrent urinary tract infection who was transferred (sic) (Hospital #1) to (Hospital #2) for direct admission to (sic) intensive care unit because [MEDICAL CONDITION] secondary to urinary tract infection. ... It seems the patient used to have a recurrent urinary tract infection in the past, but the last time he was found to have a urinary tract infection and got admitted to the hospital was in early 2010. Since the placement of (sic) cystostomy tube (a suprapubic catheter) in early 2010, the patient did not get admitted to the hospital because of urinary tract infection (sic). ..." "In the emergency room , the patient was evaluated by the ER physician who found the patient to [MEDICAL CONDITION] with temperature 101.8 degrees, heart rate in excess of 110 per minute and also respiratory rate in excess of 24 per minutes. His white blood cell count also was high at 14,600. Because he needed to be admitted and there was no hospital bed in the (name of Hospital #1), the patient has been transferred to (name of Hospital #2). I admitted the patient to the intensive care unit for close monitoring, because of his complicated previous history and also serious hospital admission." Under the heading "Impressions" were noted: "1. High fever, secondary [MEDICAL CONDITION]. 2. Urinary tract infection. ..." Under the heading "Plans" were noted: "1. Admit to ICU. 2. Blood and urine cultures which were done in the (Hospital #1) emergency room . Will send wound culture from cystostomy (suprapubic) tube area. 3. Empiric IV antibiotics with Imipenem, [MEDICATION NAME] (sic) and [MEDICATION NAME] will be continued, which were started in the emergency room in (name of Hospital #1). 4. IV hydration will be given cautiously. 5. Will continue home medications." - 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, also listed from his catheter tip although I am not sure which catheter this was as it was not documented. Presumably it was some type of a central line. 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. Elevated Temperatures (a) Vitals Summary Report (VSR) A review of the resident's electronic medical record at the nursing facility revealed a weights and vitals summary report (VSR) for the period of 10/16/10 to 11/17/10 revealed the following consecutive entries: - 10/16/10 at 3:55 a.m. - 97.4 (axilla) - 11/05/10 at 10:51 p.m. - 99.2 (axilla) - High of 99.0 exceeded - 11/05/10 at 11:30 p.m. - 101.10 (axilla) - High of 99.0 exceeded - 11/06/10 at 12:51 a.m. - 98.1 (axilla) - 11/08/10 at 3:29 a.m. - 98.7 (axilla) - 11/09/10 at 3:37 a.m. - 97.2 (tympanic) - 11/09/10 at 9:52 p.m. - 97.2 (axilla) - 11/10/10 at 2:28 a.m. - 98.3 (axilla) - 11/10/10 at 11:45 a.m. - 98.2 (axilla) - 11/11/10 at 5:55 a.m. - 100.1 (axilla) - High of 99.0 exceeded - 11/11/10 at 5:56 a.m. - 97.8 (axilla) - 11/11/10 at 10:01 p.m. - 98.2 (axilla) - 11/12/10 at 4:41 a.m. - 98.7 (axilla) - 11/13/10 at 3:52 a.m. - 99.7 (axilla) - High of 99.0 exceeded - 11/13/10 at 2:07 p.m. - 97.4 (axilla) - 11/13/10 at 9:37 p.m. - 96.7 (axilla) - 11/14/10 at 4:59 a.m. - 97.8 (axilla) - 11/14/10 at 9:48 p.m. - 97.9 (axilla) - 11/15/10 at 2:50 a.m. - 97.5 (axilla) - 11/16/10 at 4:02 a.m. - 98.4 (axilla) - 11/17/10 at 5:08 a.m. - 99.5 (axilla) - High of 99.0 exceeded - 11/17/10 at 9:52 p.m. - 101.7 (axilla) - High of 99.0 exceeded - 11/17/10 at 10:54 p.m. - 102.4 (axilla) - High of 99.0 exceeded According to the VSR, between 09/11/10 and 11/05/10, Resident #28 had only one (1) temperature reading that was flagged for review as "High of 99.0 exceeded". This occurred at 2:37 p.m. on 09/23/10, at which time his axillary temperature measured 99.5 degrees F. -- (b) Nursing Notes Further review of the resident's electronic medical record at the nursing facility revealed the following consecutive nursing notes: - 10/13/10 at 5:45 p.m. - "Temp: 98.7. zero (sic) signs or symptoms of distress (sic) will cont(inue) to monitor." - 10/14/10 at 1:47 p.m. - "Peg (sic) tube pulled out during care, scant amount of bleeding notes at site. Cleansed area with [MEDICATION NAME] (sic), replaced with 20Fr 15cc magna port (sic) Proper placement noted, flushes without difficulties. [MEDICATION NAME] 1.5cal (sic) running at 85cc/hr. no (sic) problems noted." - 10/17/10 at 11:30 a.m. - "REsident (sic) g tube (sic) flushed with ease and proper placement. 