cms_WV: 11431
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 11431 | BOONE HEALTH CARE CENTER | 515117 | P.O. BOX 605 | DANVILLE | WV | 25053 | 2010-11-11 | 309 | G | IP7Z11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Part I -- Based on family interview, closed medical record review, staff interview, and review of Lexi-Comp's Drug Information Handbook for Nursing 2007 (8th Edition), the facility failed to provide the necessary care and services to maintain the highest practicable physical well-being for one (1) of eleven (11) sampled residents. Resident #45, who had a history of [REDACTED]. Beginning on [DATE], Resident #45 was noted to have an increased frequency in bowel elimination with three (3) BMs per shift for the next four (4) consecutive shifts; then her high frequency of BMs continued beginning on the day shift of [DATE]. Staff did not identify this increased frequency of BMs, did not describe the characteristics of these frequent BMs in the medical record (e.g., color, consistency, presence of foul or unusual odor, etc.), continued to administer her routine laxatives except when the resident refused, failed to identify a decrease in fluid intake, and failed to collect / record, monitor, and report to the physician any physical assessment data related to this resident's change in condition. All nursing documentation stopped with the last entry made at 12:05 p.m. on [DATE]. On the morning of [DATE], after intervention by the resident's legal representative, Resident #45 was transferred to the hospital due to an altered mental status and was subsequently admitted with [MEDICAL CONDITION] (C. diff.) [MEDICAL CONDITION] and proctitis; urinary tract infection [MEDICAL CONDITION]; altered mental status secondary to the above; acute hemorrhagic stroke in the parietal lobe; and dehydration. Resident #45 expired at the hospital on [DATE]. Resident identifier: #45. Facility census: 84. Findings include: a) Resident #45 1. During a telephone interview beginning at 5:45 p.m. on [DATE], the daughter of Resident #45 reported that she had visited her mother at the facility and found her with a dry mouth and a foul odor associated with bowel movement and urine; according to her daughter, Resident #45 was not very responsive and could barely say her name. The daughter reported her findings to a nurse at the facility, who "pinched" the resident's skin and said she did not believe the resident was dehydrated. The daughter reported her belief that the facility failed to assess her mother for about one (1) week; she had visited her mother on [DATE] and "everything was fine", but when she returned on [DATE], she found her mother in a "gravely ill" condition. The daughter reported she did not hear from the facility during the period from [DATE] through [DATE] to let her know that her mother was sick. (See also citation at F157.) Her mother was not transferred to the hospital until she brought her mother's condition to the staff's attention on [DATE]. Her mother later expired at the hospital on [DATE]. -- 2. Closed record review revealed this [AGE] year old female was originally admitted to the facility on [DATE]. Her current [DIAGNOSES REDACTED]. Review of her nursing notes revealed the last entry was made at 12:05 p.m. on [DATE]. Further review of her record revealed a physician's telephone order dated [DATE] (no time written) to transport the resident to the local hospital's emergency room due to "(symbol for 'change') in mental status", although there was no corresponding entry discussing when or why this occurred. (See also citation at F514.) -- 3. Information obtained from the hospital history and physical, electronically signed by the physician on [DATE], revealed Resident #45 arrived at the emergency roiagnom on [DATE], with a chief complaint of "altered mental status". Under the heading "History of Present Illness" was found: "This is an [AGE] year old white female who resides at Boone Nursing whose history comes from family as well as nursing staff who report (sic) that she had a (sic) altered mental status since last night. She had a decreased appetite, weakness, and diarrhea for several days. ... Symptoms