WESTABBE HEALTHCARE CENTER
Facility ID Number 0043687
2301 W. Monroe St.
Springfield, IL 62704
Date of survey May 11, 2000 Complaint survey
Facility has failed to follow its plan of correction for the survey of 4/17/99 which states, in part, "The facility will ensure that a resident who is fed by a naso-gastric or gastrostomy tube receives the appropriate treatment and services to prevent aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers and to restore, if possible, normal eating skills."
The facility shall notify the resident's physician of any accident, injury or significant change in a resident's condition that threatens the health, safety or welfare of a resident, including, but not limited to, the presence of incipient or manifest decubitus ulcers or a weight loss or gain of five percent or more within a period of 30 days. The facility shall obtain and record the physician's plan of care for the care or treatment of such accident, injury or change in condition at the time of notification.
The facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of the resident, in accordance with each resident's comprehensive assessment and plan of care. Adequate and properly supervised nursing care and personal care shall be provided to each resident to meet the total nursing and personal care needs of the resident.
All treatments and procedures shall be administered as ordered by the physician.
Objective observations of changes in a resident's condition, including mental and emotional changes, as a means for analyzing and determining care required and the need for further medical evaluation and treatment shall be made by nursing staff and recorded in the residents's medical record.
Treatment sheets shall be maintained recording all resident care procedures ordered by each resident's attending physician. Physician ordered procedures that shall be recorded include, but not limited to, the prevention and treatment of decubitus ulcers, weight monitoring to determine a resident's weight loss or gain, catheter/ostomy care, blood pressure monitoring, and fluid intake and output.
Significant observations or developments regarding resident responses to activity programs, social service, dietary services and work programs shall be recorded as they are noted. If no significant observations or developments are noted for three months, an entry shall be made in the record of that fact.
The resident shall be observed to determine acceptance of the diet, and these observations shall be recorded in the medical record.
AN OWNER, LICENSEE, ADMINISTRATOR, EMPLOYEE OR AGENT OF A FACILITY SHALL NOT ABUSE OR NEGLECT A RESIDENT.
These requirements are not met as evidenced by the following:
Per record review, R6 is a 63-year-old male with multiple pressure ulcers, G-tube feeding, supra pubic catheter, MRSA (methicillin resistant staph aureous) and mental retardation. Per record R6 has a history of T7 and T8 osteomyelitis (status post lumbar laminectomy for an epidural abscess- "no malignancy"), PVD (peripheral vascular disease), CAD (coronary artery disease), depression and a history of prostate cancer (transurethral resection of the prostate). Resident Assessment of 4/2/00 states that R6 is totally dependent on staff for bed mobility, dressing, eating, personal hygiene and bathing.
Examples are as follows:
1. Facility failed to monitor R6's tube feeding intake of Jevity Plus and water and R6's daily food/fluid intake, resulting in unplanned weight loss, dehydration, hypernatremia and seizures.
Per interview with E3 (LPN-Licensed Practical Nurse) on 4/28/00 at approximately 9:30A.M., during tour of the facility, E3 stated that R6 was in the hospital due to having seizures and dehydration. E3 stated that R6 did not have a history of seizures and that R6 was sent to the hospital because R6 is a "full code".
Per interview with Z2 (Physician Assistant) on 4/28/00 at approximately 10A.M., R6 was admitted to the hospital on 4/20/00 with a diagnosis of seizures and dehydration. Z2 stated that the last time Z2 was at the facility R6 had another weight loss. Facility weight records reveal that R6 weighed 134.75 lbs. on January 2, 2000 and was down to 106 lbs. on April 19. Z2 stated that R6's mucous membranes were sticky. Z2 stated that R6's tube feeding was disconnected during Z2's last few visits to the facility and this was not during meal time. Z2 stated she would frequently call facility nursing staff and ask R6's attending nurse how much tube feeding and water flushes R6 was getting. Z2 stated the nurses caring for R6 did not know and had to call her back. Z2 stated she was concerned that R6 was not getting the tube feeding and flushes as ordered.
Z2 stated that R6 had a history of constipation, dehydration and UTI's (urinary tract infections) and it was important for R6 to get adequate fluids and Z1 (physician) had recently increased order for tube feeding water flushes. Z2 stated that R6 was being treated for an UTI since admission to the hospital on 4/20/00.
