| 88 |
BRANDYWINE NURSING & REHABILITATION CENTER |
85004 |
505 GREENBANK ROAD |
WILMINGTON |
DE |
19808 |
2017-07-19 |
327 |
G |
1 |
1 |
ZBS111 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review and interview, it was determined that the facility failed to ensure that one (R204) out of 55 residents sampled was offered sufficient fluid intake to maintain proper hydration and health. The facility failed to identify R204 as being at risk for dehydration, failed to care plan accordingly and failed to consistently monitor and evaluate R204's fluid consumption. When R204's meal and fluid intakes steadily declined there was no notification of the physician and/or RD and no new interventions implemented until 1/17/17. On 1/17/17, R204 became unresponsive and was sent out to the ER where she was found to be severely dehydrated with an acute kidney injury (AKI). This deficient practice resulted in harm to R204. Findings include: Review of R204's clinical record revealed the following: 12/29/16 - R204 was admitted to the facility with [DIAGNOSES REDACTED]. 12/29/16 - The admission Nutritional Assessment stated, .Weight: 141.0 .Estimated Nutritional Requirements: Fluid (ml) 1400-1700 (amount required per 24 hours) .no nutritional problems at present. Assessment/Plan: New admit: reweight: 141 lbs .Current diet regular/thins/NAS .Resident dines independently with % meal completion 75%. Per nursing, appetite good .Resident added to weekly weights and will monitor nutritional parameters. 12/29/16 - The nursing admission assessment stated R204 appeared well nourished, had a good appetite, and was alert, but uncooperative and combative. 12/29/16 - A care plan for the problem Unable to do own ADLs without assistance stated R204 required supervision while eating and nursing was to assist the resident with her meal tray and feeding if necessary. Additionally, a care plan for the problem Resident at nutritional risk was developed which included approaches to provide diet/meals as ordered, monitor food and fluid preferences, encourage food and fluid intake, provide assistance as needed with food/fluids, and monitor for signs of diet intolerance. A care plan was not developed for the potential for dehydration. 12/30/16 - The facility completed a Functional Abilities Review, completed by the SLP, which stated R204 was tolerating the current diet texture with no signs of choking or difficulty swallowing. The review stated that speech therapy services were not warranted at this time. 12/30/16 3:41 PM - A Psychological Initial Assessment stated, .severe dementia with behavioral disturbances .Resident has been hitting staff and yelling. Has needed medication to attempt to decrease behaviors .Staff encouraged to anticipate residents needs (toileting, addressing hunger/thirst) to avoid behavioral disruption. 12/30/16 - R204's re-weight recorded as 141.0 lbs. 1/1/17 - A physician's orders [REDACTED]. 1/3/17 - Laboratory blood test results revealed the following values: Sodium = 146 (normal range: 135-145); BUN = 22 (normal range: 10-26); Creatinine = 0.7 (normal range: 0.5 - 1.5). 1/3/17 5:05 PM - A nurse's progress note stated that medication given for constipation was held due to R204 having loose bowel movements. A second note, timed 11:26 PM, stated the resident was extremely agitated .oral mucosa pink and moist, appetite fair, fluids encouraged . 1/4/17 - Laboratory blood test results revealed the following values: Sodium = 147; BUN = 23; Creatinine = 0.6. 1/4/17 - The admission MDS assessment stated R204 had short and long term memory problems, was moderately impaired for daily decision making skills (decisions poor; cues/supervision required), and was exhibiting behaviors daily. Additionally, the MDS stated R204 required extensive assistance of one staff person for walking in her room and corridor, dressing, toilet use, hygiene and bathing. R204 was identified as requiring supervision and set up help for eating. 1/4/17 12:34 PM - A nurse's progress note stated while sitting up in a wheelchair at the nurse's station, R204 appeared to be unresponsive. R204 was taken back to her room where she responded to painful stimuli, became alert but was still not responding appropriately. The physician was called and ordered R204 be sent to the ER for evaluation. 1/5/17 3:52 AM - A nurse's progress note stated R204 returned from the ER at 1:30 AM and was alert and responsive. 1/5/17 - A physician's orders [REDACTED]. 1/5/17 12:38 PM - A nutrition/dietary note stated R204's weights were being monitored weekly, however, nursing reported they were unable to complete R204's weight that morning due to her being lethargic. There was no evidence the facility attempted to obtain a weight until the following week. 1/5/17 12:43 PM - A nurse's progress note stated, Resident alert and responsive .appetite fair .assistance w/lunch .sitting quietly at nurse's station. 1/5/17 3:19 PM - A nurse's progress note stated the resident had a new order to encourage fluids every shift. Review of the corresponding MAR indicated [REDACTED]. This order did not identify how much fluid was to be encouraged, nor was there any consistent documentation as to whether R204 was accepting adequate fluids. 1/5/17 8:28 PM - A nurse's progress note stated the medication used for constipation was held due to R204 having loose bowel movements. 