60cc (sic) of residual noted." - 11/04/10 at 5:14 a.m. - "Increased temp. of 100.6 axillary ,skin (sic) warm and moist. 650 mg. tyneol (sic) given vie (sic) peg tube. Will continue to monitor." - 11/05/10 at 1:59 p.m. - "Resident extremely sweaty (sic) temp taken 100.4ax (axillary). Contacted Dr. (name). Verbal order for [MEDICATION NAME] 1gram IM (intramuscular injection) qd (everyday) x 3 days for UTI. Will continue to monitor." - 11/05/10 at 10:53 p.m. - "Resident showing s/s (sign and symptoms of) illness as temp cont(inues) to rise. Tylenol via GT ([DEVICE]) given with decrease of temp at this time. ... Will continue to monitor." ?- 11/06/10 at 9:54 p.m. - "Temp 98.9 Axillary (sic) Resident continues on an ABT (antibiotic therapy) for UTI, no adverse reactions noted." - 11/07/10 at 2:12 a.m. - "Temp 97.2 axillary. Continues ABT related to UTI. ... No signs and symptoms of distress. Will monitor." - 11/07/10 at 9:21 p.m. - "Temp 98.1 (sic) Completed ABT today for UTI. 0 (no) adverse reactions noted." - 11/09/10 at 3:36 a.m. - "S/P (status [REDACTED]." - 11/11/10 at 6:00 a.m. - "temp (sic) 100.1 ax. tylenol (sic) 350mg (sic) per g.t. (sic) @ 0245." - 11/11/10 at 4:36 p.m. - "97.9 (sic) continues with tube feed of [MEDICATION NAME] ,flushes (sic) with ease. ... exhibits no signs of distress." - 11/14/10 at 12:01 p.m. - "VS (vital signs): 97 20 100/70 97.8. alert. Total care. Suprapubic cath patent. [DEVICE] flushed with each ... Zero signs or symptoms of distress noted. Will continue to monitor." - 11/15/10 at 2:42 p.m. - "Residents (sic) mothers (sic) was in today to visit ..." - 11/16/10 at 6:57 a.m. - "resident (sic) alert. total (sic) care.area (sic) around suprapubic cath.cleaned, (sic) temp 102.2 ax at 0500.tyleol (sic) 650mg per [DEVICE] given. resting (sic) at this time." - 11/16/10 at 2:11 p.m. - "Resident heard moaning from hallway (sic) Temp 100.6ax (sic). Gave tylenol (sic) 650mg via gt (sic). Called Dr. (name) (sic) verbal order given from [MEDICATION NAME] 1gram (sic) IM QD x3days (sic). Meds ordered from pharmacy. Resident resting quietly now." - 11/17/10 at 3:34 p.m. - "Temp 98.1ax (sic). New order [MEDICATION NAME] IV (intravenously) x3days (sic), ordered stat from pharmacy along with flushes and IV pump. [MEDICATION NAME] 1gram IV (intravenous) given via PICC at 1:30pm (sic) without difficulty. No adverse reactions noted. No s/s (signs / symptoms) IV complications noted." - 11/17/10 at 6:01 p.m. - "Resident moaning loudly, when asked if uncomfortable he said 'yeah'. V/S (vital signs) stable, tylenol (sic) given for apparent discomfort. GT turned off for time r/t (related to) abd (abdominal) discomfort. ... Will cont to monitor. Urinary output >200cc at this time. ABT [MEDICATION NAME] IM (sic) continues for UTI. No adverse effect noted. Fluid tolerated via GT." - 11/17/10 at 8:28 p.m. - "Monitoring resident frequently, no futhur (sic) moaning noted. Resting quietly. V/S remain stable, afebrile. T&P (turn and position) frequently. HOB (head of bed) ele (elevated) for comfort. Will continue to monitor." - 11/17/10 at 9:48 p.m. - "(Resident #28) transferred to hospital-unplanned (sic) for evaluation and treatment via ambulance to (name of Hospital #1). Physician notified of transfer. Physician called 2145 (9:45 p.m.) with info of condition change, order to send to (Hospital #1) for eval and tx (treat). Responsible party notified of transfer ..." -- (c) Medication Administration Record (MAR) Review of the resident's November 2010 MAR revealed staff initialed having administered "Tylenol 650 mg via GT ([DEVICE]) for temp > 101 Q 4 hours PRN (as needed)" to Resident #28 on the following dates: - 11/05/10 at 11:45 