Z2 stated that she had talked with Z1 (physician) and that Z1 agreed that the only way R6 could be dehydrated was if R6 was not getting the tube feeding and water flushes as ordered by Z1.
Z2 stated that there was no underlying medical condition that would lead R6 to have weight loss and dehydration and R6's condition had to be due to inadequate tube feeding and water intake.
Per facility RD (Registered Dietitian) assessment of 10/20/99, the RD identified R6's IBW (Ideal Body Weight) to be 122 - 150 lbs. Per record review, a new facility Consultant RD assessed R6 on 4/13/00 and assessed R6's IBW to be 106 - 129 lbs. and stated that R6 weighed 107 lbs. The RD stated, "Currently within idea body weight". Per hospital progress notes of 4/25/00, the hospital RD identified R6 to be at 81% of his IBW. Hospital Seizure form of 5/20/00 identified R6 as being "emaciated". Per surveyor observation of R6 in the hospital on 4/28/00, R6 was emaciated and below his IBW.
Per record review of physician order sheets, R6 had a doctor's order on 3/17/00 for "Jevity Plus at 78cc's per hour continuous for 23 hours". R6 was also receiving a mechanical soft diet with prune juice daily and unprocessed bran at breakfast. Per interview with the Dietary Manager on 4/28/00 at approximately 11A.M., R6 had poor food intake. Per March 2000 food intake record, R6's food intake was documented for only 25 of the 93 meals served in March. Of these 25 meals, 7 meals recorded "0" intake on March 1, 12, 25, 28, 29 and 30. 1 meal recorded 100% intake on March 14. 13 meals documented R6 ate less than 25% on March 3, 4, 7, 14, 16, 17, 18, 19, 20, 27 and 30. The facility was unable to provide surveyor with April food intake records for R6. Per interview with E14 (corporate nurse) on the morning of 5/9/00, "We have looked everywhere for (R6's) April food intake records. We can't find any. I'm not sure there even is one." Per interview with the Dietary Manager on 4/28/00 at approximately 11A.M., R6 had poor food intake. Tube feeding order was changed on 4/18/00 per RD (Registered Dietitian) recommendation to "Shut off Tube feeding 1 hour around meal to attempt to increase oral intake". R6 had a physician's order of 3/30/00 to increase G-tube water flush to 200cc's of water per shift.
Per physician's order, R6 should have received 1794 cc's of Jevity Plus per day up to 4/18/00 and 1638 cc's on 4/18/00 and 4/19/00. Per April MAR, there is no documentation of tube feeding intake for 4/1/00. 12 of 18 days recorded in April (April, 2, 4, 5, 6, 7, 10, 11, 12, 13, 15, 16 and 17) revealed that R6 received less tube feeding than ordered by the physician. 4 of these days (April 5, 7, 10 and 17) indicated that R6 received less than 600cc's of feeding per day. Facility also gave surveyor "Enteral Feeding Record" form that showed documentation of tube feeding intake and water flushes per shift. This form was documented on from 4/1/00 thru 4/7/00. The documentation of tube feeding intake and water flushes on this form conflicted with information documented by staff on the MAR.
Per interview with E2 (Acting DON) on 5/9/00 at 4:30P.M., "If I were a Surveyor, I would go by the information on the MAR. It's probably more accurate."
Record review revealed that R6 was admitted to the hospital at 1435 on 4/20/00 and remained in the hospital on 4/21/00. Yet, facility Nurse's notes on 4/21/00 state, "(R6) in bed, G. Tube feeding infusing well, flush as ordered given."
Z3's (physician) Hospital Progress notes of 4/20/00 states that R6 was admitted to the hospital with seizures, decreased responsiveness, dehydration, fever, possible urosepsis, hypernatremia secondary to dehydration, probable candidal skin infection and multiple pressure ulcers.
