ZION CARE & REHAB CENTER
Facility I.D. Number 0044958
Date of Survey: 08/29/02
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 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.
All treatments and procedures shall be administered as ordered by the physician.
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.
The DON shall oversee the nursing services of the facility including:
Overseeing the comprehensive assessment of the residents needs, which include medically defined conditions and medical functional status, sensory and physical impairments, nutritional status and requirements, psychosocial status, discharge potential, dental condition, activities potential, rehabilitation potential, cognitive status, and drug therapy.
Planning an up-to-date resident care plan for each resident based on the residents comprehensive assessment, individual needs and goals to be accomplished, physicians orders, and personal care and nursing needs. Personnel representing other services such as nursing, activities, dietary, and such other modalities as are ordered by the physician shall be involved in the preparation of the resident care plan. The plan shall be in writing and shall be reviewed and modified in keeping with the care needed as indicated by the residents condition. The plan shall be reviewed at least every three months.
AN OWNER, LICENSEE, ADMINISTRATOR, EMPLOYEE OR AGENT OF A FACILITY SHALL NOT ABUSE OR NEGLECT A RESIDENT.
Based on record review and interviews the facility neglected to:
The findings include:
1. A review of the facility's patient/resident information sheet reveals that R1 is a 79 year old who was admitted with diagnoses of Cancer of the Prostate and Pancreas. R1 was receiving chemotherapy. An admission nursing assessment reveals that R1 was readmitted to the facility on 8/2/02.
Nurses notes document the following:
8/2/02-8/9/02, document amber colored urine.
8/8/02, 8:20 p.m.--received a call from the physician. R1's wife had called the physician requesting some medicine for pain. Resident was restless around 5:20 p.m.--he was picking at his covers, pulling on the indwelling Foley catheter and removing his gown. Redirections were ineffective, Ativan 0.5 milligrams (mgms.) was given.
8/9/02, 8:00 a.m.--resident hollering and trying to pull his Foley catheter out. Ativan 0.5 mgms given. 8/9/02, 2:00 p.m.--resident quiet and sleeping. Confused and disoriented. No distress noted. Nursing notes do not address the color/quality of the urine.
8/10/02, 12:00 a.m.--received resident asleep, well rested, no signs of pain and discomfort. Foley catheter draining well with amber colored urine, assisted during self care activity.
8/10/02, 8:45 a.m.--resident in bed awake, responding verbally, but words are hard to understand. Spoon fed by staff. Foley catheter intact, note small amount of urine with sediment. 12:30 p.m.--called into the dining room that resident is not waking up and not responding even on pain stimuli. 12:35 p.m.-- taken back to his room, noted breathing with apnea. Pulse oximeter at 70%. Oxygen at 6 liters started. Resident still not responding, wife requesting resident to be sent to the hospital.
Unable to get a reading for a pulse oximeter. Pulse=61. Temperature=100.9, Blood Pressure 60/40. 1:10 p.m.-- rescue squad here, resident still breathing with apneic episodes, blood pressure at this time only 50/nothing.
There are no nursing notes to show that nursing staff assessed R1's medical needs on 8/10/02, until R1'swife announced she would be taking him to the hospital. There is no nursing documentation to show that R1 was assessed when he began hollering and trying to pull out his catheter or that the physician was contacted regarding the change or decline in R1's condition on 8/10/02.
A review of R1's daily vital signs sheet documents normal blood pressures on 8/2/02 through 8/7/02. On 8/9/02, R1's blood pressure was 180/80. There are no nurse notes to show that R1 was assessed for the cause of the elevated blood pressure.
A nutritional assessment dated 7/8/02, documents that R1 is in a high neuronal risk category. Estimated daily fluid needs are 1770 cc's. R1's intake records for 8/2/02 through 8/9/02, document that R1's daily fluid intake ranged between 450cc's -1100cc's.
2) R1's care plan dated 8/6/02, documents R1 is at risk for dehydration, to encourage/help the resident to drink at least 1500-2000cc's per day, and to assess for signs and symptoms of dehydration (e.g. increased confusion, increased weakness, dark urine etc.)
A nurses note on 8/10/02 at 8:45 a.m. documents that R1 took one cup of water without difficulty. There are no other nurses notes to show that interventions were made when R1's fluid needs were not met.
A review of R1's 24 hour output records documents that R1's daily output ranged from 1150 cc's. -350cc's.
On the night shift (11-7) on 8/8/02, R1 had no urine output. There is no documentation in the nurses notes that R1 was assessed or that the physician was notified regarding not having urine output on 8/8/02.
Z1 was interviewed on 8/15/02 at 12:50 p.m. in the emergency room at the local hospital. Z1 stated that when R1 arrived in the E.R. the catheter bag had a small amount of dark brown urine (50cc's). Z1 stated that the drainage tubing was heavily lined with "brownish junky sediment" and when R1 was catheterized urine was received back and it became a cloudy yellow. Z1 stated that R1's wife kept telling them that she had told the nurses at the nursing home to change the catheter, but that no one listened to her. Z1 stated that R1 was in septic shock.
