"A" VIOLATION(S):

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.

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 resident’s medical record.

AN OWNER, LICENSEE, ADMINISTRATOR,EMPLOYEE OR AGENT OF FACILITY

SHALL NOT ABUSE OR NEGLECT A RESIDENT.

These REQUIREMENTS are not met as evidenced by:

Based on review of the clinical record, review of the ambulance record, review of the hospital record and interviews, the facility neglected R#3 as evidenced by the facility’s failure to assess, monitor, document and intervene in the declining nutritional and hydration status which resulted in hospitalization with diagnoses that included severe dehydration, sepsis, and ultimately respiratory failure.

Findings include:

1) According to the clinical record and interviews of E#1, E#2, E#4, E#6, Z#1 and Z#6, R#3 is a 45 year old resident with a diagnosis of Huntington’s Chorea. She has resided at this facility since 1/15/01. As of 12/01 the resident was described as very active, walked with an unsteady gait, was alert and verbal though difficult to understand at times, and partially fed herself with staff assistance.

2) On interview on 1/12/02, Z#1 (the resident’s physician) stated that in the past year R#3 had

stopped eating and drinking and required a gastrostomy tube (G-tube) to ensure adequate nutrition and hydration. He further stated that there was no organic reason for the G-tube; the tube was necessary for nutrition and hydration. On 11/24/01 R#3 pulled out the G-tube and Z#1 decided that since she was eating and drinking at the time, that he would leave the tube out as long as she was eating and drinking.

3) R#3 stopped eating and drinking on 1/3/02. This was confirmed by interviews of E#8 and E#9

on 1/10/02 and by E#5 on 1/16/02. In addition, the nurses’ note dated 1/3/02 for the PM shift stated that R#3 was not eating. The nurses’ note dated 1/4/02 (Friday) stated that R#3 was not eating or drinking and that the staff would get back to the family on Monday (1/7/02) regarding possible placement of a G-tube. A screening dated 1/3/02 and signed by E#4 recommended that the physician of R#3 be notified to consider alternative forms of nutrition. There was no attempt to provide hydration by an alternative method until 1/7/02 when E#7 attempted to start an I.V. On interview, on 1/10/02 E#7 stated that both attempts were unsuccessful because R#3's “veins collapsed”.

In addition, there was a decline in the general condition of R#3 as stated in the interviews of E#8

and E#9. Interview of E#8, a CNA who had taken care of R#3, on 1/10/02 revealed that the resident used to be more active, but in the last week she wasn’t doing anything. She indicated that she did report this to the nurse, but was unsure of which nurse she told. According to E#8, the resident stayed in bed all day on Saturday (1/5/02) and Sunday (1/6/02)

On interview E#8, stated that she had noticed a change in the resident, that R#3 had stopped eating “about 1 week ago.” When asked how she had changed, E#8 stated that R#3 used to move around and then she just laid in bed. She further stated that R#3 didn’t eat or drink or do anything for about 1 week.

She stated that on the weekend (1/5-1/6) they just cleaned her up and left her in bed.

On interview on 1/10/02, E#9, a CNA who had taken care of R#3 between 1/3/02 and 1/7/02, stated that she had noted that the disease was getting worse. She further stated that the resident’s movements (uncontrollable) were getting worse and that standing was too difficult for her. She also stated that she had been assigned to R#3 during the week prior to 1/5/02 and that the resident did not eat breakfast or lunch. E#9 stated that she told the nurse, but does not know the nurse’s name.

There was no documentation in R#3's clinical record to indicate that the resident’s condition was

being monitored. There was no nutritional assessment done between 1/3/02 when the resident

stopped eating and drinking and 1/7/02 when R#3 was hospitalized. There was no attempt at

alternative methods of hydration between 1/3/02 and 1/7/02. According to the facility records, R#3's weight in January 2002 was 115#; on admission to the hospital on 1/7/02 R#3's weight was 90#. This represents a 25# weight loss in 1 week.

On interview, Z#1 stated that he was not notified of R#3's change in condition until the day that

she was sent to the hospital (1/7/02). He further stated that if he had been aware of the extent of her condition that he would have started an I.V. sooner and he would have sent her for a G-tube insertion. When asked if R#3's dehydration was related to her diagnosis of Huntington’s Chorea he stated that Huntington’s Chorea was a progressive and debilitating disease, but it was not a cause for dehydration.

On interview, Z#6 (family member) stated that she had not been notified of R#3's change in condition until the day that she was sent to the hospital (1/7/02).

4) R#3 was transported to the hospital on 1/7/02 at 9:09 p.m. by ambulance. On interview on 1/11/02, Z#3 and Z#4 (the paramedics) stated that when they arrived on the unit they waited 10 minutes for the nurse to give them report, but she remained talking on the phone. They further stated that at that point they decided to prepare R#3 for transport and get the paper work on the way out.

The initial assessment of the resident at the facility by Z#3 and Z#4 described R#3 as being unresponsive except to sternal rub (she responded by opening her eyes), her skin was cold and clammy, her upper and lower extremities were mottled and she was “in obvious distress”. Her pulse was 128, her respirations were 36 and shallow and they were not able to obtain a blood pressure, “even with palpation.” Due to the status of the resident, the paramedics decided to divert her to the nearest hospital.

Z#6 was present at the facility at the time that R#3 was sent to the hospital. On interview, Z#3, Z#4 and Z#6 stated that while the paramedics were in the process of preparing the resident for transport, E#6 stated, “I don’t know why everybody’s panicking?” At the time this statement was made, R#3 had no palpable blood pressure, her pulse was 128 and she was unresponsive except to pain. Z#3 and Z#4 stated that after they had prepared the resident for transport they had to wait for E#6 to give them the appropriate paper work for the transfer.

5) At the time of admission to the emergency room, the nurse documented at 9:25p.m. that R#3

was reported to have had no oral intake for 5 days. According to the emergency room record, on arrival at the hospital, R#3 was unresponsive, her skin was cold, mottled and moist, her respirations were 34 and labored. R#3's blood pressure was 86/61. They infused 1 liter of I.V. fluid, running it wide open. 45 minutes later, documentation indicated that the resident was responsive, able to follow the sound of a voice and seemed to recognize her niece.

The laboratory values from the emergency room included a Blood/Urea/Nitrogen(BUN) of 134

(normal is 7-18), a sodium of 175 (normal 136-145), a chloride of 132 (normal 98-107) and a

creatinine of 4.0 (normal 0.6-1.0). The note written by the medical resident on call (dated 1/9/02)

documented that R#3 had “severe dehydration”.

On interview 1/14/02 Z#2, the emergency room physician who treated R#3 confirmed that the

resident’s condition was due to dehydration and that the lab values supported that diagnosis. He also stated that something should have been done sooner.

According to the progress notes, on 1/8/02 R#3 became unresponsive and was diagnosed with

Respiratory failure due to a decrease in oxygen saturation to 36%. She was intubated and placed on a ventilator to maintain her oxygen level.

The medical resident on call wrote a note on 1/9/02 at 1:00a.m. documenting the resident’s problems as respiratory failure, severe dehydration/hypernatremia and sepsis.

As of 1/15/02, R#3 remained in the Cardiac Care Unit on a ventilator for assisted breathing.