Hospital labs of 4/20/00 reveal, decreased hemoglobin at 9.9 gm/dl (normal 13-18), hematocrit of 30.4% (normal 37-52), Prealbumin 16 mg/dl (normal 20-40), Albumin 2.6 (normal 3.4-4.9), calcium 7.4 mg/dl (normal 8.2-10). Labs of 4-20 revealed an elevated sodium of 160 mmol/L (normal 136-148), chloride at 129 mmol/L (normal 98-110), Osmolality Calculated at 333 mosm/Kg (normal 262-286) and BUN (blood urea nitrogen) of 55 mg/dl (normal 10-25) with creatinine within normal limits at .9 mg/dl.
Urine culture of 4/21/00 confirmed UTI.
Z6's (physician) progress notes of 4/21/00 state, " Acute presenting problems:
1) Severely dehydrated - Na (sodium) 160 hyperosmolor free water depleted by approximately 5 Liters
2) Seizures likely secondary to hyperosmolarity and sepsis
3) Sepsis/ UTI "
Per record review of physician's order sheets for April, R6 had a doctor's order for vital signs every day. Per interview with E4 (LPN) on 5/2/00 at approximately 11:50A.M., daily vitals are documented on the "medication administration records" Per interview with E2 (Acting Director of Nursing) on 5/2/00 at approximately 6:00P.M., E2 confirmed that daily vital signs should be documented on the MAR and if they were not documented on the MAR they would be on the nurse's progress notes. Per review of the MAR and nurse's notes from 4/1/00 thru 4/20/00, R6's vital signs were not documented for 13 of the 20 days April 2, 4, 6, 7, 11, 12, 13, 14, 15, 16, 17, 18 and 19). Per interview with E17 (LPN) on 5/9/00 at approximately 3:50P.M., E17 stated she did care for R6 when he was in the facility. E17 stated R6 had "routine vitals once a month." E17 stated that vitals would be done more often if R6 showed a decline in condition.
Per interview with E2 (Acting DON) and E14 (Corporate RN), on 5/9/00 at approximately 6P.M., facility has not been able to find daily vital sign documentation for R6. Both E2 and E14 stated that they felt that vitals were done, but just not documented.
Per interview with E9 (CNA) at 11:30P.M., "(R6's)vital signs were done at least every other day and sometimes daily. It would be documented on the "Daily Unit Management" record if CNA's took vitals on (R6)."
Review of R6's "Daily Unit Management" records that were provided to the surveyor by the facility on 5/10/00 indicated that vitals were not documented on April 1, 2, 4 (no temperature documented), 5,6,8,12,13,14,17,18 (temperature elevated at 99.2 - no other vitals documented) and 19.
Per record review, R6 had a supra pubic catheter. Per records provided to the surveyor on 5/2/00, facility recorded R6's April urine output on 3 different forms. Urine output was documented on the treatment records, intake and output worksheets and the enteral feeding record, however, the output recorded on these forms is not consistent. For example, April 10th Urine output for 11-7 shift is recorded as being 300 cc's on the intake and output work sheet, but is recorded on the treatment record as 10-6 shift with output of 400 cc's. On 4/16/00 it is recorded on treatment record that R6 had "0" urine output on the 6-2 shift and only 700cc's output for the day. There are no nurse's notes that indicate that R6's physician was notified of no urine output for 1 shift and only 700cc's for 24 hours.
Review of "Daily Unit Management" form of 4/16/00 ( 6-2 shift) provided by the facility on 5/10/00 states under catheter output, "(R6) 0 - leaking".
Review of MAR "Catheter Output" documentation indicates that R6 had output of 950 cc's on 4/6/00, 600cc's on 4/14/00, 675 cc's on 4/15/00 and 625 cc's on 4/16/00.
Per record review, there is no documentation in R6's medical record that licensed staff assessed R6's low urine output. Review of R6's medical record reveals that there are no nurse's notes for R6 on April 6, 14, 15 and 16.
Interview with E2 ( Acting DON ) on 5/9/00 at approximately 4:30P.M., E2 stated that as far as she could tell, R6's physician was not contacted of low urine output.
Per hospital record review, R6 was admitted to the hospital on 4/20/00 with dehydration, hypernatremia, seizures due to dehydration, UTI and sepsis.
Per record review of March and April Physician Order sheets, R6 has a doctor's order, "Please keep careful record of BM's."
Per interview with Z2 (Physician Assistant) on 4/28/00 at approximately 10A.M., R6 has a history of constipation.
