cms_WV: 11411
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 11411 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2010-11-11 | 309 | G | 50T311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on closed medical record review, review of facility policies and procedures, review of records from an area hospital and the ambulance service, and staff interviews, the facility failed to ensure one (1) of six (6) sampled residents received care and services necessary to attain or maintain her highest level of physical well-being and to avoid physical harm. Resident #119, who was admitted to the facility on [DATE] for Medicare-covered skilled nursing and rehabilitation services to include observation and assessment of her care plan, began exhibiting an acute change in condition. The facility's licensed nursing staff failed, in accordance with the facility's policy and procedures, to provide on-going assessment / monitoring, administer interventions when ordered by the physician extender, and/or obtain timely medical intervention as the resident's condition continued to decline. A registered nurse (RN) first recorded in the medical record that Resident #119 was lethargic at 5:10 p.m. on [DATE]; prior to that time, the resident had been noted to be free of signs and symptoms of distress and discomfort. A licensed practical nurse (LPN) first recorded in the medical record, in an entry dated 5:00 a.m. on [DATE], Resident #119 had vomited three (3) times during the 11:00 p.m. to 7:00 a.m. (,[DATE]) shift. After this entry, there was no evidence of any physical assessment data having been contemporaneously collected and recorded in the resident's medical record related to the resident's level of consciousness (LOC), vital signs, respiratory status, and/or vomiting until the certified nurse practitioner (CNP - Employee #123) employed by the facility evaluated the resident and recorded a progress note that was electronically signed at 11:59 a.m. on [DATE]. In addition to the absence of evidence that physical assessment data was being contemporaneously collected and recorded with respect to Resident #119's acute change in condition, routine assessment data of the resident's respiratory status were not collected every four (4) hours before and after each inhalation treatment that had been administered at 8:00 a.m., 12:00 p.m., and 4:00 p.m. on [DATE]. No interventions were ordered to address the resident's vomiting until about 1:00 p.m. on [DATE], when, according to information contained in a late entry recorded a week later by the desk nurse (Employee #19) on [DATE] at 3:27 p.m., Employee #19 received orders from the CNP for [MEDICATION NAME] (an antiemetic to treat nausea / vomiting), [MEDICATION NAME] (a protein pump inhibitor to treat [MEDICAL CONDITION] reflux), and [MEDICATION NAME] (a stool softener). Once ordered, there was no evidence to reflect any of these medications was administered. According to information contained in a late entry recorded on [DATE] at 3:27 p.m. by Employee #19, after the CNP reviewed the results of some labs that had been sent to the facility, to start intravenous (IV) fluids, start supplemental oxygen, administer a stat dose of [MEDICATION NAME] (an antibiotic), and obtain a chest x-ray for possible pneumonia, Employee #19 received a second set of orders from the CNP at about 2:00 p.m. on [DATE]. According to information contained in a late entry recorded on [DATE] at 12:35 p.m. by the nurse assigned to care for Resident #119 from 7:00 a.m. to 7:00 p.m. on [DATE] (Employee #79), she started an IV shortly thereafter, applied supplemental oxygen at about 2:45 p.m., and collected physical assessment data at 4:00 p.m. noting the resident was alert with confusion, lethargic, with decreased lung sounds, with [MEDICAL CONDITION] in lower extremities, and with an oxygen saturation level of 88%. However, there was no contemporaneous documentation in the nursing notes related to insertion of the IV and no evidence of any physical assessment data having been contemporaneously collected and recorded in the resident's medical record related to the resident's LOC, vital signs, respiratory status, and/or vomiting after the entry made by the CNP at 11:59 a.m. earlier that morning. Interviews with nursing assistants (Employees #59, #54, and #67) revealed the resident continued to vomit on [DATE] during both the 7:00 a.m. to 3:00 p.m. (,[DATE]) shift and the 3:00 p.m. to 11:00 p.m. (,[DATE]) shift. However, there was no evidence of any physical assessment data having