p.m. - 11/09/10 at 6:00 p.m. - 11/11/10 at 2:45 a.m. - 11/11/10 (this second entry on 11/11/10 is illegible) - 11/13/10 at 2:30 a.m. - 11/13/10 at 5:00 p.m. - 11/14/10 at 5:00 p.m. - 11/15/10 at 8:00 p.m. - 11/16/10 at 5:00 a.m. - 11/16/10 at 11:00 a.m. - 11/17/10 at 5:45 p.m. -- (d) Comparison of VSR, Nursing Notes, and MAR Record review, including a comparison was made of documentation found in the nursing notes, in the VSR, and on the November 2010 MAR related to the administration of Tylenol for elevated temperatures, revealed the following: (1) 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). All entries in the nursing notes between 11/04/10 and 11/16/10 were made by licensed practical nurses (LPNs). There was no evidence of any nursing assessment having been completed by an RN and recorded in the resident's nursing notes. 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]. No labs were ordered during this period of intermittent fevers beginning on 11/04/10, in an effort to identify the infectious organism(s) and/or what antibiotic(s) would be effective in treatment. (According to labs collected at Hospitals #1 and #2, the resident had multiple infectious organisms at multiple sites (central line catheter tip, urine, blood, and at the insertion sites of his suprapubic catheter and gastrostomy tube), all of which were resistant to [MEDICATION NAME], meaning the [MEDICATION NAME] that was administered prior to the resident's transfer to Hospital #1 was ineffective in treating these infections.) The only entry made by an RN prior to his transfer to the hospital was recorded at 9:48 p.m. on 11/17/10. It contained no assessment information but stated the resident was transferred to the hospital "unplanned" for evaluation and treatment, after the physician was notified of a "condition change" at 2145 (9:45 p.m.), and an attempt was made to notify the resident's responsible party. -- (2) Not all temperatures were recorded in a single location in the resident's medical record where the user could access and review all temperature readings for analysis, tracking, and trending. On thirteen (13) occasions between 11/04/10 and 11/17/10, temperatures were recorded in the nursing notes (NN) and/or nurses initialed the MAR to indicate Tylenol was given for an elevated temperature, but no corresponding entry of a temperature reading was found on the VSR: - NN on 11/04/10 at 5:14 a.m. - "Increased temp. of 100.6 axillary ,skin (sic) warm and moist. 650 mg. tyneol (sic) ..." - MAR on 11/09/10 at 6:00 p.m. - Tylenol was given for elevated temperature - NN on 11/05/10 at 1:59 p.m. - "Resident extremely sweaty (sic) temp taken 100.4ax (axillary). ..." - MAR on 11/11/10 at 2:45 a.m. - Tylenol was given for elevated temperature. (A corresponding entry was also found in a NN at 6:00 a.m. on 11/11/10 as follows: "temp (sic) 100.1 ax. tylenol (sic) 350mg (sic) per g.t. (sic) @ 0245.") - MAR on 11/13/10 at 2:30 a.m. - Tylenol was given for elevated temperature - MAR on 11/13/10 at 5:00 p.m. - Tylenol was given for elevated temperature - MAR on 11/14/10 at 5:00 p.m. - Tylenol was given for elevated temperature - MAR on 11/15/10 at 8:00 p.m. - Tylenol was given for elevated temperature - NN on 11/16/10 at 6:57 a.m. - "... temp 102.2 ax at 0500.tyleol (sic) 650mg per [DEVICE] given. ..." (A corresponding entry was also found on the MAR for 11/16/10 at 5:00 a.m.) - NN on 11/16/10 at 2:11 p.m. - "... Temp 100.6ax (sic). Gave tylenol (sic) 650mg via gt (sic). ..." - MAR on 11/16/10 at 11:00 a.m. - Tylenol was given for elevated temperature - NN on 11/17/10 at 3:34 p.m. - "Temp 98.1ax (sic). ..." - MAR on 11/17/10 at 5:45 p.m. - Tylenol was given for elevated temperature -- (3) Two (2) instances of elevated temperatures (greater than 100.0 degrees F axillary, which would be equivalent to 101 degrees F orally), which were recorded either in the VSR or NN, were not treated with Tylenol in accordance with standing orders: - NN on 11/05/10 at 1:59 p.m. - "Resident extremely sweaty (sic) temp taken 100.4ax (axillary). ..." - VSR on 11/17/10 at 9:52 p.m. - 101.7 (axilla) -- (4) Not all instances when Tylenol was administered were recorded on the MAR. On one (1) occasion between 11/04/10 and 11/17/10, a nurse recorded (in the nursing notes) having administered Tylenol to Resident #28, for which there was no corresponding entry in the MAR: - NN on 11/04/10 at 5:14 a.m. - "Increased temp. (temperature) of 100.6 axillary ,skin (sic) warm and moist. 