Per record review of R6's BM sheets, there were no BM's documented in March. April BM records indicated a large BM on the 3rd and medium on the 5th with no BM's documented after the 5th. Per record review, there is no documentation of BM's in nurse's notes.
Per interview with licensed nurse on 5/2/00, residents' BM's are documented on the BM record sheets and kept in the BM Book.
Per interview with E2 (Acting DON on 5/9/00, at approximately 5:30P.M., E2 was unable to provide surveyor with any more documentation of R6's BM's. E2 stated, "(R6) must have had a BM after 4/5/00 or he would have been hospitalized with a fecal impaction." E2 stated R6 had frequent BM's due to being a tube feeder. E2 stated it was important to monitor R6 for diarrhea since he received a tube feeding.
Per record review of facility 4/18/00 "Skin Record" for pressure areas, the facility identifies R6 as having a stage 3 pressure area (admitted to the facility with) on the right hip measuring 1.5 x 1.5 x .5 cm. (centimeters). Skin record of 4/11/00 identifies area as being 1.5 x 1.0 x .5 cm. This would indicate that the pressure area on the right hip had increased in size.
4/18/00 skin record identifies 4 more pressure areas that were acquired in the facility. These are as follows: Right outer foot .3 x .4 cm Stage 2. Right inner foot .3 x .3 cm Stage 2. Right inner ankle 1.0 x 1.0 cm Stage 2. Left outer foot .8 x .5 cm Stage 2.
Facility nurse's notes of 4/7/00 at 0300 state, "Foul smelling, pustular, blood tinged drainage from site of right side hip decubitus ulcer." There is no documentation that physician was notified of foul smelling drainage.
Per interview with Z8 (Hospital admitting RN), on 4/28/00 at 2:40P.M., Z8 stated, the pressure sore on the right hip had a foul smelling serous drainage with a duoderm over the area.
Z7's (Physician) progress note of 4/21/00 states "Plastics... Grade 2-3 ulcers on lateral and medial aspect of both feet..Grade 1 ulcer over left hip...Grade 3, 3 x 2 cm ulcer over right hip...Should likely heal with dressing changes and pressure relief."
Per review of facility inservice records dated March 7, Inservice Records state, in part, "State Monitor Review Results" Monday, March 6, 2000 revealed that at 7:30 AM, R6 had BM on pad and no care was done until 9:15A.M..
R6's care plan of 4/10/00 states, "Oral hygiene 1 x day Caregiver: Nursing." Care plan note of 4/19/00 states, "Resident does not like to have oral care complete. Reapproach as needed to complete." Per interview with Z2 (Physician Assistant) on 4/28/00 at 10A.M., Z2 stated that R6's oral care was bad and that the last time she visited she asked a CNA to do oral care. Per facility Physician Progress Notes, Z2 documented, "Oral tissues dry - (spoke with CNA to try more frequent oral care)".
Per interview with Z8 (Hospital RN) on 4/28/00, R6 was admitted to the hospital with poor oral hygiene and sores in his mouth.
Per R6's care plan of 4/6/00, "Shampoo shower/bath 1 x week. Fingernails and toe-nails cleaned and checked." Per interview with E2 (Facility Acting DON) on 5/2/00 at approximately 2P.M., E2 stated that all residents are to receive a shower 1 time a week and a bed bath daily.
Per interview with E5( LPN) on 5/9/00 at approximately 5:30P.M., R6 had not been receiving a weekly shower for the past 2 months due to declining condition. E5 (LPN) stated that R6 would get a daily bed bath. E2 (Acting DON) stated that it was difficult to put R6 on the wheelchair and take into the shower due to contractures. E2 stated there was also the problem with MRSA. The facility provided surveyor on 5/10/00 with " Daily Unit Management" forms for April that documented R6 had a shower on April 4, 2000. E2 also provided surveyor on 5/10/00 with "Shower/Bath Day Skin Audits" form for April 4 and 10 and stated this is proof that R6 had a shower on these days. Per interview with E9 on 5/10/00 at approximately 11:15A.M., "(R6) was given shower probably every 2 weeks until (R6) was put on complete bedrest."