for twenty hours (sic) altered mental status but other symptoms for several days. ..." Under the heading "Physical Examination" was found: "... Positive lethargy but no comatose state. Alert. Dehydration with dry mucous membranes. ... Bowel sounds hyperactive. ..." Under the heading "Labs" was found the following abnormal values: glucose 141 (normal range = ,[DATE]); blood urea nitrogen (BUN) 58 (normal range = ,[DATE]); white blood cells 15.3 (normal range = 4XXX,[DATE]); 2+ protein in urine (normal = negative); 2+ leukocyte esterase in urine (normal = negative). Under the heading "Assessment / Plan" was found the following: "1. [DIAGNOSES REDACTED] [MEDICAL CONDITIONS] and proctitis ... "2. UTI (urinary tract infection) ... "3. Altered mental status secondary to the above. "4. Acute hemorrhagic stroke in parietal lobe ... "5. Dehydration. Given light IV fluids to prevent any kind of fluid overload. ..." -- 4. A review of the nursing notes recorded in Resident #45's medical record in the days prior to her transfer to the hospital revealed the following: - On [DATE] at 9:00 a.m. - "N/O (new order) noted for Fleets enema per rectum x i (1) D/T (due to) (symbol for 'no') BM x 4 days. Resident tolerated procedure well /c (with) effective results noted /c med (medium) BM noted." - On [DATE] at 11:00 a.m. - "S/T (skin tear) to (L) (left) wrist during AM (morning) care noted. Dr. (doctor) notified /c orders for steri-strips & TAO (triple antibiotic ointment) applied. ...(Symbol for 'no') distress noted, will continue to monitor." - On [DATE] at 12:05 p.m. - "Resp (respirations) even & unlabored. (Symbol for 'no') SOB (shortness of breath) or cough noted. ... (Symbol for 'no') distress noted @ (at) present. Will monitor." According to the hospital history and physical, "... Symptoms for twenty hours (sic) altered mental status but other symptoms for several days. ..." However, there was no mention in the resident's nursing notes of any decreased appetite or weakness or of the resident having had "diarrhea for several days" in the days preceding the resident's transfer to the hospital on [DATE]. -- 5. Review of Resident #45's nursing notes for [DATE] revealed staff called the physician and obtained an order for [REDACTED]. Review of the nursing notes for [DATE] and [DATE] found no documentation related to the resident's fluid intake and/or bowel elimination, and all nursing documentation stopped after 12:05 p.m. on [DATE]. Review of Resident #45's [DATE] ADL flow sheet revealed she had an extra large BM on the evening shift of [DATE], and then she did not have another BM until the day shift on [DATE], for which a Fleets enema was administered. According to coding on the ADL flow sheet, the resident had two (2) BMs on the day shift of [DATE]. This was followed by: - No (0) BMs on the evening and night shifts of [DATE]; - Three (3) BMs on the day shift of [DATE]; - Three (3) BMs on the evening shift of [DATE]; - Three (3) large BMs on the night shift of [DATE]; - Three (3) BMs on the day shift of [DATE]; - No (0) BMs on the evening and night shifts of [DATE]; - Three (3) BMs on the day shift of [DATE]; - Three (3) BMs on the evening shift of [DATE]; - One (1) small BM on the night shift of [DATE]; - One (1) large BM on the day shift of [DATE]; - Two (2) large BMs on the evening shift of [DATE]; - Three (3) large BMs on the night shift of [DATE]; and - One (1) large BM on the day shift of [DATE]. Due to an absence of nursing notes after 12:05 p.m. on [DATE], there was no evidence to reflect the licensed nursing staff collected or recorded any physical assessment data regarding the resident's overall health status, including but not limited to data regarding the resident's bowel movements (whether the stool was formed, soft, liquid, or watery and/or whether the color or odor of the stool was abnormal, etc.), the presence and quality of bowel sounds, level of consciousness, and/or hydration status. There was no evidence the licensed nursing staff identified and reported to the physician or the resident's legal representative that this resident, beginning on [DATE], was having excessively frequent BMs. -- 6. Review of the resident's