| 85 |
AVAMERE HEALTH SERVICES OF ROGUE VALLEY |
385024 |
625 STEVENS STREET |
MEDFORD |
OR |
97504 |
2019-06-20 |
658 |
G |
1 |
0 |
90J611 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review it was determined facility staff failed to ensure professional standards were followed related to equipment safety and medication administration for 2 of 8 sampled residents (#s 4 and 5) reviewed for medications and accidents. Resident 4 experienced a symptomatic hypoglycemic (low blood sugar) episode with a low blood sugar level of 22. Findings include: 1. Resident 4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A public complaint was received on [DATE] indicating Resident 4 was administered 70 units of [MEDICATION NAME] (a long-acting insulin used to lower blood sugars) despite the resident stating she/he was not receiving that dose in the hospital. This resulted in a low blood sugar and the resident was sent out to the hospital. A physician order [REDACTED]. The resident received 70 units on [DATE] at 7:00 PM. A physician order [REDACTED]. The residents blood sugar at 9:00 PM was 427 and she/he was administered 12 units of Humalog per sliding scale. A Situation, Background, Assessment or Appearance (SBAR) progress note dated [DATE] at 3:45 AM indicated the following: -At 5:05 AM Staff 30 (LPN) was called to the residents room. The resident's skin was cool to touch, sweaty and the resident had mild shaking. Staff 30 checked the resident's blood sugar and the reading was 22. The note indicated Staff 30 consulted with another nurse and the hospital emergency department was contacted. -The emergency medical technicians (EMTs) arrived and checked the resident's blood sugar which was lower than their machine could read. The EMTs started an Intravenous (IV) [MEDICATION NAME] (a form of glucose injected into a vein through an IV to treat low blood sugar) and rechecked the blood sugar level which was 118. At 5:50 AM Resident 4 left for the hospital. Hospital records dated [DATE] through [DATE] indicated the following: -Resident 4 admitted for significant hypoglycemic (low blood sugar), [MEDICAL CONDITION] activity with [DIAGNOSES REDACTED] (low potassium in the bloodstream). Resident 4 indicated she/he was given too much insulin at the nursing facility. - Resident 4 developed [MEDICAL CONDITION] (abnormal heart rhythm characterized by rapid and irregular beats) and her/his lactic acidosis (an overproduction of lactic acid) was elevated, likely due to her/his low blood sugar. On [DATE] at 9:31 AM Resident 4 stated she/he admitted to the facility on [DATE] from the hospital. During her/his hospital stay she/he recalled being administered 30 units of [MEDICATION NAME] two times daily. On [DATE] the nurse came in to administer her/his insulin and indicated she/he would be given 70 units of [MEDICATION NAME]. The resident told the nurse this was not what she/he received in the hospital. The nurse stated this is what the order is and that is what will be given. The resident stated she/he woke up around 4:00 AM and was groggy, hot, sweaty and felt out of sorts, did not really know how (she/he) called for help, but did. The same nurse that administered the insulin came in and took her/his blood sugar, which was in the low 20s. The resident thought the paramedics arrived around 6:15 AM and blood sugar was even lower. Resident 4 stated they transported her/him to the hospital. The resident requested not to return to the facility at the hospital and stated I could have died . On [DATE] at 10:28 AM Staff 30 stated she recalled the resident and worked with her/him the night of [DATE]. She indicated she reviewed the medications in the system and administered the insulin per physician orders. When asked if the resident had concerns regarding the 70 units of insulin Staff 30 did not recall the resident having any issues or concerns regarding the dosage. She stated a CNA called her into the resident's room due to the resident reporting she/he feeling shaky. She stated she took the resident's blood sugar and the reading was low, that's when she contacted the paramedics. She could not recall anything else about the incident. On [DATE] at 11:34 AM Staff 11 (RNCM) stated if a resident was questioning her/his insulin dosage she would have expected Staff 30 not to administer the medication and follow up on the concern. Staff 11 stated the residents voice trumped the administration of medication when in question. On [DATE] at 11:42 AM Staff 2 (DNS) stated she would expect staff to utilize subjective data especially related to physician orders. She stated when a resident tells the nursing staff a medication does not look right or dosage does not sound right staff should stop and follow up on the questioning before administering the medication. 2. Resident 5 admitted to the facility ,[DATE] with [DIAGNOSES REDACTED]. An undated Kardex (a form utilized by CNAs to provide care to residents) indicated Resident 5 was a two person assist with all ADLs including transfers. A Fall Investigation dated [DATE] at 11:00 AM by Staff 36 (Interim DNS) revealed the following: -The resident was sent out to the hospital for uncontrolled pain and agitation. The resident had a right [MEDICAL CONDITION]. -The investigation indicated Staff 36 spoke with the Witness 5 (Complainant) and she reported Resident 5 was placed in the sit to stand (used to assist with mobility for patients that are unable to transition from a sitting position to a standing on their own) to be toileted and only one CNA, Staff 43 (CNA) was available and the resident started to slip down. The patient fell down to the floor and complained of leg pain. -Witness 5 reported Staff 44 (LPN) called the witness and was worried the resident may have had a blood clot so Staff 44 sent the resident out to the hospital. Witness 5 then found out the resident had fractured her/his hip. -Interviews completed indicated Staff 43 (CNA) and Staff 40 (CNA) were both transferring the resident to the bed side commode when the battery on the