Z2 was interviewed by telephone on 8/15/02 at 1:00 p.m. Z2 stated she was the one who removed R1's catheter on 8/10/02. Z2 stated that R1's catheter was "so foul and so pussy--it was disgusting--that catheter should have been changed a long time ago."
Z4 was interviewed on 8/15/02 at 1:05 p.m. in the emergency room. Z4 stated that R1's wife was frantic about how dirty the catheter tubing was and that no one at the nursing home had listened to her. Z4 stated that R1 presented as "neglect".
Z3 was interviewed on 8/15/02 at 1:15 p.m. in the emergency room. Z3 stated that on admission R1 had frank pyuria (pus in the urine.) The urine was a white cottage cheese and there was a tepid brown drainage in the catheter--they should have seen the frank pus in the bag and the color of the urine. Z3 stated R1 was very dehydrated and that the urinary condition was not acute--it was going on for at least 24 hours. Z3 stated that R1 was in urosepsis and had a gram negative sepsis (septic shock). Z3 stated that R1's condition was so critical that R1 would have died if he had not been treated.
A review of R1's emergency room record dated 8/10/02, reveals that R1 was admitted to the E.R at 1405. R1 had an intravenous solution which was running wide open and also had a Dopamine titrate (a drug used to elevate the blood pressure when in shock). Z3 documents that R1's catheter appears to need a change as it is encrusted with debris.
E7 and E8 were interviewed on 8/15/02 at 2:00 p.m. on the 2 East nursing unit. E7 and E8 stated that on the day before R1 went to the hospital he went wild trying to pull out his catheter. E7 and E8 stated that he kicked his feet, was grabbing his penis, yelling "I have to pee." E7 and E8 stated that the drainage tubing had pieces of white gunk and there were white lines and that there was very little urine in the bag his last few days here.
E5 was interviewed by telephone on 8/15/02 at 2:05 p.m. E5 stated that she had cared for R1 the day (7-3) shift before he went to the hospital and that he was hitting, swinging his legs, trying to get out of bed and that she medicated him with Ativan.
E5 stated R1 had a catheter with concentrated urine that was thick and cloudy. E5 was unaware that R1 had no urine output on the night shift.
E6 was interviewed on 8/15/02 at 4:45 p.m. at the 1 West Nurses Station. E6 stated she took care of R1 in the evening (3-11) on 8/9/02-- the day before he went to the hospital. E6 stated that she was told in shift report that he had been very agitated in the morning, that he was trying to pull out his catheter, and that he had been medicated with Ativan. E6 stated that R1 slept on the 3-11 shift and that there were blood streaks in the catheter tubing. E6 stated that when staff did the output for the shift that there was dark dried blood in the urine.
Z5 was interviewed on 8/20/02 at 1:15 p.m. in room 214. Z5 stated that when she visited R1 on Wednesday (8/7/02) that he was in a lot of pain, pulling at the catheter, saying please take it out. On Thursday (8/8/02) Z5 stated that R1 was in so much pain and that she did not feel good about the catheter, so when she went home she called the physician. When the physician returned the call on 8/9/02, Z5 told the physician that Z5 had never seen R1 in so much pain and so agitated. Z5 stated that a granddaughter visited in the evening of 8/9/02 and that she told Z5 that R1 had not eaten and was in so much pain and telling her to take the catheter out. The granddaughter went to the nurse, but the nurse told her that the physician wanted the catheter in because R1 had so many open sores. On 8/10/02, Z5 visited along with other family members. She stated that when they arrived--approximately at noon, that R1 was not arousable--he just stared one way and never moved his eyes. Z5 stated that R1 was gotten out of bed and the nurse told the family that he was staring that way because of his medication. Z5 stated that R1 closed his eyes and did not respond to the family or the nurses--he was getting deeper and deeper from us. At this point Z5 told the nurse she was taking R1 to the hospital and this is when the nurses got busy. Z5 stated his blood pressure was zero.
On arrival at the emergency room, Z3 said to Z5--I hope you got him here in time--he is in septic shock. Z5 stated that when the catheter was removed it was full of infection, it was brown, the bag was nasty--everyone in the emergency room (staff) came to see how filthy it was. Z5 stated that on 8/8/02 and 8/9/02, the urine was dark brown/crusty. The tubing was bad--you could tell something was wrong. R1 was eating good, told us to bring him
some scrambled eggs--he was eating well before the infection. On 8/8/02 and 8/9/02 he was thrashing so bad--like a wild animal--the nurse stood in the door and watched him thrash. Four people from our family reported to the nurses about the pain and the thrashing and wanting to take the catheter out and nobody listened.