Per interview with Z8 (Hospital admitting RN) on 4/28/00 at 2:40P.M., Z8 stated, "(R6) was very dirty when admitted to the hospital. (R6) had thick debris caked under his fingernails. (R6) had a layer of dry oily matter on his skin that looked like cradle cap. He had a terrible odor. It took 2 days to get the smell off him. Another nurse and I washed him when he came in to the hospital. We spent about 1 1/2 hours cleaning him up. His hair was matted when he arrived. (R6) got 2 more baths the next day and by the 3rd day bath, the film on his skin was gone. When (R6) was admitted to the hospital he looked like he hadn't had a bath in 2 weeks. (R6) looked like someone put him in a hole and left him there."
Z6 (physician) confirmed in hospital progress notes of 4/21/00 that R6 had very dry skin and poor hygiene.
Z5 (physician) also wrote a progress note on 4/21/00 stating that R6's fingernails and ears were dirty.
Per review of hospital physician's order sheet of 4/20/00, Z5 (physician) stated that R6's condition was guarded.
Hospital progress note of 4/20/00 states, "(R6) was dehydrated by labs and had a fever of 101.3 by report. (R6) also has significant mental status changes and by report he is usually vocal and can speak fairly clearly. Presently (R6) is not verbally responsive."
Per record review, Z3 (Physician) wrote order on 4/22/00, "Notify Social Services to contact Nursing Home Hotline regarding neglectful condition (R6) arrived in."
Per record review, Z4 (Physician) progress note of 4/23/00 states, "(R6) had signs of physical neglect."
Per record review, Z3 (physician) progress note of 4/23/00 states, "Dehydration,urosepsis, hypernatremia much improved after rehydration...Mental status - much improved."
Per interview with Z3 (Physician) on 5/4/00 at approximately 6P.M., Z3 stated that R6 did not have any underlying medical condition that would cause weight loss and dehydration. Z3 stated that you would not expect R6 to have weight loss and dehydration when R6 is receiving tube feeding. Z3 stated that R6 was severely dehydrated when admitted to the hospital causing sodium blood level of 160 which probably caused seizures. Z3 stated, "If (R6) hadn't gotten attention, he probably would have died. (R6) was definitely a case of neglect."
Per interview with Z4 on 5/10/00 at 3:30P.M., Z4 stated, "There was no underlying medical condition that would cause (R6) to be in the condition he was when he was admitted to the hospital. No medical condition other than neglect. If (R6) had adequate care, hydration and tube feeding he would not have developed pressure sores, dehydration, had weight loss or been filthy. It appears he was put into a corner and neglected."
Interview with E4 (facility LPN - Licensed Practical Nurse), on 5/2/00 at 11:45A.M., revealed tube feeding intake is documented on the MAR each shift. E4 stated that licensed staff check the feeding pump at about 30 minutes before end of shift and document volume fed on the MAR. Record indicates that R6 received 625 cc's of formula on 4/6/00. Facility also had "Enteral Feeding Record" form that had tube feeding intake documented from April 1 thru April 7, 2000. The information recorded on this form conflicts with the information on the MAR.
Per record review of facility "Monthly Record of Vital Signs and Weights" form, R6 weighed 134 lbs on 1/2/00 and was down to 107.5 lbs. on 4/2/00. April MAR states R6's weight was down to 106 lbs on 4/19/00. This is a significant unplanned weight loss of 28.75 lbs. in 3 months.
Per record review, facility Dietitian reports give conflicting information as to R6's IBW (ideal body weight). Facility Dietitian assessment of 10/20/99 identifies R6's IBW (ideal body weight) as being 122-150 lbs. Per record review, a new Facility Dietitian assessed R6 on 4/13/00 stating that R6's IBW is 106 to 129 lbs. and that R6 was within IBW. Surveyor observation of R6 at the hospital on 4/28/00 revealed that R6 was emaciated and below his IBW. The hospital Dietitian states in progress note of 4/25/00 that R6 is at 81% of his IBW and had gained 4 lbs since admission to facility on 4/20/00.
Per hospital record review, R6 was admitted to the hospital on 4/20/00 with a final diagnosis that included urosepsis, hypernatremia, dehydration with seizures, and multiple pressure sores.
