Provena Our Lady of Victory
Facility I.D. Number: 0041723
Date of Survey: 09/19/2003
Annual Licensure Survey
The facility shall have written policies and procedures governing all services provided by the facility which shall be formulated by a Resident Care Policy Committee consisting of at least the Administrator, the advisory physician or the Medical Advisory Committee and representatives of nursing and other services in the facility. These policies shall be in compliance with the Act and all rules promulgated thereunder. These written policies shall be followed in operating the facility and shall be reviewed at least annually by this committee, as evidenced by written, signed and dated minutes of such a meeting.
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.
General nursing care shall include at a minimum the following and shall be practiced on a 24-hour, seven-day-a-week basis:
Medications including oral, rectal, hypodermic, intravenous, and intramuscular shall be properly administered.
These regulations are not met as evidenced by:
Based on observation, interview and record review the facility failed to:
This is for three residents inside the sample of 20 and one resident outside the sample.
The examples include:
1. A review of the facility's nursing progress notes dated for 11/02/02 found that R20 was readmitted to the facility with diagnoses which included Alzheimer disease, Degenerative Joint Disease, Hypertension and Congestive Heart Disease. R20 also had a midline heplock for continuous Intravenous therapy and a nephrostomy tube.
A review of the facility's incident report dated for 11/13/02 indicated that at 5:30 p.m., a facility staff nurse (E20) gave R20 2 cc of Heparin Sodium 20,000 usp/ml instead of Heparin Lock Flush 100 usp/ml to flush the midline heplock. A review of E20's hand written statement, read "it was discovered that (R20) received 2cc of Heparin 20,000 usp/ml instead of 2cc of Heparin 100 usp/ml. The physician was notified and (R20) was transferred to the hospital for emergency care." A review of the hospital's emergency room report diagnosed R20 with Coagulopathy and hematuria.
A review of lab values for R20 found the following:
-a urine lab report dated for 11/13/02 collected at
6:25 a.m. at the facility described R20's urine as yellow with moderate (high) amount of blood and 6 - 8 (high) of red blood cells.
-a urine lab report dated for 11/13/02 collected at
8:15 p.m. at the hospital described R20's urine as red with large (high) amount of blood and over 100 of red blood cells. (The reference level for red blood cells is 0).
- a protime dated for 11/13/02 at 7:59 p.m. at the hospital described the protime for R20 as 38.2 (high), the INR
(international normalized ratio) was 11.55 (high) and the partial was over 240 (high).
- a protime dated for 11/14/02 at 1:30 p.m. described the protime for R20 as 12.2, INR was 1.20 and the partial was 31.0 (the normal is 22 - 32.4).
The Physician's Desk Reference (PDR) for 2003 describes the symptoms of an overdose of Heparin is bleeding from the nose, in the urine and in the stool. Heparin Lock Flush Solution, USP is not to used for anticoagulant therapy. Heparin Lock Flush Solution is intended to maintain patency of an indwelling venipuncture device designed for intermittent injection or infusing therapy. (Pages 1284 - 1287)
A review of a consultation report dated 11/14/02 by Z2 (personal physician for R20) read that R20's problem could be classified as intensely severe on a scale of 1-10, it was 9 - 10. The hematuria has been present for approximately 18 hours. Modifying factors include Heparin irrigation.
A review of the facility's Admission order sheet dated for 11/6/02, and follow-up order sheets found no orders for the midline heplock flush.
Interviews with E2 (DON) daily on 09/10/03, 09/11/03 and 09/12/03, E2 stated that Physician's orders are not required, the facility has standing orders to follow the facility's policy and procedure for heplock flush.
A review of the facility's policy and procedure for heplock flush found, "Flush catheter with 3cc 0.9 normal saline and 3cc heparin (100 units/cc)."
2. A review of the facility's nurses progress notes dated for 07/22/03, 07/27/03 and the facility's social service monthly summary note dated for 08/06/03 found that R1 was sent to the emergency room when she (R1) became lethargic.
A review of the facility's incident report dated for 07/22/03 and the emergency room report indicated that the emergency room staff found R1 wearing two Duragesic 100 mcg patches. R1 was treated with 500 cc Normal Saline wide open and a bolus of one (1) liter Dextrose 50 intravenous therapy and was returned to the facility.
A telephone interview with E21 (pharmacist) on 09/12/03, E21 stated that an elderly person wearing two Duragesic 100 mcg. patches simultaneously could absolutely cause somnolence, lethargy, nausea, dizziness and confusion. One patch is designed to be replaced after approximately 72 hours of use. If a second patch is applied and the original patch is not removed, the above adverse effects could occur. These reactions could especially occur in an elderly person as they may have altered pharmacokinetics due to poor fat stores, muscle wasting, or altered clearance.
3. A review of the Physician's Orders for R44 dated for 07/30/03 read "Hold coumadin, PT (protime) INR Friday (08/01/03)." Another order dated for 08/01/03 read "Hold coumadin x 2 more days then restart Coumadin at 1mg. every day in p.m. Recheck PT in one week."
A review of the facility's incident report dated for 08/04/03 read "On 08/01/03, an order was written to hold coumadin for two days and then restart Coumadin 1mg. every day in the p.m. Coumadin 2 mg. was given 08/01/03, 08/02/03 and 08/03/03."
A review of the Protime results for R44 are:
4. A review of the facility's nurses notes dated for 04/28/03 at 8:00 p.m. found that R10 received two doses of her 8:00 p.m. medications.
A review of the facility's Medication Administration Record found that R10 was scheduled to receive Klor-Con 20 meq, Isosorbide 10 mg., and Acetaminophen 500 mg.
A telephone interview with Z4 (Student nurse) on 09/12/03 at approximately 2:10 p.m., Z4 stated that she was assigned to R10 on 04/28/03. Z4 stated "I checked the Medication Administration Record and I saw that the medications were not signed out. I checked with my instructor and was told to give the meds. When I came out of R10's room, E22 (LPN) asked me if I had given the meds and I told her yes. E22 stated at that time that she had already given the medications. We then informed the my instructor and the supervisor."
A telephone interview with E22 on 09/18/03 at approximately 12:12 p.m., E22 stated that she had asked the instructor to give her the students room assignment in writing. I started passing my meds and when I came back to sign out I noticed that the student had already initial on the MAR. That's when I found out that we had given R10 her medications twice.