1/5/17 11:31 PM - A nurse's progress note stated R204 was exhibiting frequent episodes of agitation especially during care, but that her appetite was good and fluids adequate. 1/6/17 11:46 PM - A nurse's progress note stated, .appetite fair, fluids adequate . 1/8/17 10:04 PM - A nurse's progress note stated, .Decreased appetite during breakfast dinner and lunch .Husband visited .complained about her mental status . A second note timed 10:20 PM stated, Late Entry 1/8/17 Did attempt to offer alternatives and ensure (liquid dietary supplement) due to decreased appetite in presence of husband. gave alternatives to husband, but attempts were ineffective as resident continue (sic) to refuse and become combative. Despite this documented decline in intakes there was no evidence that the physician and/or RD were notified. 1/5/17 through 1/11/17 - Review of the MAR indicated [REDACTED]. However, there was no documented evidence of how much fluid was consumed or whether it was accepted. 1/5/17 through 1/11/17 - Review of the CNA ADL Flowsheet of percentage of meal consumption revealed the following for intake of solids: 1/5/17 - breakfast 75%; lunch 25%; dinner 75%; 1/6/17 - breakfast 25%; lunch 25%; dinner 50%; 1/7/17 - breakfast 25%; lunch 25%; dinner 25%; 1/8/17 - breakfast 50%; lunch 50%; dinner 25%; 1/9/17 - breakfast 50%; lunch 75%; dinner 75%; 1/10/17 - breakfast 50%; lunch 25%; dinner 75%; 1/11/17 - breakfast refused; lunch refused; dinner no % documented. Review of the clinical record lacked evidence that the physician and/or RD were notified regarding R204's fluctuating food intakes. Additionally, review of the CNA ADL flowsheet revealed that from 1/1/17 through 1/10/17, R204 was feeding herself or requiring supervision or verbal cuing only. However, starting 1/12/17 documentation revealed R204 was requiring more assistance eating, with multiple occasions noting she was totally dependent for eating. Review of R204's meal time fluid intakes (for all 3 meals) from 1/2/17 through 1/11/17 revealed the following total amounts: 1/2/17 - 720 mls; 1/3/17 - 360 mls; 1/4/17 - 120 mls; 1/5/17 - 480 mls; 1/6/17 - 360 mls; 1/7/17 - 360 mls; 1/8/17 - 240 mls; 1/9/17 - 720 mls; 1/10/17 - 720 mls; 1/11/17 - refused breakfast and lunch and no intake documented for dinner. Review of the above listed totals revealed that unless R204 was being provided additional fluids (e.g. during medication administration or between meals) ranging in amounts from 680 mls to 1280 mls, depending on the amount of fluids consumed at each meal, she was not meeting her daily fluid requirement of 1400-1700 mls to maintain good hydration and health. Although nursing staff were documenting on the MAR from 1/5/17 through 1/11/17 that fluids were encouraged there was no documented evidence that R204 was actually consuming the fluids. Review of the clinical record lacked evidence that the facility monitored and evaluated R204's fluid intakes; no evidence that they identified that her fluid needs were not being met, and no evidence that the physician and/or RD were notified in an attempt to implement new interventions. Review of the clinical record revealed that the 1/5/17 physician's orders [REDACTED]. 1/13/17 - R204's weight recorded as 140.2. 1/14/17 8:46 AM - A nurse's progress note stated, Resident alert and responsive .appetite fair .mucous membranes pink and moist . 1/15/17 7:30 PM - A nurse's progress note stated that R204 was given a [MEDICATION NAME] suppository for nausea and vomiting and that it was effective. 1/16/17 1:22 PM - A nurse's progress note stated, Resident has a new order to begin mechanical soft diet per family request. 1/16/17 - A PT Evaluation & Plan of Treatment was completed. The evaluation stated, .Reason for Referral: Received a nursing referral due to decline in function, unsteady gait and frequent falls. According to nursing, patient was previously ambulatory without assistive device upon admission to this facility, and is currently in a WC .Clinical Reasoning .difficulty participating in functional activities due to lethargy and behavioral disturbance, unable to ambulate . Review of R204's meal intake records from 1/12/17 through 1/16/17 revealed the following amounts: 1/12/17 - breakfast and lunch refused; dinner 75%; 1/13/17 - breakfast and lunch 50%; dinner 25%; 1/14/17 - breakfast and lunch 50%; dinner 25%; 1/15/17 - breakfast and lunch 25%; dinner 0%; 1/16/17 - breakfast and lunch 25%; dinner 0%. Review of R204's meal time fluid intakes (for all 3 meals) from 1/12/17 through 1/16/17 revealed the following total amounts: 1/12/17 - 360 mls; 1/13/17 - 480 mls; 1/14/17 - 360 mls; 1/15/17 - 120 mls; 1/16/17 - 240 mls. There was no evidence that staff were encouraging or that the resident was consuming additional fluids in an attempt to meet her estimated minimum fluid requirement of 1400 mls per 24 hours. The clinical record lacked evidence that the facility monitored and/or evaluated R204's fluid intakes, that the facility identified her fluid needs were not being met, and that the physician and/or RD were notified in a timely manner in an attempt to implement new interventions. There was no evidence that the RD was notified of R204's declining intakes until 1/17/17. 