cms_WY: 22
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 22 | GRANITE REHABILITATION AND WELLNESS | 535013 | 3128 BOXELDER DRIVE | CHEYENNE | WY | 82001 | 2017-10-04 | 309 | G | 0 | 1 | GX9L11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff, family, and hospital case manager interviews, and policy and procedure review, the facility failed to ensure physician orders [REDACTED].#113) who had a significant change in condition. This failure resulted in delayed treatment and further decline in condition that required transport to the emergency room . In addition, the facility failed to ensure effective pain management for 1 of 7 sample residents (#114) who were assessed as needing pain management to help maintain his/her highest practicable level of well-being. This failure resulted in a decline in health status and inability to participate in activities and bedside therapy. The findings were: 1. Review of the medical record for resident #113 showed an admission date of [DATE] with a discharge date of [DATE]. The resident had [DIAGNOSES REDACTED]. The following concerns were identified: a. An interdisciplinary progress note dated 2/19/17 and timed 12:30 AM noted the resident had a pulse of 89 beats per minute (bpm), an oxygen saturation level of 86%, and expiratory wheeze noted in RLL (right lower lung) and LLL (left lower lung), more significant wheeze in LLL. Audible crackles without stethoscope (sic). Resident displays/reports no SOB (shortness of breath). Asked resident to deep breathe and cough multiple times. Resident attempted each time but struggled to produce a productive cough. Resident is in no acute distress .left resident in bed in the lowest position, to go back to sleep. Will continue to monitor. Further review of progress notes showed the next entry was dated three days later, on 2/22/17 and timed 2 PM, and showed the resident was started on [MEDICATION NAME] (an inhalation solution that dilates lung cells) every 6 hours for 5 days and [MEDICATION NAME] (an antibiotic) for 5 days with a [DIAGNOSES REDACTED]. No evidence was provided to show the resident was assessed during the three days between progress notes, or that the resident's signs/symptoms were addressed prior to 2/22/17. b. Review of an SBAR communication form showed the medical doctor was notified of the resident's condition on 2/19/17 at 4:15 AM by fax. A faxed response dated 2/20/17 showed an order for [REDACTED]. c. Review of a progress note, dated 2/23/17 and timed 3:45 PM showed the resident had a pulse of 131 bpm and temperature of 101.1 Fahrenheit (F). d. Review of the progress note dated 2/24/17 and timed at 4 AM showed the resident had a pulse of 124, temperature of 101.6 F and oxygen saturation of 87% on 3L (liters of oxygen). The note showed the resident was short of breath and sweating. The note further showed the doctor had contacted the facility, and thought the resident may have had pneumonia and may have been going septic, and ordered for the resident to be transferred to the hospital for evaluation and treatment. The resident was transferred to the emergency department on 2/24/17. e. Interview on 10/4/17 at 3:02 PM with the DON revealed the facility had reviewed the charting and assessments for resident #113 and confirmed it was not sufficient. The DON stated the nurse who had made the progress note entry on 2/19/17 was new and had not placed the resident on alert charting for follow up from her assessment. The facility provided education to staff on 3/8/17 regarding charting requirements. f. Review of inservice education attendance sheets dated 3/8/17 indicated education was provided to staff which included 24 hour documentation. Handouts included the facility policy for Alert Charting Guidelines which stated the following for upper and lower respiratory infections: Alert charting Q (every) shift until condition improves or resolves. Vital Signs Q shift - Allow to sleep on 3rd shift unless condition warrants interruption. Lung sounds Q shift or as condition warrants. Characteristics of sputum. Activity tolerance. Oxygen use, Oxygen saturation. Dietary tolerance, fluid intake. For exacerbation of cardiac/respiratory condition, the guideline stated Alert charting Q shift. VS Q shift. Heart & lung sounds. Circulatory changes, [MEDICAL CONDITION]. Daily weight. Activity tolerance. Oxygen use, oxygen saturations. medications: [REDACTED] 2. Review of the medical record showed resident #114 was admitted from the hospital on [DATE] and [DIAGNOSES REDACTED]. Further review showed at the hospital the resident's pain was effectively managed with a [MEDICATION NAME], [MEDICATION NAME], and [MEDICATION NAME] (all are medications for pain). Review of the nursing admission assessment revealed the resident did not have cognitive impairment and required assistance with toileting and transfers. This review also revealed the resident had constant pain in his/her lower back. Review of the physician admission orders [REDACTED]. Review of nursing notes dated 8/30/17 showed the resident received a neuromuscular block injection in the lumbar area of the spine. According to the nursing notes the resident reported the procedure greatly improved the pain, but s/he continued to need the [MEDICATION NAME] pain medication every 4 hours. Review of the physician orders, dated 8/31/17, showed an order to apply a [MEDICATION NAME] to the lower back each day for lumbar stenosis pain. The following concerns were identified regarding ineffective pain management: a. Review of the narcotic book sign out sheet for the resident showed after receiving the daily [MEDICATION NAME] the resident continued to need [MEDICATION NAME] for pain. This review revealed 25 doses of [MEDICATION NAME] were administered after the [MEDICATION NAME] was started on 8/31/17 and before the facility obtained an order for [REDACTED]. b. Review of the nursing assessments before and after administering the pain medication showed the medication was effective only for a short time. Interview with LPN #1 on 10/4/17 at 3 PM revealed the resident had a lot of pain and it was never completely controlled. The LPN stated the resident was unable to participate in a lot of activities and bedside therapy due to the pain. He further stated it was difficult to get the physician to prescribe additional medications. c. Interview with the hospital case manager on 10/9/17 at 9:10 AM revealed she visited the resident at the hospital prior to the transfer to the nursing home and was concerned when she saw the resident at the nursing home on 9/5/17 because there was a noticeable decline in health status and the resident complained of severe back pain. d. Interview with the family on 10/10/17 at 5:45 PM and again on 10/13/17 at 9:50 AM revealed the family visited 1 to 2 times daily and verbalized their concerns about the resident's pain to the nursing staff. During the interview the family member described the resident's pain as s/he was always hurting and the resident remained in bed most of the time due to the pain. e. Review of the admission and nutrition hydration status care plans, developed on 8/24/17, showed pain was an identified problem, but there were no documented interventions for this problem. The facility was unable to provide evidence of an individualized plan for managing the resident's pain, an initial pain assessment to establish desirable goals, and evaluation of this effectiveness of non-pharmacological approaches. f. Interview with the DON on 10/4/17 at 10:30 AM revealed staff talked with the physician about the resident's pain, but the physician was reluctant to prescribe different medications. Review of the documentation provided by the facility revealed the nursing staff contacted the physician on 8/31/17 and 9/5/17 to report the pain medication was not effective. This review also revealed additional efforts to report the ineffective pain management to the physician and/or request for involvement from other practitioners were lacking g. Review of hospital records showed the resident was admitted on [DATE]. Review of the hospital physicians progress note dated 9/11/17, revealed the resident had a lumbar burst fracture with retropulsion causing severe canal stenosis and impinging conus. h. Review of Pain Management Policy -495, updated (MONTH) (YEAR), showed the following procedures were included in the measures for effective pain management: When pain is not adequately controlled by current regiment, l, or if there is newly identified pain, the Licensed Nurse (LN) contacts the physician for consideration of new or modified treatment orders. The information on the Pain Evaluation Record is used in conjunction with the Center's other evaluation and data collection tools to develop an individualized care plan including non-pharmacological interventions, if appropriate. | 2020-09-01 |