sit-to-stand died . Staff 40 had to go down and exchange the batteries. Upon Staff 40's return the resident stated My legs are giving out and instead of using the sit-to-stand machine Staff 43 and Staff 40 both controlled lowered the resident to her knees and then laid the resident with pillows under her head . A Fall investigation dated [DATE] completed at 9:05 PM by Staff 44 (LPN) revealed Resident 5 continues to have behaviors, yelling at staff and very forgetful. Resident was up in a sit-to-stand to be transferred to bed. Battery to the sit-to-stand dead x 3. Resident yelling, so staff lowered Resident to floor onto blue mesh sling for Hoyer transfer to bed. Resident hoyered to bed with 3 staff assist . Hospital records dated [DATE] revealed Resident 5 had a mildly displaced right [MEDICAL CONDITION]. On [DATE] at 9:51 AM Staff 43 (CNA) stated she worked night shift, which started 10:00 PM at night and she recalled on [DATE] the resident needed to use the bathroom. Staff 43 indicated she and Staff 40 (CNA) got the resident up in the sit to stand and the battery went dead in the machine. Staff 40 went out and got a battery just outside the hallway and that battery was not good either, so Staff 40 had to go a little farther down the hall to get a second battery and that one was not good either. Staff 43 stated two sets of batteries and both were dead. She indicated the batteries were often dead in the sit-to stands you never knew when they were going to stop working until you used them. The battery worked just fine to get the resident up into the sit to stand and then went dead prior to being able to lower her back down into the resident's bed. Staff 42 indicated Resident 5 was only in the sit to stand for about 2 minutes before she and Staff 40 lowered the resident to the ground manually, we took the resident out of the sit-to-stand station and down to the floor. She and Staff 40 then had a Hoyer (mechanical lift) sling (a device used to suspend a resident in the Hoyer and move them appropriately) that was not underneath the resident when they lowered her manually to the floor, so we had to log roll the resident on the floor to get the Hoyer sling underneath the resident. We then lifted the resident up into bed. Staff 43 further indicated Staff 40 was in the room when the resident was put into the sit to stand station prior to trying to get the resident to the bathroom. Staff 43 stated the resident was screaming the whole time that she was hurting, hurting for months. She indicated the resident was a screamer, did not like to use the call light and pounded on the walls. She stated Staff 44 (LPN) came into the room and sent the resident out to the hospital. An observation on [DATE] at 8:34 AM revealed the sit to stands, hoyers, scale and batteries were located at the front of the 200 hall. There were four batteries on the wall adjacent to the scale. The batteries were all plugged in the outlet and all four revealed a small green light indicating charge/on. Below that green light was another light and a word next to it that indicated charge. The batteries and the sit to stand station was approximately ,[DATE] feet from Residents 5's room. On [DATE] at 5:17 PM Staff 44 (LPN) worked night shift was familiar with Resident 5 and indicated she was alert most of the time with mild confusion. She recalled the incident on [DATE] and stated Resident 5 was hollering in the hallway and she saw Staff 43 take the resident into her/his room. The resident continued screaming so she finally went down to the room to see what was going on and both Staff 40 and 43 were in the room with the resident on the floor and on a Hoyer sling. They preceded to get the resident back up using the Hoyer and she supported the resident's head as the two CNAs moved the resident back into bed. Staff 44 indicated she did not witness Staff 40 or 43 lowering the resident to the floor but arrived after the incident and both the CNAs were very upset about all three batteries being dead and having to lower the resident to the ground manually. Once the resident was back in bed the resident was complaining of back pain so she asked the resident if she/he wanted a pain pill, which the resident accepted. Staff 44 stated the resident continued to holler about being painful and needing to use the bathroom, however they did not get the resident back up. She stated after 30 minutes the pain medication was not effective and she then completed an assessment on the resident, although since the resident did not walk she did not do any range of motion testing to the the lower extremities. The resident continued complaining and pointing to her low back area and she sent the resident out to the hospital, she had a feeling it may have been the resident's leg. On [DATE] at 2:44 PM Staff 36 (Interim DNS) stated both Staff 40 (CNA) and Staff 43 (CNA) reported to him they were both in the room at the time the resident had the fall. The CNAs both reported the battery died in the sit to stand machine and they had to manually lower the resident to the floor as they lowered the resident to the floor, the resident's hip could have spontaneously fractured her/his hip. Neither Staff 40 or 43 utilized the emergency lever on the sit to stand machine to his knowledge. When asked the question how would Staff 40 and 43 get the resident out of the sling from the sit to stand? Staff 36 stated both CNAs would have to be able to lift the resident up, then the straps would have to be removed and then lower the resident down to the floor. On [DATE] at 11:33 AM Staff 1 (Administrator) acknowledged they did not have a system in place at the time of the incident related to assuring batteries were charged out appropriately after each shift. On [DATE] at 3:14 PM he stated maintenance does weekly checks to assure batteries are working and charged appropriately. When asked when the system was put into place for maintenance to check batteries Staff 1 indicated this was implemented last week. -Refer to F689, F908 |
2020-09-01 |