DADRIAN CONVALESCENT CENTER
Facility I.D. Number: 0016147
Date of Survey: 07/12/02
The facility shall notify the residents physician of any accident, injury or significant change in a residents 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 physicians 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 residents 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 residents condition as a means for analyzing and determining care required and the need for further medical evaluation and treatment are made by nursing staff and recorded in the residents medical record.
AN OWNER, LICENSEE, ADMINISTRATOR, EMPLOYEE OR AGENT OF A FACILITY SHALL NOT NEGLECT A RESIDENT.
These regulations are not met as evidenced by:
Based on record review and interviews, the facility neglected to provide necessary care and services for one of seven residents (R3). The facility failed to promptly notify the physician of abnormal lab results indicating an infection, and R3's continuing deterioration from 6/21/02 until 6/23/02. R3 was hospitalized and died on 6/23/02.
1.) R3 was an 87 year old with partial diagnoses (from June, 2002 Physician's Order Sheets) of: Chronic Anemia, Anxiety, Peripheral Vascular Disease, Cerebral Vascular Accident, Dementia, Carcinoma of Left Breast, and Osteoporosis. R3's most recent assessment was dated 6/17/02. R3 was assessed as being independent for all activities of daily living, able to take care of herself with only minimal staff supervision for dressing, eating, and personal hygiene. She was continent of bowel and bladder and able to use the toilet independently. She was able to leave the facility for doctor's appointments with minimal supervision.
On 6/13/02, R3's Nurses Notes documented, "Res. has discharge to vaginal area. (Z1) (resident's physician) here at facility, left orders for Metrogel Vaginal Cream bid (twice daily) x 7 days for dx (diagnosis): Vaginitis." Review of the MAR (medication administration record) shows this medication was administered from 6/14/02 until 6/21/02.
Documentation in R3's Nurses Notes, dated 6/19/02, at 5 PM, reports R3 "not feeling well. Hands trembling. Refused to eat supper". Vital signs were documented in the Nurses Notes "110/74, 112, 20, 98.7, Sats 93%." There is no documentation of physician notification or interventions for the low O2 saturation of 93%. The following day, 6/20/02, at 1:50 PM, the Nurses Notes state, "Resident very weak, unable to get out of bed in A.M., had incontinence episode of stool....refused to go to the D.R. (dining room) for meals, refused any food at breakfast and lunch. Dr. ... here at facility...saw res. gave orders for lab." There is no documentation of vital signs being obtained to fully assess R3. The physician's orders for 6/20/02 read: "CBC, Chem 13, Free T4, TSH level, B12 level. Dx (diagnosis): Generalized weakness, weight-loss." There is no documentation in the chart showing when the blood was drawn but laboratory results dated 6/21/02 were on the chart.
The results of the CBC with differential are dated 6/21/02, at 5:05PM. These results were faxed to the facility on 6/21/02, at 5:30 PM., and showed abnormal results of elevated white blood count of 15.1 (normal results 4.8 - 10.8), which indicates the presence of an infection. The red blood count was low at 3.59 (4.2 - 5.4 normal), hemoglobin was low at 11.0 (12.0 - 16.0), and hematocrit was low at 33 (normal is 37 - 47). The blood chemistry also had abnormal results of low bicarbonate 19.2 (normal 22 - 29), high anion gap 21.4 (10 - 20), high glucose 120 (70 - 105), and elevated urea nitrogen at 34 (normal 6 - 20). There is no documentation of physician notification of the abnormal laboratory results.
On 6/21/02, at 10:50 AM, the Nurses Notes document "Res. refused all food and fluids, only sips of H20 with meds - res. is very weak - gait unsteady." There is no documentation of vital signs being obtained to asses this resident. The physician was not notified of R3's continuing deterioration on 6/21/02.