been contemporaneously collected and recorded in the resident's medical record related to the resident's LOC, vital signs, respiratory status, and/or vomiting after the entry made by the CNP at 11:59 a.m. earlier that morning. Interviews with staff revealed Employee #54, at the start of her ,[DATE] shift, found Resident #119 had vomited a brownish-colored liquid on her clothes, and she and another nursing assistant (Employee #67) cleaned her up. Employee #54 went to the nurse's station and told Employee #79 that Resident #119 had vomited. Employee #67 reported that, at that time, the resident was talking and her breathing sounded "OK". About thirty (30) minutes later, the resident vomited again. Employee #67 reported that, after Resident #119 vomited a third time, the resident started gurgling and was struggling to breathe, and she grabbed Employee #67 by the arm. According to Employee #67, Employee #54 left the room saying she was going to find out if the nurse would suction her. Interview with Employee #54 revealed she had gone to the nurse's station to ask the nurse if Resident #119 was a full code, and she told the nurse she thought the resident was dying. According to Employee #67, two (2) nurses then came to the room and "looked at the resident, then turned around and left the room", and one (1) of the nurses stated, "I'm sending her out of here. I'm leaving at 7:00." There was no evidence that interventions were provided in an effort to clear the resident's airway. According to information contained in late entries recorded by Employees #19 and #79, the resident's IV stopped flowing. At 5:00 p.m., an ambulance crew was called in the re-start the IV. The ambulance crew arrived and, at 6:20 p.m., was attempting to restart an IV. Employee #79 recorded, in her late entry on [DATE] at 12:35 p.m., that at 6:20 p.m., Resident #119 was alert with labored respirations and had vomited tea-colored fluid; in the same late entry, Employee #79 recorded that, at 6:40 p.m., a nurse aide came to her to ask about the resident's code status, at which time Resident #119 was having difficulty breathing, with decreased LOC, no response to verbal stimuli, raspy breath sounds, and "eyes not reactive to light accommodation". However, again, there was no evidence of any physical assessment data having been contemporaneously collected and recorded in the resident's medical record related to the resident's LOC, vital signs, respiratory status, and/or vomiting after the entry made by the CNP at 11:59 a.m. earlier that morning. The resident was transported from the facility at 7:22 p.m. on [DATE] to the hospital, where she expired at 9:50 p.m. that same evening; her cause of death was listed on the death certificate as [MEDICAL CONDITION] due to aspiration due to [MEDICAL CONDITION]. Resident identifier: #119. Facility census: 118. Findings include: a) Resident #119 1. Review of Resident #119's closed medical record revealed this [AGE] year old female resident was initially admitted from the hospital to the nursing facility at 1:08 p.m. on [DATE], with [DIAGNOSES REDACTED]. Further review of her record revealed that, during her extended hospital stay prior to admission to the facility, she was treated for [REDACTED]. According to multiple entries in the nursing notes made contemporaneously on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE], the resident was admitted for the purpose of receiving Medicare-covered skilled services for observation and assessment of her care plan and rehabilitative therapies. According to her admission minimum data set assessment, with an assessment reference date of [DATE], she was alert, could hear with minimal difficulty, had clear speech, was usually understood when she verbally expressed ideas to others, was usually able to understand what was said to her when spoken to, and was able to participate in the interviews during the assessment process. She was totally dependent upon staff for bed mobility, transferring, and locomotion, she required extensive physical assistance with dressing, toilet use, and personal hygiene, and she required set-up assistance with eating. -- 2. Review of Resident #119's nursing notes found a contemporaneous entry, dated [DATE] at 3:00 a.m., stating, "Skilled services continue. (Symbol for 'no') S/S (signs / symptoms) of distress or discomfort @ this time. Meds taken /s (without) difficulty. In bed /c (with) eyes closed. Call light in reach." The next consecutive entry, dated [DATE] at 5:10 p.m., stated, "N/O (new order) noted. CBC (complete blood count), BMP (basic metabolic panel), sed (sedimentation) rate d/t (due to) lethargy. Family aware." Between 3:00 a.m. and 5:10 p.m. on [DATE], there was no documentation in the nursing notes of any observations and/or nursing assessments of Resident #119's health status completed by the facility's licensed nursing staff. The next consecutive entry in the nursing notes, dated [DATE] at 5:00 a.m., stated, "Resident vomited x 3 this shift. Will monitor." This is the first mention in the resident's record of her having vomited. There was no description of the characteristics of the emesis (e.g., color, quantity, consistency, etc.), and no vital signs (e.g., temperature, blood pressure, heart rate, respirations) were recorded either in the nursing notes or a separate vital signs flow sheet. There was no documentation to indicate nursing staff notified the resident's responsible party, attending physician, or the CNP employed by the facility, of this change in the resident's condition. There was also no discussion of whether the resident remained lethargic, as had been noted at 3:00 a.m. on [DATE] and for which the CNP had previously ordered lab studies. The next consecutive entry in the nursing notes, dated [DATE], at 10:00 a.m., stated, "Weekly care team IDT (interdisciplinary team) review: Tylenol Q 8 ATC x 7 days. F/U (follow-up appointment) Dr. (name) on [DATE]. [MEDICATION NAME] & [MEDICATION NAME] for dementia. OT (occupational therapy), PT (physical therapy) as ordered. ST (speech therapy) as ordered. [MEDICATION NAME] to groin & breasts. Dry drsg (dressing) to Lt (left) knee." This interdisciplinary note was recorded by an RN, but it did not contain any mention of acute changes in condition exhibited by the resident in the previous twenty-four (24) hour period (e.g., lethargy or vomiting). The next consecutive entry in the nursing notes, dated 1:05 p.m. on [DATE], stated, "N.O. (new order) Bilateral heels off bed /w (with) pillows @ (at) all x's (times) for prevention. N.O. Sure Prep to bilateral heels 2x's QD (twice daily) on NS (night shift), DS (day shift) for prevention." This entry was not signed by its author. The next consecutive entry in the nursing notes, dated [DATE] at 4:-0 p.m. (the exact time of the entry was illegible), stated, "N/O for chest x-ray d/t cough & congestion, Attempts x 3 to call MPOA (medical power of attorney) /s success. This entry was recorded by Employee #19, an LPN. There was no mention of the resident's level of consciousness with respect to whether she remained lethargic, there was no mention of whether she had continued to vomit, and even though this was the first mention of the resident having exhibited any cough or congestion, there was no quantitative or qualitative description of her respiratory status (e.g., rate of respirations, blood oxygen saturation level, presence or absence of adventitious sounds in her lung fields, difficulty or ease of breathing, etc.) or her vital signs. The next consecutive entry in the nursing notes, made by LPN Employee #19 and dated [DATE] at 5:25 p.m., stated, "QMI (name of mobile imaging company) on site; CXR (chest x-ray) done." The next consecutive entry in the nursing notes, made by Employee #19 and dated [DATE] at 7:00 p.m., stated, "MPOA notified of decline; wish (sic) to send to TMH (area hospital)." The next consecutive entry in the nursing notes, made by Employee #19 and dated [DATE] at 7:22 p.m., stated, "KCA (local ambulance service) on site to transport to KCA (sic) /c (with) accompanied (sic) on ii (2) attendants." The next consecutive entry in the nursing notes, dated [DATE] at 8:00 a.m., stated, "Expired @ TMH ER (emergency room ) @ 9:50 p.m. [DATE]." This entry was then followed by a series of late entries recorded at 12:35 p.m. on [DATE] by Employee #79 (the LPN assigned to care for Resident #119 from 7:00 a.m. to 7:00 p.m. on [DATE]), which was then followed by another series of late entries recorded by Employee #19 (the desk nurse who worked on [DATE]) at 3:27 p.m. on [DATE] a week after the resident had expired. (See also citation at F514.) -- 3. In addition to the absence of evidence that physical assessment data was being contemporaneously collected and recorded with respect to Resident #119's acute change in condition, routine assessments of the resident's respiratory status were not performed every four (4) hours before and after each inhalation treatment that had been administered on [DATE]. (See also citation at F281.) Review, on [DATE], of Resident #119's [DATE] MAR