cms_ID: 89
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 89 | GATEWAY TRANSITIONAL CARE CENTER | 135011 | 527 MEMORIAL DRIVE | POCATELLO | ID | 83201 | 2016-06-24 | 309 | D | 0 | 1 | X31E11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of the facility's hospice agreement, and staff and resident interview, it was determined the facility failed to ensure hospice communications were available for staff, and physician orders were clarified regarding catheter size and catheter balloon fill amounts. This was true for 1 of 2 (#11) residents reviewed for hospice care and 2 of 3 (#1 & #14) residents reviewed for catheters. This failure had the potential for more than minimal harm if residents did not receive appropriate services based on lack of coordination of hospice care or experienced pain due to improper catheter size or improper inflation of catheter balloons: Findings include: 1. The facility's Hospice Agreement, dated 10/1/06, stated: Documentation of Services. Both parties shall maintain appropriate documentation of services provided under this Agreement in accordance with applicable state and federal laws and regulations .Patient medical records and documentation maintained by each Party shall be available for review and inspection by the other Party . Resident #11 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #11's 10/12/15 physician's orders documented an ongoing order for hospice services. Resident #11's hospice care plan documented an intervention, dated 7/15/15 of, Work cooperatively with hospice team to ensure (Resident #11's) spiritual, emotional, intellectual, physical and social needs are met . Resident #11's clinical record did not contain hospice visit notes from 5/21/16 to 6/22/16. On 6/23/16 at 11:35 am, LN #3 said she coordinated with hospice staff when they provided services for residents on hospice. She said if she did not receive a verbal update from the hospice staff, she would review hospice nurse and CNA visit notes. On 6/23/16 at 11:40 am, the DON said the hospice notes from 5/21/16 through 6/22/16 were just received from Resident #11's hospice agency and had not been available to staff until that morning. 2. Resident #14 was admitted to the facility on [DATE] with multiple diagnoses, including neuromuscular dysfunction of the bladder. Resident #14's 10/6/15 physician's orders documented, Change suprapubic catheter monthly and PRN every . every 30 day(s) . Resident #14's 10/9/15 physician's progress note documented, She has had several incidents of catheter pulling, which has increased tissue damage in the past. Resident #14's (MONTH) and (MONTH) (YEAR) TARs documented the catheter was changed as ordered. On 6/23/16 at 3:30 pm, LN #4 said when changing a catheter she would determine the size of the catheter and how full to fill up the balloon with water by checking the size written on the order. LN #4 showed the surveyor various sizes of catheter packages in a storage room. Each package documented the size and how many CC's to fill the catheter balloon, which is inserted into the bladder. On 6/23/16 at 3:40 pm, the DON reviewed Resident #14's catheter order and said the order was not clear regarding the size or how many CC's of water were to be used to fill the balloon. The DON said the order should have been clarified. 3. Resident #1 was initially admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #1 was readmitted to the facility from the hospital on [DATE] post back surgery. Resident #1's annual MDS assessment, dated 8/8/15, and quarterly MDS assessment, dated 3/7/16, documented he had a BIMS of 15, did not ambulate, used a wheelchair for locomotion with the assistance of 1 person, and had a suprapubic catheter. The 6/2016 Physician's Orders included an order to change the suprapubic catheter every month (every 30 days) on the night shift. The order did not specify the size of the catheter or the amount of water to be instilled to inflate the balloon of the suprapubic catheter. A Nurses' Progress Note, dated 6/1/16, did not include documentation of changing Resident #1's suprapubic catheter, the size of the suprapubic catheter that was inserted, or the amount of water instilled. Resident #1's 6/2016 TAR documented his suprapubic catheter was changed on 6/1/16. There was no note regarding the size of the catheter used or the amount of water instilled to inflate the balloon of the suprapubic catheter. Resident #1's record included a Care Plan for the Suprapubic Catheter, with the Focus Area Titled: Has Suprapubic Catheter, [DIAGNOSES REDACTED]. The goals were: Resident #1 will show no signs or symptoms of urinary infection through the review date, and Resident #1 will remain free from catheter related trauma through the review date. A Care Plan intervention documented to change the suprapubic catheter monthly and as necessary, however, the size of the suprapubic catheter and the amount of water to instill to inflate the balloon of the catheter were not documented. During an interview with Resident #1 on 6/23/16, at approximately 2:00 pm, he stated he may have an occasional small amount of leakage from the suprapubic catheter when he was having some spasms. In addition, he stated there had been no problems or pain when the suprapubic catheter was changed. LN #2 who changed the suprapubic catheter on 6/1/16, was not available for interview. During an interview on 6/23/15, at approximately 5:00 pm with LN #1, who said she took care of the resident in the past, stated if the physician's order did not specify what size catheter to use or the amount of water to instill, she would check the size of the catheter to be removed and instill the amount of water documented on the bulb connector of the suprapubic catheter. LN #1 also stated if the resident was complaining of pain or having a problem with leakage (unrelated to presence of spasms) or the suprapubic catheter was not draining, she would notify the physician and obtain an order for [REDACTED]. During an interview with the ADON on 6/24/16, at approximately 9:30 am, the ADON stated the Physician's Order documented for the month of 6/2016, did not include the size of the suprapubic catheter or the amount of water to instill to inflate the balloon of the suprapubic catheter. The ADON showed the surveyor several different sized catheters used as suprapubic catheters and said the amount to be instilled is listed on the catheter. | 2020-09-01 |