Hospital labs of 4/20/00 reveal, decreased hemoglobin at 9.9 gm/dl (normal 13-18), hematacrit of 30.4% (normal 37-52), Prealbumin 16 mg/dl (normal 20-40), Albumin of 2.6 mg/dl (normal 3.4-4.9), Calcium 7.4 mg/dl (normal 8.2-10). Labs of 4/20/00 revealed elevated Sodium of 160 mmol/L (normal 136-148), chloride at 129 mmol/L (normal 98-110), Osmolality Calculated at 333 mosm/Kg (normal 262-286) and Blood Urea Nitrogen of 55 mg/dl (normal 10-25) with Creatinine within normal limits at .9 mg/dl.
Per hospital dietitian progress note of 4/25/00, "(R6's) nutrition status continues to appear compromised per low albumin, low pre albumin."
2. Per record review of physician's order sheet, R3 is a 72 year old male admitted to the facility on 4/17/00. Per record, R3 had an admitting diagnosis of Aphasia, CVA (Cardio vascular accident) and cancer of the brain. R3 has a supra pubic catheter and (MRSA) Methicillin Resistant Staph Aureous of the urine.
Per record review, R3 has a physician order of 4/17/00 for Nutren 1.0 with Fiber at 85 cc's per hour per feeding pump. R3 has a doctor's order of 4/26/00, "May discontinue tube feeding when wife wants to take him outside or push him."
Per physician's order, R3 should receive approximately 2040 cc's of Nutren 1.0 in 24 hour. Per review of April MAR, there is no documentation of 4/17/00 tube feeding intake. 9 of the 13 days documented in April (April 19, 20, 21, 23, 26, 27, 28, 29 and 30) revealed that R3 received less tube feeding than physician ordered.
Per observation on 4/28/00 at approximately 9:20A.M., R3 had approximately 1200cc's of Nutren in tube feeding bag. The 1500cc feeding bag was labeled as being hung on 4/28/00 at 4:30A.M.. This would indicate that approximately 300cc's of formula infused in approximately 4 hours and 50 minutes. At 85 cc's per hour R3 should have received approximately 411 cc's. This indicates that R3 received over 100 calories less than ordered in 4 hours and 50 minutes.
Per observation on 5/1/00 at 8:30A.M., R3's tube feeding bag was labeled with hang date of 4/30/00 and hang time of 1900 (7P.M.). At 2:20P.M. there was approximately 90cc's of feeding in bag. This would indicate that feeding was behind approximately 243 cc's in 19 hours and 20 minutes.
Per observation on 5/2/00 at approximately 11:15A.M., R3's tube feeding was disconnected and R3's wife was taking R3 outside. Per observation the tube feeding was not reconnected until approximately 12:55P.M.. R3's wife was observed to reconnect the tube feeding. Per interview with R3's wife, the facility nurses taught her how to disconnect and reconnect the feeding pump. Per interview with E2 (acting DON ) on 5/2/00, there is no tracking system of how much time R3's feeding pump is disconnected.
Per record review, R3 weighed 142 lbs when admitted to the facility on 4/17/00. The surveyor asked that R3 be weighed on 5/1/00. Weight was obtained and recorded as 130.5 lbs. R3 had a significant weight loss of 11.5 lbs in 2 weeks.
Per record review, Z10 (Facility Medical Director) wrote a progress note on 5/3/00 stating in part, "(R3) has not lost weight by my estimate and wife estimate...No such thing as weight loss 12 lb. Scale wrong." Per interview with E18 (corporate regional vice president), E1 (Acting Administrator), E2 (Acting DON) and E14 (corporate nurse), on 5/4/00 at approximately 3:45P.M., the scales had been recalibrated that day and there hadn't been a problem with the scales after all. Per interview, the chair scale had been 1.5 lbs off and the hoyer scale was perfect.
Per Nutritional Assessment of 4/19/00, R3 is 6'0" with an IBW of 160 - 196 lbs. Per dietitian note, R3's nutritional needs are estimated at 1980.1 calories, 71 gm of protein and 1936.4 cc's of fluid per day. Per note, R3's tube feeding provides: 1955 calories, 78.2 grams (gm) protein and 2214 cc's of fluid a day. Per observation on 4/28/00, 5/1/00 and 5/2/00, R3 received less calories, protein and fluid than ordered by the physician and the amount of formula that is needed to meet R3's nutritional needs.