indicated [REDACTED]. Review of the resident's care plan, which had been initiated on [DATE], revealed the following problem statement: "Short of breath / difficulty breathing related to: [MEDICAL CONDITION]." Interventions to address this problem included: "Administer medication as ordered. ... Notify physician of increased complaints of difficulty in breathing. Obtain oxygen saturation levels. Obtain vital signs. Provide nebulizer treatments as ordered." Review of documentation recorded in the resident's nursing notes and on the October MAR found no evidence that any physical assessment data regarding the resident's respiratory status had been collected and recorded either prior to and after each nebulizer treatment. Review of the facility's policy "Aerosolized Medication (Neb Med)" (with a revision date of [DATE]) found the following under Item #4 under guidelines: "h. Assess the Resident "(1) Note the resident's skin color and temperature, skin characteristics (warm and dry vs. cold and clammy; elastic vs. [MEDICAL CONDITION]), pattern and effort of breathing, ability to take a deep breath and cough and quality of breath sounds. If medication is being given for wheezing, note quality and intensity so as to be prepared to document post-[MEDICATION NAME][MEDICATION NAME] effects. "(2) Check respiratory rate prior to treatment." According to the policy, after the nebulizer treatment ceases, the following steps were to be completed: "n. Assess the resident to determine therapeutic outcome. ... "r. Document medication, [MEDICATION NAME], dose, pulse and breath sounds before and after the treatment, O2 (oxygen) liter flow, cough, color and consistency of sputum, resident (sic) subjective response and any adverse reactions and action taken." During an interview on [DATE] at 3:30 p.m., the director of nursing (DON - Employee #81) revealed that any documentation related to the implementation of this policy would be recorded in the resident's nursing notes. During an interview on [DATE] at 4:15 p.m., the LPN (Employee #79) who initialed Resident #119's MAR indicated [REDACTED]#119's respiratory status before and after administering each of these nebulizer treatments. -- 4. Review of the run sheet completed by personnel from the emergency medical services (EMS) that transported Resident #119 from the facility to the hospital on the evening of [DATE] revealed, under pertinent findings, the primary signs and symptoms necessitating EMS was "Respiratory Arrest"; other signs and symptoms included "Decreased LOC". In the narrative section on page 1 of 6 was recorded, "Patient found by staff (sic) decreased LOC (sic) Upon arrival found thw (sic) patient snoring resp 3 breaths amin (sic) ..." Under event chronology beginning on page 3 of 6, a physical assessment by EMS personnel found her eyes / pupils were reactive to light when assessed at 1914 (7:14 p.m.) on [DATE]. At 1915 (7:15 p.m.), her B/P was ,[DATE] and her respiratory rate was 3 breaths per minute and labored with an oxygen saturation of 85%. The resident was intubated, and the ambulance left the scene at 1930 (7:30 p.m.). Her care was transferred to the ER at 1942 (7:42 p.m.) -- 5. According to notes from the hospital ER, Resident #119 arrived and was triaged at 1942 (7:42 p.m.) on [DATE]. When assessed at 1952 (7:52 p.m.), her B/P was ,[DATE], heart rate 134, respiratory rate 14, temperature 98.7 degrees F, oxygen saturation at 96%, and she was not alert. At 2041 on [DATE], a note recorded, "Daughter states Pt is DNR (do not resuscitate) and as MPOA requests that all 'artificial life support and tx (treatment) for [MEDICAL CONDITION]' be dc'd (discontinued). (MPOA) also spoke these requests to Dr,. (name), ER attending." Resident #119 was subsequently extubated, and she expired at 9:50 p.m. on [DATE]. -- 6. A copy of Resident #119's certificate of death, which was obtained from the hospital, revealed her time of death was 2150 (9:50 p.m.) on [DATE], and her cause of death was [MEDICAL CONDITION] due to aspiration, due to [MEDICAL CONDITION]. -- 7. Review of the facility's policy on Change of Condition of a Resident (policy # CL-,[DATE], with an effective date of ",[DATE]") revealed the following: "Policy Statement - It is the policy of the center to take appropriate action and provide timely communication to the resident's physician and responsible party relating to a change in condition of a resident." "Procedure - Action Steps "1. The Licensed nurse determines if there has been a change in condition of a resident. (Attachment