Crestwood Terrace Facility I.D. Number: 0022863 Date of Survey: 12/09/2002 Complaint Investigation "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 psycho social 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. Based on record review, staff interview and physician interview, the facility failed to ensure that R3, one of four sampled residents receiving a gastrostomy tube feedings, received the appropriate service to prevent dehydration and metabolic abnormalities.
The facility’s failure to assess and evaluate R3's abnormal labs, and to act upon the abnormal labs in a timely manner contributed to R3's medical condition of hypernatremia. R3 experienced respiratory failure and was hospitalized on 11/24/2002. Findings include: 1. R3 is an eight-seven-year-old resident admitted to the facility on 5/7/2002. R3's diagnosis included Anemia, Schizophrenia, Hypertension, Dysphagia with peg-tub (gastrostomy tube [g-tube]), Dementia and Glaucoma. R3's medical record stated the following physician’s orders:
The original order for the sodium chloride was indicated as 5/7/2002. The nurse’s admission notes for R3, dated 5/7/2002 at 4 P.N. stated, “Call to Dr.....to verify orders.” The surveyor was unable to find any documented reason for the use of the sodium chloride in R3's record. R3's medication administration records (MAR) for October and November of 2002, indicated that the order for the sodium chloride was implemented and administered from October 1, 2002 to November 23, 2002, on a daily basis into the g-tube. Documented labs available in R3's chart on 12/4/2002, were as follows: 11/13/2002 Sodium 153 mEq/L (high), normal/expected range 136-145 mEq/L; Chloride 134mEq/L (high), normal/expected range 98-107 mEq/L; Glucose 107 mEq/L (high) normal/expected range 70-105 mEq/”; urea Nitrogen 48 mg/dl(high), normal/expected range 7-18 mg/dl; albumin 3.0 gm/d(low), normal/expected range 3.4-5 gm/dl. 10/09/2002 Urea Nitrogen 19 mg/dl (high); Albumin 2.6 gm/dl(low); Calcium 8.1 mg/dl (low) normal/expected range 8.4-10.2 mg/dl. 8/14/2002 Chloride 113 mEq/L (high), Urea Nitrogen 34 mg/dl (high); Creatinine 1.3 mg/dl (high), normal/expected range 0.6-1.2 mg/dl; Albumin 3.1 gm/dl (low). On 12/4/2002, the surveyor conducted interviews with staff members regarding R3's condition prior to the hospitalization of 11/24/2002. E5 (a nurse) reported during an 11:05 A.M. interview in the administrator’s office while E2 (the director of nurses) was present that she had received the 11/13/2002 abnormal labs for R3 on 11/15/2002, and paged R3's physician (Z1) twice with no response. E2 told the surveyor that the lab report was placed int the nurse’s twenty-four hour report book. E2 was asked by the surveyor what is the procedure after E5 was unable to contact the physician? E2 answered the next shift should have followed-up on it. The surveyor asked E2 where would this information be found? E2 stated in R3's chart. The surveyor, while E2 was present, reviewed the nurses’ notes and found no evidence that R3's physician was called about the abnormal lab values of 11/13/2002. On 12/4/2002, Z1 was interviewed via phone at 10:49 A.M. by the surveyor. Z1 reported that he was not made aware of R3's abnormal labs of 11/13/2002. Z1 reported that he visited R3 on 11/12/2002, and labs were not available for review. The surveyor questioned Z1 about R3's past history and present abnormal labs about possible intervention. Z1 state that he was not familiar with all of R3's medical history because he just took over caring for R3. Z1 stated that the elevated BUN (Urea nitrogen) could be a result of dehydration which would be easy to correct by giving R3 more fluid. On 12/4/2002, E4 ( the consultant dietitian) was interviewed by the surveyor via phone at 12:05P.M. about R3's abnormal labs after reviewing E4's assessment note documented on 11/18/2002, in R3's medical chart, E4 told the surveyor that the labs of 11/13/2002 was not available to her and she was not aware of the abnormal labs at the time of her assessment on 11/18/2002. When the surveyor questioned E4 about how she addressed the history of R3's elevated BUN and low albumin levels, E4 stated that the abnormal labs were addressed in her progress notes. E4 stated that from her notes the BUN level had improved and that R3 was put on a Fiber source HN for her low albumin levels. E4 was asked by the surveyor what was the intent of her recommendation made 9/9/2002 of additional 100cc of water fluid per shift when outside temperature is above 90 degrees F? E4 indicated this is a standard recommendation. Water was to be increased in hot weather. E4 was asked by the surveyor did she recommend additional fluid? E4 reported that R3 was receiving her calculated fluid need. The surveyor reviewed R3's monthly nutritional assessments and progress notes from 5/14/2002 through 11/18/2002. The surveyor noted that abnormal labs were reported in the nutritional documentation but no investigation nor assessment was done. In addition, there was no recommendation for intervention to correct the abnormal nutritionally related labs. The surveyor on 12/4/2002 interviewed E1, the administrator in her office at 11:08A.M. about R3's condition. E1 reported that she received a call from Z2 (a physician at the hospital), concerning an elevated sodium level. E1 stated she conducted an investigation to see if R3 was receiving her tube feeding as ordered and found no problem. E1 stated she conducted an investigation to see if R3 was receiving her tube feeding as ordered and found no problem. E1 stated that since E3 (medical director) was familiar with Z2, she asked E3 to talk to Z2 about the matter. As a result of this conversion, the surveyor conducted an interview with E3 on 12/4/2002 at 11:30A.M. by phone. E3 reported he talked to Z2 yesterday (12/3/2002). I asked him about the problem (with R3) Elevated sodium was discussed. I told him that the resident is from the facility but not my patient. I agreed that the elevated sodium is possible due to dehydration. Z2 stated he would update me. The surveyor asked E3 was he aware of R3's high sodium level? E3 state No, R3 was not his patient. On 12/5/2002 at 8:40A.M., the surveyor interview Z2 by phone about R3's condition. Z2 reported that R3's sodium level on admission to the hospital was over 190 (mEq/L)(normal range 136-145). R3 is currently intubated and has some kindney function problem. The surveyor asked Z2 if R3's condition was caused by the elevated sodium. Z2 stated he did not believe the dehydration was the cause of R3's respiratory failure, but it contributed to her condition. On a follow-up interview conducted on 12/5/2002 by phone at 8:58A.M., the surveyor interviewed Z1. Z1 was asked if he was aware of R3's order for sodium chloride 2gm daily? Z1 reported he was not aware because he did not order the medication. On 12/5/2002 at 11:40A.M., E1 reported via phone to the surveyor that R3 was on the sodium chloride when she was admitted to the facility in May, 2002. E1 was unable to report the reason for the use of the sodium chloride for R3, who has a documented in R3's medical chart showed no irregularities. |