Per physician order of 5/5/00, R3's tube feeding formula was changed from Nutren 1.0 at 85cc's per hour to Jevity Plus at 85cc's per hour. Jevity Plus has more calories and protein per cc than Nutren 1.0.
Per observation on 5/1/00 at 2:32P.M., R3 was observed to be lying in bed with tube feeding running. E19 was observed to ask R3 if he wanted his head of bed elevated. E19 left the room without raising R3's head of bed.
Per review of facility policy and procedure for tube feeding dated 4/96, "Elevate head of resident to prevent possible aspiration and facilitate digestion."
Per record review, R3 did not have any pressure sores when admitted to the facility. Per surveyor observation on the morning of 5/1/00, R3 had 5 small stage 2 pressure sores on his left buttock.
Per observation on 5/4/00, R3's feeding pump alarm was going off at approximately 2:50P.M. until 3P.M. when surveyor informed E12 (LPN). Per observation, R3 had tubing tangled around his arms and legs which was restricting the flow of the feeding. R3's room is right next to the nurse's station and a nurse was observed to be sitting at the desk, yet the nurse did not get up to check the alarmed feeding pump.
Per review of 5/4/00 "G-tube feeding 24 hour monitoring tool" there is no documentation of R3 getting tangled in tubing and tube feeding being off from 2:50P.M. to 3P.M..
3. Per record review of physician order sheets, R1 is a 91 year old female with a diagnosis that includes MRSA, history of Dehydration, Urosepsis and has a Peg tube. R1 was readmitted to the facility from the hospital on 4/24/00. R1 has a physician order of 4/24/00 Tube feeding per G tube of Nutren 1.0 full strength at 60 cc's per hour full strength and a 200cc water flush each shift and 50cc's every 4 hours. Per review of facility April MAR, there is no documentation that R1's G-tube is being flushed with 50cc's of water every 4 hours as ordered by the physician. Per interview with E14 (Corporate RN) on 5/11/00 at 8A.M., R1 was not receiving the 50 cc water flush every 4 hours as ordered. R1's physician was contacted on 5/3/00 by facility to get tube feeding order verified and 50 cc water flush was discontinued by the physician.
Per surveyor observation on 5/1/00 at 8:20A.M., R1's tube feeding of Nutren 1.0 was infusing at 60 cc's per hour and there was approximately 1500 cc's of formula in the 1500cc bag. The bag was labeled as being hung at 7:45 A.M. on 5/1/00. Per observation of the previously hung bag that was in R1's garbage can, that bag was labeled with a hang date of 4/30/00 and hang time of 0030 (12:30A.M.). There was approximately 100 cc's of formula left in the bag. This indicates that approximately 1400 cc's of Nutren 1.0 infused in 31 hours and 15 minutes. Per physician's order R1 should have received 1875 cc's of Nutren 1.0 in 31 hours and 15 minutes. R1 received approximately 475 calories and 19 grams of Protein less than what the physician ordered in 31 hours and 15 minutes.
Per physician's order, R1 should receive approximately 1440 cc's of Nutren 1.0 in 24 hours. Per review of the April MAR, 3 of the 5 days documented in April indicate R1 received less formula than ordered. Per the MAR, R1 received 1069 cc's of formula on 4/26/00, 983 cc's of formula on 4/28/00, and 947 cc's on 4/30/00. This resulted in R1 receiving less calories, protein and fluid than ordered by the physician.
Per surveyor observation on 5/1/00, R1 did not have any pressure sores. Per facility 5/5/00 skin assessment form, R1 had obtained 2 newly developed pressure sores, stage 2 one on the left and one on the right buttock.
4. Per record review of physician order sheet, R2 is a 49 year old female with a diagnosis that includes in part, Spastic Quadraparesis, Stage 3 decubitus on coccyx, history of dehydration, obesity and urosepsis.
Per April physician order sheet, R2 has a tube feeding order for Promote with Fiber at 70 cc per hour per G-tube and a 200 cc water flush every 4 hours.