E) "2. The Licensed Nurse notified, via telephone, the attending physician and the resident's responsible party of the specific nature of the change in condition. - The primary mode of urgent communication is by telephone. ... - The Medical Director will be contacted in the event that the attending physician is not available for consultation. - If unable to reach either the attending physician or the medical director, the resident will be transported immediately via 911, the DNS (director of nursing services) / designee will be notified. "3. The Licensed Nurse initiates action to ensure the immediate safety of the resident. "4. The Licensed Nurse confers with the Physician / Physician Extender to determine what actions may be necessary to meet the immediate needs of the resident. "5. The Physician / Physician Extender providers orders to direct the care of the resident. (Attachment A) "6. The Licensed Nurse / designee implements the physician's orders [REDACTED]. "7. The Licensed Nurse documents in the interdisciplinary progress notes and on the 24 Hour Report of Resident change in Condition Book: (Attachment B, C, D, E) - The condition of the resident - Whom was notified and when - Care & treatment orders dictated by the physician - Implementation of physician orders - Care interventions in the resident's plan of care - Residents (sic) response to interventions." According to page 3 of 8 of the policy, the forms to be used when implementing this procedure are as follows: - Attachment A - Physician Telephone Orders (form #,[DATE]) - Attachment B - Interdisciplinary Progress Notes (form #,[DATE]) - Attachment C - 24 Hour Report of Resident Change in Condition Book (form #,[DATE]) - Attachment D - ICP (interdisciplinary care plan) Goals and Approaches (form # ,[DATE]) - Attachment E - Change of Condition Documentation (form # ,[DATE]) Review of Resident #119's closed record found no use of the Change in Condition Documentation form, which would have prompted the licensed nurse completing the form to collect and record data under the headings objective / underlying illness / symptoms (including vital signs and food / fluid intake in the last 24-hours), general appearance (including the presence of lethargy), and physical evaluation (including a change in mental status, the presence of a cough, the presence of adventitious breath sounds, oxygen saturation levels with and without the use of supplemental oxygen, and if vomiting is present, a description). Resident #119's interdisciplinary progress notes (also known as "nursing notes") did not contain documentation to indicate nursing staff notified the resident's responsible party, attending physician, or the CNP employed by the facility when the resident vomited three (3) times on the ,[DATE] shift ending on the morning of [DATE] documentation to indicate the resident continued to vomit on both the ,[DATE] shift and the ,[DATE] shift of the same day. There was no ICP in her closed record addressing her acute change in condition with respect to her decreased LOC (lethargy) and vomiting. While orders were written by the physician extender (Employee #123, the CNP), not all of the orders were implemented by the licensed nurses. Review of the facility's 24 Hour Report of Resident Change in Condition Book for the time period of [DATE] through [DATE], found the first mention of Resident #119 on an undated page found between [DATE] and [DATE], which noted she was to have a CBC, BMP, and sed rate. Although there were columns under the heading of "Change in Condition" in which check marks could be placed to indicate such things as the presence of vomiting, there was no evidence Resident #119 was identified on the 24 Hour Report as requiring monitoring related to her vomiting, which (according to a nursing note) began on the ,[DATE] shift ending on the morning of [DATE] and which (according to staff interviews) continued through both the ,[DATE] shift and the ,[DATE] shift on [DATE]. The next mention of Resident #119 on the 24 Hour Report was an entry a the page dated [DATE], which stated, "to (sic) ER d/t fixed pupils & severe congestion - MPOA stated, 'send (sic) her to ER.' Expired 9:50 p.m. @ ER." The facility's licensed nursing staff did not follow the facility's policy and procedures when Resident #119 exhibited an acute change of condition. -- 8. Medical record review revealed Resident #119 was seen by the facility's CNP on [DATE], [DATE], and [DATE]. A CNP progress note dated [DATE] (and electronically signed at 1:25 p.m. on [DATE]) identified, under