medication administration records (MARs) for September and [DATE] revealed physician's orders [REDACTED]. - [MEDICATION NAME] 15 cc by mouth twice daily for constipation - Senna Plus 2 tabs by mouth twice daily for constipation - Power Pudding 60 cc at bedtime due to constipation According to the [DATE] MAR, when Resident #45 continued to have frequent BMs on [DATE], staff continued to administer Senna Plus and [MEDICATION NAME] on [DATE] and [DATE]; the resident refused the Power Pudding. According to the [DATE] MAR, when Resident #45 continued to have frequent BMs on [DATE] and [DATE], staff did not withhold all doses of laxatives; rather, the facility continued to administer as follows: - [DATE] - [MEDICATION NAME] at 6:00 p.m.; Senna Plus at 6:00 p.m.; Power Pudding at 9:00 p.m. - [DATE] - [MEDICATION NAME] at 10:00 a.m. and 6:00 p.m.; Senna Plus at at 10:00 a.m. and 6:00 p.m.; - [DATE] - [MEDICATION NAME] at 10:00 a.m.; Senna Plus at 10:00 a.m. (The nurses' initials were circled on the MAR for the 10:00 a.m. doses of [MEDICATION NAME] and Senna Plus on [DATE], although no explanation for this was documented on the reverse side of the MAR.) According to Lexi-Comp's Drug Information Handbook for Nursing 2007 (8th Edition): - For [MEDICATION NAME], under "Nursing Actions: Physical Assessment" on page 704: "Monitor ... therapeutic effectiveness (soft formed stools...) ... Monitor frequency / consistency of stools ..." Under "Nursing Actions: Patient Education" on page 704: "... Report persistent or severe diarrhea or abdominal cramping ..." Under "Geriatric Considerations" on page 704: "Elderly are more likely to show CNS (central nervous system) signs of dehydration and electrolyte loss. Therefore, monitor closely for fluid and electrolyte loss with chronic use...." - For Senna Plus, under "Nursing Actions: Patient Education" on page 385: "...Stop use and contact prescriber if you develop nausea, vomiting, persistent diarrhea, or abdominal cramps. ..." -- 7. Review of the "Shift to Shift Report" forms dated [DATE], [DATE], and [DATE], there was no mention of the resident's increased frequency of bowel elimination, decreased intake of food or fluids, or changes in level of consciousness. The only mention of Resident #45 on these 24-hour reports was related to the skin tear on her left wrist which, according to her last nursing note, she sustained during morning care on [DATE]. -- 8. According to her [DATE] recapitulation of physician orders, Resident #45's diet order was as follows: "LCS / NAS (low concentrated sweets / no added salt) diet w/ ground meats. Encourage fluids w/ meals." To prevent weight loss, Resident #45's orders also included Glucerna 1 can by mouth twice daily and Med Pass 120 cc by mouth twice daily. According to her care plan, Resident #45 was "at risk for weight loss" related to [MEDICAL CONDITION] reflux, dementia, [MEDICAL CONDITION], and diabetes mellitus. Interventions for maintaining her weight at plus / minus 5# through the next review included: "Encourage fluids with meals." According to her weight record on [DATE], Resident #45 weighed 196# (89.1 kg). Her estimated daily fluid needs, based on a formula of 30 cc/kg, would be 2673 cc of fluid per day. Review of the ADL flow sheets for September and [DATE] revealed Resident #45 consumed less than 50% of her estimated fluid needs per day on [DATE], [DATE], and [DATE]; less than 35% of her estimated fluid needs on [DATE] and [DATE]; and she consumed on 240 cc of fluid on day shift on [DATE], prior to her transfer to the hospital. (See also citation at F327.) Review of the medical record, on [DATE] at 11:15 a.m., found no evidence to reflect the licensed nursing staff identified the resident's inadequate fluid intake and notified the physician or Resident #45's responsible party. -- 9. Resident #45 was sent out to the hospital on day shift on [DATE], but no nursing documentation was found related to assessment of the resident prior to her being sent to the hospital. According to her hospital record, she was admitted for [DIAGNOSES REDACTED], [MEDICAL CONDITION], proctitis, urinary tract infection [MEDICAL CONDITION], dehydration, leukocytosis