MERCY HEALTH CARE REHAB CENTER
Facility I.D. Number 0025940
Date of Survey:03/12/02
Notice of Violation:05/22/02
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, 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.
General nursing are shall include at a minimum the following and shall be practiced on a 24- hour, seven-day-a-week basis:
Objective observations of changes in a residents 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 medical record.
These REQUIREMENTS are not met as evidenced by:
Based on interview with Z2, Z3, E1, closed record review, review of advanced directives as well as policy and procedure for change of resident's condition/notification, the facility failed to provide timely assessment and emergency care to R5. There was no attempt to resuscitate R5 who did not have a DNR (Do Not Resuscitate) in place. The Medical Director was not notified of R5's condition after staff failed to reach R5's attending physician. R5 was never transported to a hospital even though there was a significant change in her condition starting at 1:00 PM on 02/17/02. Resident expired in the nursing home on 02/18/02 at 8:10 AM, which is a full 19 hours after R5's condition started to deteriorate.
Findings are as follows:
R5, is a 73 year old, admitted to the facility on 02/12/02 with diagnosis including hypertension, dehydration. R5 was alert, but confused, moving all extremities. Interview with Z2 per telephone on 03/07/02 at approximately 9:10 AM stated " I cannot believe R5 deteriorated in such a short period of time. There was no attempt to resuscitate, we did not give any DNR (do not resuscitate) instructions". Z2 continued "On 02/17/02 I requested the staff call an ambulance".
Closed record review revealed R5's condition progression as follows:
02/17/02 1:00pm "R5 more lethargic, not eating. fluids taken well. Family visiting, very concerned would like doctor to evaluate. Put on Dr. list. Left leg cool to touch and darker than other leg. B/P 120/80, p 76.
Interview with E1 on 3/7/02 regarding above documentation "put on Dr . list " E1 stated "that means the next time a doctor is here, he will be asked to see her".
02/17/02 5:00pm "R5 continues to be lethargic, B/P 100/70, p 72.
02/17/02 9PM "Responsive to verbal and tactile stimuli but still lethargic. Dilantin held d/t pt. not swallowing".
02/17/02 11:30Pm "more lethargic, however extremities cool to touch sole of both feet appears cyanotic nailbeds slightly cyanotic to both lower extremities. Pulse 53 B/P 100/78 shallow, labored respirations". Reported to supervisor. New order for O2 @ 2L/nc (nasal cannula) prn faxed to pharmacy".
02/18/02 12:30AM "continue lethargy".
02/18/02 2:00AM "B/P 100/68, p 68, O2 remains at 2L/nc".
02/18/02 4:00AM "Pulse ox continues 90-96%".
02/18/02 6:30AM "increasing difficulty with respirations 32, O2 @ 2L/nc. pulse O2 saturation down 87%, Supervisor notified of change in status. Reported to AM nurse, MD ( medical doctor) paged , awaiting return call endorse to AM nurse to get MD order to send to hospital for evaluation."
02/18/02 7:30AM "assessment of resident notes resp. 38, shallow, lower extremities cold to touch, toe nails blue in color. Does not respond to verbal or tactile stimulation. p 100, B/P 100/50 O2 per n/c @ 2l pulse ox 88 saturation. Dr. paged immediately waiting for return call".
02/18/02 7:45AM " still awaiting for return page from MD".
02/18/02 8:00AM "R5 continues to breath rapidly, comfort measures rendered. MD re-paged".
02/18/02 8:10AM "R5 with no resp, no pulse, no B/P. MD returned page. Per MD, R5 expired with diagnosis of HTN ( hypertension), dehydration and gastritis".
02/18/02 8:15AM " Family member Z2 notified will be here to view body ASAP".
02/18/02 9:30AM "Family here and very upset, asked to speak to E1".
Surveyor interviewed E1 on 03/07/02 in the conference room of the 1st floor regarding policy and procedure of significant change in resident's condition. E1 stated "If a resident has a significant change and staff cannot get hold of the attending, they know to call the Medical Director or send the resident to the hospital. Staff has had plenty of inservices on what to do for significant change." Surveyor reviewed R5's clinical record with E1 as above, E1 stated "I can't explain why they (staff ) didn't call the medical director or send the resident to the hospital as they should have. I can't answer for them. I wasn't here, I don't work week ends. R5 went bad that Sunday, and died on Monday morning".
Surveyor also interviewed E1 regarding staff not attempting to resuscitate R5, E1 was unsure if a DNR order or signature existed. Later, E1 provided surveyor with an advanced directives signed by Z3, however upon review of this form and under the DNR column the "no" box was checked. Z2 revealed 'A social worker explained the DNR to her but, she did not sign for R5 not to be resuscitated."
Further review of this closed record revealed R5 had not been seen by a physician since admission on 02/12/02. There was no physician's order except admitting orders. None of these orders included a "DNR" order.