review of symptoms, the patient denied fever and chills and shortness of breath. Under physical examination, the CNP recorded the resident as being "frail and alert oriented x 2" and her lungs were clear to auscultation bilaterally. Her vital signs were assessed as follows: "blood pressure at Left Arm while Sitting is ,[DATE] mm/Hg 96 bpm (beats per minute) regular 98.0F 139 pounds clothed." At the end of this progress note was written: "Resident does have discomfort during PT-family (sic) requests that Tylenol be schedules, rather thatn (sic) prn (as needed). Will schedule and observe -possible (sic) will have to order [MEDICATION NAME] prior to PT. Dementia increases difficulty in assessing resident. Comorbidities stable and resident is stable." - A CNP progress note dated [DATE] (and electronically signed at 2:46 p.m. the same day) identified that Resident #119 presented with lethargy and "the symptom started 7 days ago." (Although this note indicated the lethargy started seven (7) days ago (which would have been [DATE]), there was no mention of lethargy in the CNP's progress note for [DATE] and no mention of lethargy in any of the nursing notes recorded in Resident #119's closed record during the time period from [DATE] to [DATE].) Under review of symptoms, the CNP recorded, "The patient complained of malaise and lethargy but denied fever and chills" and she "denied cough". Under physical examination, the CNP recorded Resident #119's pharynx was clear and her lungs were clear to auscultation bilaterally. Under services ordered, the CNP recorded a CBC, BMP, and RBC sed rate. At the end of the progress note was written: "Resident appears to be stable. Will obtain labs and reevaluate. If normal labs, will consider adjusting medication." - A CNP progress note dated [DATE] (and electronically signed at 11:59 a.m. the same day) revealed, under chief complaint, "(Resident #119) presented with vomiting. It is described as acute. The symptom is sudden in onset. The symptom started 4 hours ago. The complaint is mild. Episodes occur in the morning. ... In addition, she presented with shortness of breath. It is described as stable. The symptom is gradual in onset. ... Patient denies apnea, cough, [MEDICAL CONDITION] and sputum production. ... Evaluated yesterday for lethargy-today (sic) having episodes of vomiting. Reevaluation." Under review of symptoms, the CNP recorded, "The patient complained of lethargy but denied fever and chills", "patient denied difficulty swallowing, sore throat and headache", "patient denied sOB (sic) and cough", and "patient complained of nausea, vomiting (small amount x 3) and decreased appetite but denied diarrhea and constipation". Under physical examination, the CNP recorded the resident's pharynx was clear, her respiratory system was "CTA (clear to auscultation) Bilaterally (diminished), left lower lung field: (sic) diminished, right lower lung field: diminished and rales (faint)." The CNP recorded the resident's vital signs as: "blood pressure at Left Arm while Sitting is ,[DATE] (sic) mm/Hg 121 bpm regular 97.6F 139 pounds clothed." Under prescriptions, the CNP recorded: "[MEDICATION NAME] 10 mg Rectal Suppository, 1 Unit Dose and RTL. [MEDICATION NAME] 40 mg Cap, Delayed Release, 1 Capsule(s), PO and QD. [MEDICATION NAME] 12.5 mg Rectal Suppository, 1 Unit Dose, RTL, Q6 PRN, 5 days start on [DATE] and end on [DATE]. [MEDICATION NAME] 1 gram Solution for Injection, 1, InVt, QD, 7 days, start on [DATE] and end on [DATE]." Under services ordered, the CNP recorded a chest x-ray. At the end of the progress note was written: "Resident has hx. of Reflux but currentlyl (sic) is not on PPI. Will order [MEDICATION NAME]. O2 2 liters nc and observe closely. Will start IV fluids @ 50 cc/hr until obtain chest x ray and stat dose [MEDICATION NAME]." - The result of the sedimentation rate study was called to the facility at 9:55 a.m. on [DATE], with no abnormal finding. The results of the CBC and BMP were sent to the facility at 12:23:52 (12:23 p.m.) on [DATE] (according to the date / time stamp recorded at the top of each page of the report), with abnormal results including: glucose - 126 (normal range 83 - 110); BUN - 35 (normal range 6 - 20); white blood cells - 14.5 (normal range 4.8 - 10.8); red blood cells - 3.65 (normal range 4.2 - 5.4); hemoglobin - 10.7 (normal range 12.0 - 16.0); and hematocrit - 34.2 (normal range 36 - 48). - A second CNP progress note dated [DATE] was identified as having been an amendment to the earlier progress note at 1:57 