| 77 |
THE PILLARS OF BILOXI |
255093 |
2279 ATKINSON ROAD |
BILOXI |
MS |
39531 |
2017-03-10 |
282 |
E |
0 |
1 |
U1S311 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and facility policy review, the facility failed to follow the plan of care related to diabetic care for Resident #10, for one of eight (1 of 8) insulin dependent resident care plans reviewed, and catheter care for Residents #6, #15, and #16, for three of six (3 of 6) residents with catheters care plans reviewed. Findings include: Review of facility's policy titled, Care Plan-Comprehensive, (no date), revealed it is the policy of this facility to develop comprehensive care plan for each resident that includes measurable objectives and time tables to meet the resident's medical, nursing and psychological needs. The comprehensive care plan has been designed to: Incorporate identified focus areas; Incorporate risk factors associated with identified problems; Build on the residents strengths; Reflect treatment goals and objectives in measurable outcomes that incorporate the resident's personal cultural practices and wishes; Identify the professional services that are responsible for every element of care; Enhance the optimal functioning of the resident by focusing on rehabilitative programs and sources as needed. Resident #10 A review of Resident #10's Care Plan revealed a care plan to address Diabetes originated on 09/15/16, with a revision date of 12/05/2016. The care plan had an intervention to, Monitor/document/report PRN (as needed) any s/sx (signs/symptoms) of [DIAGNOSES REDACTED]: Sweating, Tremor, Increased heart rate ([MEDICAL CONDITION], Pallor, Nervousness, Confusion, Slurred Speech, Lack of Coordination, Staggering Gait initiated on 09/15/2015. Further reveiw of the Care Plan revealed an intervention initiated on 9/15/15, to administer [MEDICATION NAME] (Detemir) insulin as ordered. An observation, and interview 03/07/17 at 4:20 PM, revealed Resident #10 was lying in bed. Certified Nursing Assistant (CNA) #4 was present in the room. There were clear plastic bags filled with linens, sheets and bedspreads, on the floor next to Resident #10's bed. CNA #4 stated she had just changed Resident #10 because the resident was sweating profusely. At this time Resident #10 was observed to be sweating profusely, her eyes were casting far to the left, and she was non-responsive when spoken to. Resident #10's skin was cool and clammy, and she was taking shallow quick breaths. CNA #4 stated she entered the room, and found Resident #10 to be sweating profusely, the bed was soaked with sweat and possibly urine. CNA #4 stated she had informed Licensed Practical Nurse (LPN) #5. CNA #4 stated she requested LPN #5 to turn the air conditioning down in the room because the resident was sweating so much. CNA #4 stated LPN #5 came into the room and turned the air conditioning down. CNA #4 stated she did not think LPN #5 had assessed the resident when he came in the room, and further stated the resident was talking to her earlier when LPN #5 was in the room. The State Agency surveyor stepped out of the room, and asked LPN #5 to check on Resident #10. LPN #5 entered the room, and Resident #10 responded to him when he assessed her. LPN #5 stated she looked, and responded as she normally does, but the sweating was unusual. LPN #5 stated Resident #10 had recently returned from a hospitalization for a hypoglycemic episode, and he would check her blood sugar level now. An interview on 3/7/17 at 5:25 PM, revealed CNA #4 stated she had asked LPN #5 to come to Resident #10's room about 4 PM due to the resident was sweating, and he was there about five (5) minutes later. CNA #4 stated Resident #10 was able to talk, and was responsive at that time. CNA #4 stated LPN #5 turned the air conditioner down, but did not think he checked the resident. CNA #4 stated LPN #5 was on the med cart at the time, and was making his way to Resident #10's room. CNA #4 stated LPN #5 checked Resident #10's blood sugar, and it was low. An interview on 3/7/17 at 5:30 PM, with LPN #5 revealed Resident #10's blood sugar was low at 43. He treated it with two (2) cups of Koolaid, and Med Pass. He notified the doctor who gave an order to recheck the blood sugar in 15 minutes, and if it is not up to 60, give the [MEDICATION NAME] one milligram intramuscular (1 mg. IM). LPN #5 stated he rechecked the blood sugar, and it was still 43, and he administered the [MEDICATION NAME] as ordered. Review of Resident #10's (MONTH) (YEAR) Medication Administration Record (MAR), and Nurse's Notes dated 3/7/17 at 5:30 PM, revealed LPN #5 documented the administration of the [MEDICATION NAME] one (1) mg. IM on 3/7/17 at 5:30 PM. An interview with Licensed Practical Nurse (LPN) #5 on 03/08/17 at 2:50 PM, regarding the care plan, revealed he agreed he did not follow the care plan, and should have checked Resident #10's blood sugar due to the profuse sweating when CNA #4 first reported it to him. A review of Resident #10's Nurse's Notes for the month of (MONTH) (YEAR) revealed the resident had an accucheck that read a low blood glucose level of 41 at 6:00 AM on 03/06/17, and the resident was alert and responsive, was given a form of carbohydrate that contained glucose, and another accucheck was taken at 6:30 AM that read a blood glucose level of 48. Treatment was repeated, and the next blood glucose level was obtained at 6:50 AM, and read 82. There was no indication in the Nurse's Notes Resident #10's physician was notified at that time of the low blood glucose. A review of Resident #10's Medical Record revealed the following: The Medication Administration Record (MAR) for the Month of (MONTH) (YEAR), revealed Resident #10's Detemir ([MEDICATION NAME]) insulin had been held on 03/07/17 during the 7AM to 3 PM shift by RN #5. A review of the Nurse's Notes for Resident #10 revealed no note regarding holding the insulin during the day shift on 03/07/17. Resident #10's Detemir ([MEDICATION NAME]) insulin was not administered per the Care Plan. An interview with Registered Nurse (RN) #5 on 03/08/17 at 2:30 PM, revealed she had withheld the insulin for Resident #10 during the day shift on 