The Woodbine Nursing Home LLC
Facility I.D. Number: 0044446
Date of Survey: 9/3/03
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. The facility shall obtain and record the physician's plan of care for the care or treatment at the time of notification.
General nursing care 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 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.
A regular program to prevent and treat pressure sores, heat rashes or other skin breakdown shall be practiced on a 24 hour,
seven day a week basis. A resident having pressure sores shall receive treatment and services to promote healing, prevent infection, and prevent new pressure sores from developing.
An ongoing resident record including progression toward and regression from established goals shall be maintained. The progress record shall indicate significant changes in the resident's condition. Any significant change shall be recorded upon occurrence by the staff person observing the change.
In addition to the information that is specified above, each resident's medical record shall contain the following:
Nurse's notes that describe the nursing care provided, observations and assessment of symptoms, reactions to treatments and medications, progression toward or regression from each resident's established goals, and changes in the resident's physical or emotional condition.
The facility shall also notify the resident's family, guardian, representative, conservator and any private or public agency financially responsible for the resident's care whenever unusual circumstance such as accidents, sudden illness, disease, unexplained absences, extraordinary resident charges, billings, or related administrative matters arise.
These regulations were not met based on:
Interviews, record review and review of the facility policy and procedure regarding notification of change in resident condition revealed that the facility failed to:
These failures resulted in R4 being hospitalized on 6/19/03. During this hospitalization R4 had an above the knee amputation on 6/19/03 due to the gangrene on her left 1st and 2nd toe.
R4 is an 85-year old female with multiple diagnoses including Senile Dementia Alzheimer's type, contractor of the right knee and history of right femoral fracture.
Review of R4's nurses' notes dated 6/11/03 shows that on the 7-3 shift, the nurse noted that R4 had a sore in between her left big toe and 2nd toe. The nurses' notes and the POS (Physician order sheet) dated 6/11/03 showed that R4's physician was notified and gave an order to wash area between the left big toe and the 2nd toe and to apply Lidex (steroid) ointment twice a day until healed. Nurses' notes dated 6/11/03 showed that R4's public guardian was contacted but was unable to be reached until 6/12/03 wherein she was notified about the condition of R4's left toes. Further review of the nurses' notes showed that there was no documentation of the condition of R4's left toes on 6/13/03.
The next nursing entry was on 6/14/03 at 7:30 p.m., showed that R4's 1st and 2nd toe on the left foot was necrotic, foul smelling with pain and the left foot is reddened and swollen. Record review shows no documentation that the facility was monitoring the condition of R4's left foot from the time the necrosis was discovered on 6/14 thru 6/17/03 to determine the need for immediate medical evaluation and treatment. Record review also does not show that the facility was monitoring or assessing the symptoms and evaluating the reaction of R4's toes to the treatment being applied.
Further record review shows that R4's physician and her public guardian were not notified about the significant change in the condition of R4's left 1st and 2nd toe from the time the toes were noted to have a necrosis on 6/14 to 6/17/03. According to nurses' notes, R4's guardian was notified of R4's condition only on 6/18/03. The nurses' notes dated 6/18/03 at 2:00 p.m. shows that only then was R4's physician called by the nurse about the condition of the resident's left foot.
Review of the physician progress notes dated 6/19/03 shows that R4's physician came to check the resident's left foot. According to the physician progress notes, R4 had gangrene on her left 1st and 2nd toes, described as blackened with smell and with dry vesicles on the sole. R4 was sent to the hospital per physician order. Review of the facility transfer form dated 6/19/03 shows that R4 has a gangrenous left foot and R4 will be sent to the hospital for evaluation and possible amputation. R4 had a left above knee amputation on 6/19/03.
During an interview, on 8/28/03 at 3:00 p.m., E3 stated that she saw R4s toes on 6/11/03. E3 described R4's left 1st and 2nd toe on 6/11/03 as reddened but was not necrotic or swollen nor was there an opening or foul smell. E3 stated that on 6/14/03 she found the left foot necrotic with foul smell and swelling. E3 admitted to the surveyor that she did not call the physician about this change because it was already late (7:30 p.m.) and because she did not feel that it was urgent or that it was an emergency. E3 also admitted that she did not call R4's public guardian about change in condition of R4's left foot on 6/14/03. Further interview with E3 revealed that she also worked on 6/15/03 but she did not document the condition of R4's foot nor did she notify R4's physician or public guardian about the condition of R4's left foot.
During an interview with E2, on 8/28/03 at 3:15 p.m., she told the surveyor that comparing the condition of R4's left toes from 6/11/03 to 6/14/03 there was definitely a significant change because of the presence of necrosis on 6/14/03. During a 2nd interview with E2, on 9/3/03, she told surveyor that she did not think that the necrosis (on R4's left toes) noted on 6/14/03 was a significant change in condition because it was only a small necrosis. She did not feel that it was an emergency because the physician could still do something like order medications. E2 further stated that the physician should have been notified about R4s condition on 6/14/03.
During an interview, on 9/2/03 at 11:40 a.m., Z1 stated that R4 has a diagnosis of Pemphigus, which is a blistering condition of the skin primarily on the palm and on the sole of the foot, which is treated with Prednisone medications. Z1 told surveyor that the facility did not notify him of R4's left 1st and 2nd toe necrosis when it was discovered on 6/14/03. Z1 also told surveyor that no one notified him even from 6/15/03 thru 6/17/03 about the condition of R4's foot. Z1 was only notified on 6/18/03, 4 days after the necrosis was observed on R4's left 1st and 2nd toe. Z1 added that it is the responsibility of the facility to call the physician if they feel that there is a significant change in a resident's condition. Z1 further stated that a development of a necrosis is a significant change.
Review of R4's record shows that there was no care plan in place to address the condition of R4's left 1st and 2nd toe from 6/11/03 through until 6/19/03 when the resident was sent out to the hospital.
Review of the facility policy and procedure regarding notification of change in residents' condition shows that the facility shall notify (within 1 hour) the resident's next of kin/representative and physician of a significant change in condition. The changes in the resident's condition will be documented in the chart and shall include the objective, observations of changes in the resident's condition, the date and time the physician, next of kin or representative were notified of the change in condition and the physician's plan of care.
R4's left 1st and 2nd toe initially had a sore that developed into a necrosis. The facility did not meet this residents need for care, monitoring, prompt determination of immediate care required and reporting of the worsening condition of R4's left toes and foot to the physician for further medical evaluation and treatment. The facility also did not notify R4's guardian about the significant change in the condition of the resident's left 1st and 2nd toe.