p.m. on [DATE]. This amendment, which was electronically signed by the CNP at 10:44 a.m. on [DATE], contained the exact same information as found on the earlier note for [DATE] under the headings chief complaint, review of symptoms, physical examination, diagnoses, prescriptions, services performed, and services ordered. At the end of the progress note was written: "Resident has hx. (history) of Reflux but currentlyl (sic) is not on PPI (protein pump inhibitor). Will order [MEDICATION NAME]. O2 2 liters nc (via nasal cannula) and observe closely. Will start IV fluids @ 50 cc/hr until obtain chest xray and stat dose [MEDICATION NAME]. REceived (sic) labs - WBC 14.5 BMP BUN (blood urea nitrogen) 35 otherwise WNL (within normal limits). Stronger evidence of pneumonia. Have consulted Resp. Tx. (respiratory therapy) for evaluation and treatment." - The CNP progress note timed at 11:59 a.m. on [DATE] was the only evidence to reflect Resident #119 was seen / assessed by the CNP that day. - Two (2) sheets of orders handwritten by the CNP were found for [DATE]; none of the orders contained a time to indicate at what time on this date they were actually written, and neither sheet contained notations to indicate what time the desk nurse noted having received the orders. The first sheet of orders contained two (2) sets of entries as follows: "[MEDICATION NAME] 10 mg suppository now. [MEDICATION NAME] 40 mg po reflux. [MEDICATION NAME] 12.5 mg suppository Q 8 (symbol for hours) PRN nausea x 5 days vomiting." and "IV: ,[DATE] NSS (sterile normal saline) i (1) liter @ 50 cc/hr. [MEDICATION NAME] i Gm IV now & daily x 7 days. O2 3 Liters n/c (via nasal cannula)." The second sheet of orders contained one (1) set of entries as follows: "IV: 0.9 NSS i liter @ 50 cc/hr - (arrow pointing up) HR (heart rate). [MEDICATION NAME] 1 Gm IV STAT & QD (daily) x 7 days - (arrow pointing down) O2 sat (oxygen saturation). O2 3 L (liters) per N/C. [MEDICATION NAME] 12.5 mg suppository Q 6 (symbol of hours) PRN (as needed) nausea x 5 days. [MEDICATION NAME] 40 mg i daily po (by mouth) - reflux. [MEDICATION NAME] 10 mg suppository today. Resp Tx eval & treat - (arrow pointing down) O2 sat. Chest x-ray STAT - (arrow pointing down) O2." - An interview was conducted on [DATE] at 12:45 p.m. with the facility's CNP (Employee #123). The CNP reported she had been at the facility all day on [DATE] and had provided care for Resident #119. The CNP stated she initially wrote orders thinking the resident may have had an obstruction, but after receiving further assessments from the nurses and receiving the results of labs that had previously been ordered, it became evident to her the resident probably had pneumonia. The CNP further stated it was her role to provide all the care at the facility, so that she could to prevent trips by residents to the hospital. She also stated the nurses were "too accustomed to picking up the phone and calling EMS". - An interview was conducted on [DATE] at 12:15 p.m. with Employee #19, who was the desk nurse on [DATE]. Employee #19 stated she received a first set of orders from the CNP at 1:00 p.m. on [DATE] (for the [MEDICATION NAME], and [MEDICATION NAME]). Employee #19 said she later received a second set of orders from the CNP (for the [MEDICATION NAME], IV fluids, supplemental oxygen, and chest x-ray). According to Employee #19, when she questioned the CNP about what to do with the first set of orders, the CNP stated the resident had possible pneumonia and the most important thing at this point was to start the IV fluids and get the chest x-ray. - Further review of the resident's closed record, including nursing notes and medication administration records, found no evidence the stat dose of [MEDICATION NAME] had been given or that Resident #119 received a single dose of [MEDICATION NAME] to treat her nausea / vomiting prior to her transfer to the hospital at 7:22 p.m. on [DATE]. -- 9. In an interview conducted on [DATE] at 4:15 p.m., Employee #79 (who was the LPN assigned to care for Resident #119 from 7:00 a.m. to 7:00 p.m. on [DATE]) reported she was first made aware of the resident vomiting when a ,[DATE] shift nursing assistant came to her and informed her of the vomiting and inquired about the resident's code status. Employee #79 reported she "went immediately to the resident's room, recognized the resident's condition, and went immediately to the phone to call EMS." This nurse also stated, during an earlier interview conducted on [DATE] at 12:05 p.m., she believed the res | 2014-03-01 |