cms_HI: 21
Data source: Big Local News · About: big-local-datasette
| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 21 | KULA HOSPITAL | 125003 | 100 KEOKEA PLACE | KULA | HI | 96790 | 2017-04-21 | 279 | D | 0 | 1 | 1M3411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure it developed and implemented a comprehensive, person-centered care plan for 1 of 23 residents (Resident #12), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs identified in the comprehensive assessment in the Stage 2 sample. Finding includes: Cross-reference to findings at F157. Resident #12 (R #12) was admitted to the facility from an acute setting as her cardiac status had stabilized. R #12's admission was for ongoing medical management and rehabilitation services (physical and occupational therapy) due to severe weakness related to her hospitalization . Some of her [DIAGNOSES REDACTED]. Observation of R #12 revealed the resident was arousable but lethargic. A family interview revealed the resident had a recent exacerbation of her [MEDICAL CONDITION] symptoms with noted [MEDICAL CONDITION] (swelling). A review of R #12's clinical chart found a 3/31/17 nursing note which documented upon assessment, the resident was noted to be diaphoretic and lethargic. Arousable but generalized lethargy .Noted increased irregular HR (heart rate) in the 120s and BP 110/79. The record revealed the attending physician was notified and ordered a stat EKG, which was done at 10:10 AM on 3/31/17. Per the attending physician's 3/31/17 note, she assessed the resident as having sinus [MEDICAL CONDITION] wheeze, questionable asthma as symptoms were recurrent, and ordered oxygen as needed. The physician also ordered a new inhalation medication ([MEDICATION NAME]) twice daily for 5 days and noted the resident's history of [MEDICAL CONDITION] and positive fluid retention, and consider checking of BNP . The lab tests drawn on 4/3/17 included a basic metabolic panel and a B-Natriuretic Peptide (BNP) level. The BNP was significantly elevated at 908 pg/mL (normal A 4/2/17 entry by the on-call physician found R #12 was assessed to have [MEDICAL CONDITION], [MEDICAL CONDITIONS] and mild [MEDICAL CONDITION]. Orders were given for a one time [MEDICATION NAME] dose and to increase the resident's routine daily [MEDICATION NAME] dose to 20 mg. Additional orders included increasing the oxygen to 2 Liters/min by nasal prong, to check the resident's oxygen saturation (O2 sat) level every shift and to report to the physician if the O2 sat was 90 or less. Daily weights x 5 days were also ordered and a 4/2/17 nursing entry stated R #12 had a weight gain of at least 2.5# (pounds) and observed with increased facial and bilateral hand [MEDICAL CONDITION]. A concurrent chart review of the resident's care plans was done with Staff #58 on 04/13/2017 at 8:06 AM. During the interview with Staff #58, he stated with regard to the resident's [MEDICAL CONDITION], the attending physician knew of the resident's BNP level and adjusted R #12's medications. He also acknowledged daily weights for five days were ordered. Staff #58 verified there was no care plan developed for the resident's [MEDICAL CONDITION] but that it was important to have one based on the resident's [DIAGNOSES REDACTED]. Staff #58 said, It is every nurse's responsibility to develop a care plan and affirmed a care plan for it was not done. The facility failed to develop a care plan for a resident with a known history of [MEDICAL CONDITION] and during a recent exacerbation of [MEDICAL CONDITION] symptoms. | 2020-09-01 |