650 mg. tyneol (sic) ..." -- (5) One (1) entry on the MAR (on 11/11/10) was illegible; therefore, it could not be ascertained whether a second dose of Tylenol was given or, if a second dose was given, at what time it was administered. -- (6) No documentation was found on the reverse side of the MAR, when Tylenol was given for an elevated temperature, of an assessment of the effectiveness of the PRN Tylenol in reducing the resident's temperature after administration. -- (e) References Obtained Via Internet (1) According to Medline Plus (a service of the U.S. National Library of Medicine / National Institutes of Health ), in an article titled "Fever": "Fever is the temporary increase in the body's temperature in response to some disease or illness. "... An adult probably has a fever when the temperature is above 99 - 99.5 ?F (37.2 - 37.5 ?C), depending on the time of day. "... Call your doctor right away if you are an adult and you: - Have a fever over 105 ?F (40.5 ?C), unless it comes down readily with treatment and you are comfortable - Have a fever that stays at or keeps rising above 103 ?F - Have a fever for longer than 48 - 72 hours - Have had fevers come and go for up to a week or more, even if they are not very high - Have a serious medical illness, such as a heart problem, [MEDICAL CONDITION] cell [MEDICAL CONDITION], diabetes, [DIAGNOSES REDACTED], [MEDICAL CONDITION], or other chronic lung problems - Have a new rash or bruises appear - Have pain with urination - Have trouble with your immune system (chronic steroid therapy, after a bone marrow or organ transplant, had spleen removed, HIV-positive, were being treated for [REDACTED]. - Have recently traveled to a third world country" (URL: http://www.nlm.nih.gov/medlineplus/ency/article/ 0.htm) -- (2) According to the Mayo Clinic, in an article titled "Fever: First aid": "Fever is a sign of a variety of medical conditions, including infection. "... Under the arm (axillary) "Although it's not the most accurate way to take a temperature, you can also use an oral thermometer for an armpit reading: - Place the thermometer under your arm with your arm down. - Hold your arms across your chest. - Wait five minutes or as recommended by your thermometer's manufacturer. - Remove the thermometer and read the temperature. "... An axillary reading is generally 1 degree Fahrenheit (about 0.5 degree Celsius) lower than an oral reading. ..." (URL: ) -- (3) According to Drugs.com, in an article titled "How To Take An Axillary Temperature": "What is it? "An axillary (AK-sih-lar-e) temperature (TEM-per-ah-chur) is when your armpit (axilla) is used to check your temperature. A temperature measures body heat. A thermometer (there-MOM-uh-ter) is used to take the temperature in your armpit. An axillary temperature is lower than one taken in your mouth, rectum, or your ear. This is because the thermometer is not inside your body such as under your tongue. "Why do I need to check an axillary temperature? "An axillary temperature may be done to check for a fever. 