secondary to [DIAGNOSES REDACTED] and UTI, altered mental status secondary to [DIAGNOSES REDACTED] and UTI, hypercalcemia, acute hemorrhagic stroke in the parietal lobe, and lactic acid elevation. -- 10. During a telephone interview on [DATE] at 2:20 p.m. with the licensed practical nurse (LPN) assigned to Resident #45 on [DATE] (Employee #71) and the administrator (Employee #111), Employee #71 confirmed she could not be sure she had documented any nursing assessment data on Resident #45 prior to her being sent to the hospital. Employee #71 stated, "Her daughter came to me and said she was acting different, and I sent her to the hospital." -- 11. In an interview on [DATE] at 10:45 a.m., the director of nursing (DON - Employee #112) confirmed she could not locate nursing documentation related to any nursing assessment of Resident #45 prior to her transfer to the hospital. ---- Part II -- Based on closed record review, the facility failed to provide daily laxatives as ordered by the physician for one (1) of eleven (11) sampled residents who was identified as being at risk for constipation. On [DATE], Resident #45 was treated for [REDACTED]. In [DATE], Resident #45 had orders for four (4) different laxatives to be administered daily: [MEDICATION NAME] 1 tab by mouth daily; Senna Plus 2 tabs by mouth twice daily; [MEDICATION NAME] 15 cc by mouth daily; and Power Pudding 60 cc by mouth at bedtime. Record review revealed found no evidence to reflect the evening dose of Senna Plus was administered as ordered; thirteen (13) doses of [MEDICATION NAME] were not administered as ordered; and fifteen (15) doses of Power Pudding were not administered as ordered, thirteen (13) of which were marked as refused by the resident. Resident identifier: #45. Facility census: 84. Findings include: a) Resident #45 Closed record review revealed this [AGE] year old female was originally admitted to the facility on [DATE]. Her current [DIAGNOSES REDACTED]. Review of her care plan, on [DATE], revealed the following problem statement: "Resident is at risk for constipation: limited mobility; medications; history of constipation." The goal associated with this problem statement was: "Resident will have bowel movments (sic) at least every three day s (sic) thru next review." Interventions to achieve this goal included: "Monitor bowel movments (sic), if none in three days start bowel regimen. Monitor BM (sic) if none every 3 days notify nurse. [DATE] D/C (discontinue) [MEDICATION NAME] & [MEDICATION NAME], start Senna-S 2 tab po BID. [DATE] Power pudding 1xd (daily). ,[DATE] [MEDICATION NAME] 15 ml PO BID. [DATE] [MEDICATION NAME] 1 tab PO daily x 30 days then re-eval constipation. [DATE] leets enema per rectum x 1 dose D/T 0 (no) BM x 4 days per standing order." - Review of Resident #45's nursing notes for [DATE] revealed staff called the physician and obtained an order for [REDACTED]. - Review of Resident #45's September Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Documentation on the MAR indicated [REDACTED]. There was no evidence to reflect that both doses of Senna Plus were administered daily in September. - Review of the resident's [DATE] MAR indicated [REDACTED]. The nurses' initials were circled for the Power Pudding, indicating the medication was not administered as ordered, on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. There was no documentation on the reverse side of the MAR indicated [REDACTED]. (See citation at F514.) Additionally, there were no initials for the Power Pudding on [DATE] and [DATE]. This represents a total of fifteen (15) doses not administered as ordered. - Review of the resident's [DATE] MAR indicated [REDACTED]. There nurse's initials were circled for the [MEDICATION NAME], indicating the medication was not administered as ordered, on [DATE]. Documentation on the reverse side of the MAR indicated [REDACTED]." There were no initials for the [MEDICATION NAME] on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] (with the last dose initialed as having been administered on [DATE]). (See also citation at F514.) This represents a total of thirteen (13) doses not administered as ordered. . | 2014-03-01 |