1/17/17 10:52 AM - A nutrition/dietary note stated, Per nursing report Resident experiencing decreased appetite. % (percent) meal completion ranging between 0-50% .added 8 oz ensure [MEDICATION NAME] PO BID .Added 30 ml Promod BID .Reviewed labs: Na 147 slightly elevated (results from 1/4/17). Wrote dietary slip to kitchen to send extra fluids on meal trays. Will continue to monitor weekly weights, encourage po food/fluids, and nutritional parameters. 1/17/17 11:01 AM - A nutrition/dietary note stated, Addendum: Diet: mech (mechanical) soft/thins/NAS. Diet liberalized and NAS d/ced to increase palatability of meals. 1/17/17 11:09 AM - A nurse's progress note stated, Resident has a new order for STAT CBC and BMP, UA C&S and Chest X ray due to change in mental status, dark foul smelling urine and cough . 1/17/17 2:55 PM - A nurse's progress note stated, Resident alert to her name .appetite poor . 1/17/17 - Review of laboratory blood and urine reports revealed results were faxed to the facility on [DATE] at approximately 5:15 PM. Results were as follows: BUN = 163 (normal range: 10-26); Sodium = 165 (normal range: 135-145); Creatinine = 5.2 (normal range: 0.5 - 1.5); UA = negative; Additionally, the chest X ray results did not identify any pneumonia or fluid in the lungs. 1/18/17 1:25 AM - A nurse's progress note stated, Resident was resting in chair with eyes closed at start of shift, attempt was made to arouse resident, change in mental status observed, unable to speak, unable to take in fluids .sent to (hospital) via 911 at 1730 (5:30 PM) . 1/20/17 1:28 AM - Late entry for 1/15/17 3-11 shift, Resident vomited a small amount of undigested soup while eating dinner, warm ginger ale offered and accepted, [MEDICATION NAME] suppository administered, no further episode of nausea or vomiting throughout shift .loose BM at the end of the shift, fluids offered and accepted . The facility failed to identify that R204 was not meeting her minimum fluid requirement and they failed to implement interventions in an attempt to meet this fluid requirement. There was no evidence that R204's oral intake was being monitored consistently and that decreased food and fluid intakes were reported to the physician and/or RD in a timely manner. R204 was sent out to the ER when she became unresponsive and was diagnosed with [REDACTED]. R204 was admitted to the hospital on [DATE]. The hospital ED Physician Record, dated 1/17/17 and timed 6:04 PM stated, .found unresponsive in her nursing home .she has been slightly lethargic for the last several days. Somnolent. She has not been taking much oral intake including food or water. She does have some mild nausea and vomiting over the weekend .severely dry mucous membranes with dry tongue .Initial laboratory results revealed significant [MEDICAL CONDITION] (sic/should read [MEDICAL CONDITION]) with sodium 171. Acute [MEDICAL CONDITION] with BUN of 156 creatinine 6.2 .She received approximately 2L (liters) of IV fluids .sodium improving to 170 .improving creatinine of 5.6 . A second hospital ED Physician Record, dated 1/17/17 and timed 6:09 PM stated, .As per the family she has not been doing well for the past 3 weeks since her admission to the nursing home .family states she has not been eating or drinking since her admission, but significantly less over the past 1 week The family states that over the past 2-3 days she has been much more altered than her baseline mental status .dry oral mucosa .After approximately 15 minutes of being in the emergency department the patient is much more awake and alert and is able to tell me her name .2L of NS (Normal Saline) was given for [MEDICAL CONDITION]ly 2/2 (secondary to) dehydration. The patient's mental status continues to improve while in the ER . A hospital nephrologist's consult note, dated 1/18/17, stated, .progressive Alzheimer's dementia, presenting to the ED yesterday evening unresponsive .recently transferred to a nursing home .Over the past few days, she reportedly became increasingly lethargic .Upon arrival to (hospital name) ED was [MEDICAL CONDITION] (rapid heart rate), unresponsive, with elevated creatinine .[MEDICAL CONDITION] .On previous visits when tested her renal function was normal with baseline creatinine 0.8 .oral mucosa dry .Assessment/Plan: 1. Acute kidney injury: This is clearly acute, with normal baseline creatinine just earlier this month. Most likely due to volume depletion .2. [MEDICAL CONDITION]: Severe at presentation sodium 171 .Attributable to poor oral intake over some time .Additional Recommendations or Comments: 5. Long-term she will require some means of reliably maintaining adequate oral/fluid intake . 7/17/17 approximately 4:00 PM - During an interview with E16 (RD) and E17 (RD), E17 stated that when she noted on 1/5/17 the order to encourage fluids, she sent a request slip to dietary to send extra fluids on the meal trays. E17 stated she was not notified that R204 was not eating well until 1/17/17 at which time she ordered supplements. After R204's meal and fluid intakes were reviewed, E17 confirmed she should have been notified sooner. 7/17/17 at approximately 4:20 PM - During an interview with E1 (NHA) and E2 (DON) regarding the facility's failure to identify R204's risk for dehydration and subsequent care planning, the facility's lack of monitoring of fluid intakes and lack of identifying that minimum fluid needs were not being met and resulting in severe dehydration, the findings were confirmed. |
2020-09-01 |