On 6/22/02, at 10:45 AM, the Nurses Notes state, "Res. refused to go to DR for breakfast.....Res. pale in color. VS (vital signs) 102/64, 100, 18..." This is the only documentation for 6/22/02. Vitals obtained on this date are documented in the Nurses Notes but do not include resident's temperature. The physician was not notified of R3's continuing refusal to eat and continuing deterioration on 6/22/02.
On 6/23/02, at 10:30 AM, the Nurses Notes state, "Went to assess resident since she has not been getting up and did not eat breakfast. Res. very pale and shaky - BP 100/70, Resp (respirations) 28, P (pulse) 180, T (temperature) 91.9 oral, SpO2 at 71% - O2 placed on res. at this time.....res. had frothy green colored sputum coming out of her mouth...". On 6/23/02, at 10:35 A.M., the physician and R3's family were notified of her condition change and the family requested that R3 be sent to the emergency room for evaluation. At 11:10 AM, R3 was taken by ambulance to an acute care hospital emergency room. At 1:58 PM, R3 died at the local hospital. The final documentation in the Nurses Notes is dated 6/23/02, at 2:20PM, and states: "(residents guardian) called & stated that resident passed away at 1:58 PM from sepsis from very bad urine infection."
Z1, the resident's physician, was interviewed by telephone on 7/3/02, at 12:05 PM. He verified that he was not informed of the elevated white blood count and other abnormal laboratory results received by the facility on 6/21/02. When asked what he would have done if he had been aware of the elevated WBC, he stated, "I would have started an antibiotic Friday night (6/21/02) if I had known." When he was asked if he was notified of R3's continuing deterioration and decreased food and fluid intake on 6/21/02, and 6/22/02, he stated he was the doctor on call that weekend and was not notified of R3's condition until Sunday, 6/23/02. He stated, "If I had known, I would have sent her to the hospital, depending on the family's wishes."
The DON was interviewed on 7/9/02, at 2:10 PM, in the conference room. She verified in the interview that the facility did not fax or telephone the physician with the abnormal laboratory results.
R3's hospital records were reviewed on 7/3/02. The emergency room notes stated, "Pt. was brought from Nursing Home with history of diff. breathing x 2 days and spitting up greenish phlegm....obvious dyspnea...decreased breath sounds ...crackles right lower lung field....abdoman distended, esp. lower abd. with tenderness". The physician's impression on admission is "Sepsis with pneumonia and UTI (urinary tract infection)". A chest x-ray was obtained, blood tests and urinalysis were obtained. Results of the CBC shows elevated WBC at 30.9 (4.8 - 10.8), RBC, Hct, and Hgb. all low. Blood chemistry results showed elevated glucose at 201 (70 - 105), elevated BUN at 76 (8-23), elevated creatinine 2.6 (0.6 - 1.3), elevated Na (sodium) at 151 (136 - 145), elevated Cl at 117 (100 - 110). The laboratory results indicate dehydration. The chest x-ray dated 6/23/02 results indicated a new large area of infiltrate, right lower lobe, compatible with pneumonia. The urine culture results on the speciman obtained 6/23/02 showed more than 100,000 col/ml of yeast in the urine.
The Nurse's Assessment Sheet from the emergency room dated 6/23/02, also notes R3's respirations as "labored with audible congestion. Color sallow, mottled legs. Lung sounds decreased. Nursing Home report noted decreased appetite a few days..coughing with green phlegm production....Abdoman distended & tender..pt. incontinent of lg (large ) amt. (amount) dark, strong-smelling urine.....Foley catheter inserted, drains dark brownish color urine with sediments - immediated return 1100 cc. Foley tube clamped...family at bedside." At 12:50 PM, the emergency room nurse documented, "BP decreasing - IV antibiotic started with IV fluids.." At 1:30 PM, the nurse documented gasping respirations at 2-3 respirations per minute. At 1:58 PM, the nurse documented "No respiration, no pulse, no BP.. Z1 (resident's physician) pronounces."