03/07/17, did not notify the physician of holding the insulin, and had not done a nurse's note regarding withholding the insulin. RN #5 stated she recorded on the MAR she withheld insulin due to parameters. RN #5 stated she left early, and did not report to RN #6 who releived her (RN #5) when she left, the insulin was held, so RN #6 did not report the insulin was held to LPN #5 when he came on to work the 3 PM to 11 PM shift. RN #5 agreed she did not follow Resident #10's care plan related to reporting and documenting. An interview on 03/08/17 at 8:20 AM, with Resident #10's attending Physician revealed he had not been notified of Resident #10 having a hypoglycemic episode on 03/06/17, or the insulin was held on 03/07/17. The physician stated he expected that he or his assistant would be notified. An interview on 03/09/17 at 10:20 AM, with the Director of Nursing (DON) revealed hypoglycemic episodes, and holding insulin should be reported to the physician or physician's assistant. Further interview with the Director of Nursing (DON) on 03/09/17 at 11:15 AM, revealed she agreed the care plan had not been followed related to reporting and monitoring of Resident #10's diabetic symptoms, and to administer the insulin as ordered. An interview on 03/09/17 at 11:15 AM, with the Director of Nursing (DON) and the Certified Family Nurse Practitioner revealed the CFNP stated he came to the facility to perform daily rounds on 03/06/17, during the morning shift. The CFNP stated he identified on the MAR Resident #10 had a hypoglycemic episode on the morning of 03/06/17. The CFNP stated he had not been informed of the episode prior to his review of the MAR. The CFNP stated he would expect to be notified of hypoglycemic episodes, and was easily accessible to staff as was the attending physician. The CFNP stated he had not been notified of the nurse holding the insulin on 03/07/17. A review of Resident #10's Face Sheet revealed Resident #10 was originally admitted by the facility on 06/18/10, and had current [DIAGNOSES REDACTED]. A review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/17/17, revealed Resident #10 was assessed by staff for cognitive skills for daily decision making, and found to be moderately impaired, indicating decisions were poor, and cues/supervision were required. Resident #16 Review of Resident #16's Care Plan with a revision date of 03/08/17, revealed the resident will remain free from catheter-related trauma through review date. An intervention added to the Care Plan on 03/07/17, listed: Ensure leg strap is in place to secure Foley tubing. An observation in the presence of Licensed Practical Nurse (LPN) #3/Care Plan and Minimum Data Set Nurse, on 03/08/16 at 11:45 AM, revealed Resident #16 was in his bed. Resident #16 had a Foley catheter in place without a leg strap to secure the Foley catheter tubing to his leg. During an interview on 03/07/17 at 11:45 AM , LPN #3/Care Plan and MDS Nurse confirmed the findings, and revealed that using a leg strap with a Foley Catheter is to prevent damage by preventing pulling and tugging on the tubing. LPN #3 stated nurses and Certified Nursing Assistants (CNAs) were responsible for checking and applying the leg straps while delivering care. During an interview on 03/10 17 at 9:30 AM, Registered Nurse (RN) #2/MDS and Care plan Nurse, revealed a care plan's purpose is to guide caregivers to care for a resident. RN #2 revealed a revision to the plan of care was made on 03/08/17, to include the application of the Foley catheter strap. She confirmed the prior care plan did not include instructions to secure a Foley catheter to a resident's leg using a strap. RN #2 said most of the time a care plan is not that specific, and a Nurse or CNA would rely on their training. RN #2 stated placing a Foley Catheter strap is just part of Foley Catheter Care, and if they did not use a strap, then they did not follow the Plan of Care. Review of the Face sheet revealed the facility admitted Resident #16 on 12/29/16, with [DIAGNOSES REDACTED]. Resident #6 Review of Resident #6's Care Plan revealed a problem to address a Foley catheter in place with interventions to ensure a leg strap was in place to secure the Foley tubing, and position the catheter bag and tubing below the level of the bladder. Observation on 03/08/17 at 3:25 PM, revealed Certified Nursing Assistant (CNA #1) performed incontinent care on Resident #6. Resident #6's Foley catheter bag was lying on the bed near the resident's feet. Further observation during the Foley catheter care revealed at 3:35 PM, Resident #6 was lying on her back without a device to secure the Foley catheter tubing, and the Foley catheter tubing was lying between Resident #6's legs. Interview on 03/10/17 at 10:15 AM, with Licensed Practical Nurse (LPN) #2 revealed if the care plan states to provide catheter care and a Foley catheter strap is not present, then the care plan is not being followed. Review of the Face Sheet revealed the facility admitted Resident #6 on 02/01/17, with [DIAGNOSES REDACTED]. A review of the admission Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 02/08/17, revealed Resident #6 did not fully complete the Brief Interview for Mental Status (BIMS). Per staff interview, Resident #6 has moderately impaired cognitive skills. Resident #15 Review of Resident #15's Care Plan revealed a problem to address the Foley catheter related to Benign Neoplasm of the Prostate, and risk for infection initiated on 9/20/16. Interventions included to provide Foley catheter care every shift, and prn (as needed). An observation, and interview on 03/07/17 at 12:25 PM, revealed Licensed Practical Nurse (LPN) #1 pulled back the covers on Resident #15. LPN #1 confirmed there was not a catheter strap in place on Resident #15. LPN #1 revealed the catheter strap should have been in place. A review of the Face Sheet revealed the facility admitted Resident #15 on 09/20/16, with [DIAGNOSES REDACTED]. Review of the most recent quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 12/16/16, revealed Resident #15 scored 14 on the Brief Interview for Mental Status (BIMS), which indicated cognitively intact. |
2020-09-01 |