| 11432 |
BOONE HEALTH CARE CENTER |
515117 |
P.O. BOX 605 |
DANVILLE |
WV |
25053 |
2010-11-11 |
327 |
G |
|
|
IP7Z11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on family interview, closed medical record review, and staff interview, the facility failed to provide the necessary care and services to ensure one (1) of eleven (11) sampled residents to maintain proper hydration and health. Resident #45 had a history of [REDACTED]. She was also identified as being at risk for weight loss related to [MEDICAL CONDITION] reflux, dementia, [MEDICAL CONDITION], and diabetes mellitus, and her diet order and care plan both addressed the need for staff to encourage fluid intake. On [DATE], Resident #45 received a Fleets enema on [DATE], after having no BMs for four (4) consecutive days. 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, continued to administer her routine laxatives except when the resident refused, 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]. Staff also did not identify and report to the physician a decrease in Resident #45's daily fluid intake (she was consuming less than 50% of her estimated daily fluid needs based on her weight), and although her physician orders [REDACTED]. 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. 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 [DATE]. This was followed nine (9) BMs on [DATE]; three (3) BMs on [DATE]; seven (7) BMs on [DATE]; six (6) BMs on [DATE]; and one (1) large BM on the day shift of [DATE]. 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. (See citation at F309.) -- 5. 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 them except when the resident refused. (See also citation at F309.) -- 6. 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 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]. -- 7. 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 as follows: - [DATE] - 600 cc with meals and snacks; 480 cc of Glucerna; 240 cc of Med Pass (daily total fluids = 1320 cc) - [DATE] - 600 cc with meals and snacks; 480 cc of Glucerna; 240 cc of Med Pass (daily total fluids = 1320 cc) - [DATE] - 520 cc with meals and snacks; 480 cc of Glucerna; 240 cc of Med Pass (daily total fluids = 1240 cc) - [DATE] - 480 cc with meals and snacks; 240 cc of Glucerna; 120 cc of Med Pass (daily total fluids = 840 cc) - [DATE] - 360 cc with meals and snack; 480 cc of Glucerna; 120 cc of Med Pass (daily total fluids = 960 cc) - [DATE] - ADL flow sheet documentation showed resident refused all fluids offered on day shift; 240 cc of Glucerna; 0 cc of Med Pass (total fluids on day shift prior to transfer to hospital = 240 cc) 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. -- 8. Review of Resident #45's POST form, signed by the facility's social worker on [DATE], revealed the resident's medical power of attorney representative (MPOA) had indicated, in Section D, the desire for the resident to receive IV fluids and tube feeding for a defined trial period to maintain hydration and nutritional status. There was no evidence in the medical record that staff identified a change in the resident's hydration status for which the administration of IV fluids for a trial period was indicated. -- 9. Resident #45 was sent out to the hospital on day shift on [DATE]. 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. . |
2014-03-01 |