'Fever' is a word used for a temperature that is higher than normal for the body. A fever may be a sign of illness, infection or other conditions. A normal axillary temperature is between 96.6? (35.9? C) and 98? F (36.7? C). The normal axillary temperature is usually a degree lower than the oral (by mouth) temperature. The axillary temperature may be as much as two degrees lower than the rectal temperature. Body temperature changes slightly through the day and night, and may change based on your activity. ... "How do I use a digital thermometer? "Wait at least 15 minutes after bathing or exercising before taking your axillary temperature. - Take the thermometer out of its holder. - Put the tip into a new throw-away plastic cover. If you do not have a cover, clean the pointed end (probe) with soap and warm water or rubbing alcohol. Rinse it with cool water. - Put the end with the covered tip securely in your armpit. Hold your arm down tightly at your side. - Keep the thermometer in your armpit until the digital thermometer beeps. - Remove the thermometer when numbers show up in the 'window'. - Read the numbers in the window. These numbers are your temperature. Add at least 1 degree to the temperature showing in the window. ..." (URL: ) -- (f) Facility Policy Review of the facility's policy titled "3.5 Vital Signs" (revision date 10/01/10) revealed it was silent to how staff was to take a resident's temperature (e.g., route; device to be used; etc.). Review of the facility's document titled "Clinical Competency Validation - Skill: Measuring Temperature, Pulse, and Respiration" (revision date of 10/2009) revealed the steps to be taken by staff to measure and record a resident oral temperature. This document did not address how to measure a resident's axillary temperature. There was no policy or procedure available to address the difference between an axillary temperature reading and an oral temperature reading, such as whether to add 1 degree F when reading an axillary temperature or when an axillary temperature was elevated enough to require treatment with medication. -- (g) Care Plans Addressing Vital Signs A review of the resident's care plan revealed the following: (1) A problem statement related to UTIs stated: "(Resident #28) is at risk for complications of current UTI." (This problem statement had a "Date Initiated" of 11/05/10, was "Created on" 11/11/10, and was revised on 11/17/10.) The goal associated with this problem statement was: "Infection will be resolved within 14 days." (This goal had a "Date Initiated" of 11/17/10, was "Created on" 11/11/10, was revised on 11/17/10, and had a "Target Date" of 12/01/10.) The interventions developed to achieve this goal were: - "Monitor vital signs and report to physician as indicated." (This intervention had a "Date Initiated" of 11/05/10, was "Created on" 11/11/10, and was revised on 11/17/10.) - "Administer [MEDICATION NAME] as ordered." (This intervention had a "Date Initiated" of 11/17/10, was "Created on" 11/11/10, and was revised on 11/17/10.) There was no mention anywhere in this 13-page care plan of the need to measure Resident #28's temperature via the axilla due to an inability to obtain a temperature reading via another route (e.g., oral, rectal, tympanic). Given that the resident's standing physician orders [REDACTED]. -- (2) Another problem statement was: "Triple lumen PICC line due to need for IV antibiotics for urosepsis." (This problem statement had a "Date Initiated" of 09/23/10, was "Created on" 01/20/10, and was revised on 10/11/10.) The goal associated with this problem statement was: "(Resident #28) will have no complication related to IV therapy by (sic) x 60 days." (This goal had a "Date Initiated" of 09/23/10, was "Created on" 01/20/10, was revised on 11/17/10, and had a "Target Date" of 12/11/10.) One (1) intervention developed to achieve this goal was: "Vital signs q (every) shift." (This intervention had a "Date Initiated" of 01/20/10, was "Created on" 01/20/10, and was revised on 10/11/10.) - Review of the VSR found no evidence to reflect this resident's temperature was measured and recorded on every shift in accordance with this care plan intervention. -- 5. Fluid Balance / Hydration Status (a) Physician Orders 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." -- (b) Care Plan Addressing Hydration / Fluid Balance 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 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 | 2014-04-01 |