Per observation on 5/1/00 at 8A.M., R2's 1000 cc tube feeding bottle was labeled Promote with fiber, hang date of 5/1/00 and hang time of 6A.M.. Tube feeding bottle appeared to be full -slightly below 1000cc's. Surveyor checked the pump for volume infused and volume infused was 37 cc's. Volume infused should have been approximately 140 cc's. The feeding was behind over 100 cc's of formula in 2 hours. R2 was lying flat in bed and had a deep wet cough and coughed several times.
Per review of RD (registered dietitian) note of 4/13/00, R2's Tube feeding is calculated on 23 hours per day and provides approximately 1610 cc's of formula, 1610 calories and 100.6 gram of protein per day.
Per review of R2's April MAR, it was documented that there were 11 of 30 days when R2 received less than 1400 cc's of Promote with fiber a day. (April 3, 5, 6, 10, 11, 15, 16, 17, 24, 27 and 29). April 11 documentation indicated that R2 received only 510 cc's. On April 7, 2000, there was no documentation of amount of tube feeding R2 received that day.
Per facility weight records, R2 is 5'8" tall and weighed 176.5 lbs on 1/5/00. Weight of 4/4/00 was 167 lbs. RD assessment of 3/29/00 states that R2's IBW is 139 - 161 lbs. The same RD's assessed R2's IBW as being 126 -154 lbs on 4/13/00, but does not state why the IBW was changed. The RD states tube feeding provides approximately 83% of needed calories for R2.
The facility failed to have a monitoring system in place to ensure that R2 receive amount of tube feeding as ordered by the physician. The facility failed to ensure that R2's head of bed was elevated when being tube fed.
5. Per record review of physician order sheet, R5 is a 37 year old male with a diagnosis in part, of MVA (motor vehicle accident) with closed head injury, right sided hemiplegia, Diabetes Mellitus, and a history of pneumonia and septicemia.
Per record review, R5 had a physician order for Jevity plus at 76 cc's per hour. Tube feeding was changed on 5/4/00 from continuous to being on at 6P.M. and off at 6A.M..
Per observation on 5/1/00 at 2P.M., R5 was receiving tube feeding of Jevity Plus at 76 cc's per hour. Feeding bag was labeled with a hang date of 4/30/00 and hang time of 1800 (6P.M.). The feeding bag was a 1500 cc bag with approximately 150 cc's left in bag. Tube feeding had infused for approximately 20 hours. R5 should have received approximately 1520 cc's of formula in 20 hours, but received 1350 cc's. R5 received 170 cc's of formula less than physician ordered for this 20 hour period.
On 5/2/00, R5's tube feeding bag and tubing was observed to be empty. Per observation , E8 (RN) changed R5's feeding bag. E8 used the same tubing from the previous bag. Per facility policy and procedure on tube feedings dated 4/96, "Each day a new asepto syringe and feeding administration set will be utilized and date." Also per "Enteral Nutrition Handbook" put out by Ross the manufacturer of Jevity and tubing used by the facility, the entire tube feeding system including tubing should be changed every 24 hours.
Per observation, E8 did not aspirate for stomach contents or check for tube placement before starting new tube feeding as per facility policy and procedure. Also, per surveyor observation, R5's tube feeding site had a thick dried brownish green drainage at the tube site. E8 stated the site needed to be cleaned.
Per review of April MAR, the MAR is incomplete as to how much tube feeding that R5 received per day. Per interview with E2 (acting DON) on 4/28/00 at 4:30P.M., E2 confirmed that there was no tube feeding monitoring system in place to ensure that staff documented amount of tube feeding intake per shift and calculated how much feeding per day residents received.
6. Per closed record review, R8 was a 78 year old who received a tube feeding of Nutren 1.0 With fiber at 70cc's per hour. R8 should have been getting approximately 1680 cc's of formula per day.
Per review of November "Enteral Feeding Record" staff were not consistent in documenting the amount of feeding infused each shift. For example, per review of feeding records from November 9 thru November 24, records were incomplete for 3 of the 15 days reviewed. On November 13 and 14 staff fill in their initials not amount of feeding infused. On November 23 staff did not document how much feeding received on the 3-11 shift.
Per form review, a 24 hour total intake should be documented. This was not done for any of the 15 days reviewed.
Facility failed to have a monitoring system in place to ensure that R8 received tube feeding as ordered by the physician.