cms_UT: 86
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 86 | PIONEER CARE CENTER | 465020 | 815 SOUTH 200 WEST | BRIGHAM CITY | UT | 84302 | 2018-06-21 | 684 | D | 0 | 1 | EUNP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined, for 1 of 31 sample residents, that the facility did not ensure a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choice. Specifically, facility staff did not monitor and reassess a resident after the resident experienced a change in condition, causing the resident to experience [DIAGNOSES REDACTED] (low blood sugar), [MEDICAL CONDITION] (high blood sugar) and discomfort. Resident identifier: 93 Findings include: Resident 93 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 93's medical record was reviewed on 6/21/18. An admission Minimum Data Set ((MDS) dated [DATE] revealed that resident 93 had a [DIAGNOSES REDACTED]. The MDS further revealed that resident 93 received 7 insulin injections in the last 7 days. A care plan dated 6/24/18 revealed a Focus of (Resident 93) had Diabetes Mellitus type 1. She is at risk for episodes of hyper and [DIAGNOSES REDACTED]. Signs of [DIAGNOSES REDACTED] are decreased alertness and lethargy. The Goals developed were, (Resident 93) will be free from any signs and symptoms of [MEDICAL CONDITION] through the next review date, . free from any signs and symptoms of [DIAGNOSES REDACTED] through the review date, .will have no complications related to diabetes through the review date. One of the interventions developed was, Diabetes medications as ordered by doctor. Monitor/document for side effects and effectiveness. Resident 93's physician's orders [REDACTED]. a. 6/7/18, Invokana tablet 300 mg (milligrams) one tablet per day for Type 1 diabetes mellitus with other specified complication. Resident's medication was scheduled to be administered at 8:00 AM. b. 6/7/18, [MEDICATION NAME] solution 100 units/mL (milliliter), inject 20 units subcutaneously one time a day related to Type 1 diabetes mellitus with other specified complication. Resident 93's medication was to be administered at 8:00 AM. c. 6/6/18, Vancomyacin HCl ([MEDICATION NAME]) 100 mg. Use 1 gram intravensiously one time a day related [MEDICAL CONDITION], unspecified organism for 14 days. d. 6/6/18, Meropenem solution.1 gram intravensiously every 8 hours for bacterial infection for 14 days. A reviewed of the [MEDICATION NAME] pharmacology information provided by the facility revealed the Onset for [MEDICATION NAME] is 3 to 4 hours with peak amount provided 3 to 9 hours. Reference: http://www.globalrph.com/long-acting-insulins.htm# Resident 93's nursing progress notes revealed the following entries: a. On 6/7/18 at 7:43 PM, Received critical lab (laboratory) values: Glucose 31 Platelets - 938 Hgb (hemoglobin) - 6.8. Able to get BS (blood sugar) up to 114. Call received from (physician) (on call for (resident 93's physician)). Notified house MD (Medical Doctor) in AM (morning). Will CTM (continue to monitor) for any needs or changes. b. On 6/8/18 at 2:45 AM, Left message for spouse at number provided by resident to call facility for update on resident. c. On 6/8/18 at 2:47 AM, .c/o (complaints of) of (sic) abd (abdominal), bloody diarrhea.'something's not right. I want to go to the ER (emergency room ).' Resident 93's Emergency Provider Report from the local hospital dated 6/8/18 revealed a history that .She had complications of DKA (diabetic ketoacidosis) and pneumonia for which she was transferred to (another hospital) for an extended period of time. The discharge/care plan revealed, .The patient will be transported for further care and management or will be moved to an observation or inpatient service. d. On 6/9/18 at 8:55 PM, Resident admitted from (local hospital). e. On 6/11/18 at 7:18 PM, Nurse had started the pt's (patient) IV meropenem .When nurse came in to stop the meropenem and start the IV Vanco, pt was in the same place, and still was not waking up with sound. Nurse tried to wake pt up with touch, and spoke louder. Sternal rub then done, still with no response. Nurse ran and got glucometer, since pt was recently sent to hospital for low blood sugars and other critical labs. Pt's BS was too low to register. Gluco-gel given immediately following. Nurse also got some orange juice with added sugar and began using syringe to administer. The entire time pt was breathing, and pt had been sat up to about 80 degrees. Pt was swallowing the orange juice with prompting. BS checked again, and it registered at 27. Interventions continued, and BS checked one minute later, and it was 20. Ambulance called to get her to the hospital. Pt's family notified. EMTs (emergency medical technician) arrived and did vitals, and gave [MEDICATION NAME] injection to left deltoid. They then transported her to the hospital. MD notified. Resident 93's Emergency Provider Report from a local hospital dated 6/11/18 revealed, This is a [AGE] year-old femal brought in by EMS for low blood sugar. The patient is at a rehab facility receiving chronic antibiotics [MEDICAL CONDITION]. She was found unresponsive in her room by nursing staff. The patient is an insulin-dependent diabetic and was given her normal morning dose of insulin. The report further revealed On arrival we were able to access the PICC line and the patient was given an amp of D50 ([MEDICATION NAME]). After 5 minutes the patient was fully awake and conversant with a normal neurologic exam. With a lot of encouragement she was able to eat a sandwich and some fruit. The report stated that she was transported back to the facility in stable condition. A form titled Discharge Instructions dated 6/11/18 at 10:04 PM revealed, Follow-up: Monitor and write down your blood sugar at least twice daily. f. On 6/12/18 at 1:16 AM, .(Patient had) some confusion but is improving. Pt has a PICC (peripherally inserted centeral catheter) line in her right forearm that is patent and flushes well. Pt seems to be tolerating ABX (antibotics) well with no s/s (signs/symptoms) of A/E (adverse effects) .Pt returned from (local hospital) around 2230. ER staff reported that they gave her D50 IV solution that brought her BS up. Pt was given a sandwich, chips, and some dessert. Pt tolerating medications, treatments, and therapies well WCTM (will continue to monitor) closely. g. On 6/13/18 at 4:01 PM, Pt slightly lethargic and c/o dizziness. BS 37, gave glucose and 120ml of med pass. h. On 6/13/18 at 8:02 PM, Rechecked BS at 1800 and it was 68, gave another 120ml of med pass and BS is currently 101. Pt states she is feeling much better. MD aware. i. On 6/14/18 at 9:51 PM, . Pt BS continue to be low. Pt BS are check frequent and low BS are addressed with orange juice if needed. (Note: There were no additional documented blood glucose levels obtained this day.) j. On 6/14/18 6:21 PM, Hospital called regarding labs that had some critical values. MD called multiple times with no response as of yet, but the office said they would call back.Glucose 45 (L). k. On 6/15/18 at 11:25 AM, .New order to decrease [MEDICATION NAME] to 10 units Subcutaneous QD (daily). WCTM. l. On 6/15/18 at 6:57 PM, .In relation to multiple low blood sugar levels, N.O. (new order) for D50, 50% solution/50mL vial, mix with 100ml NS (normal saline) bag and administer over 1 hr. m. On 6/18/18 at 11:57 AM, Low blood sugar episodes. A Physicians Progress Note dated 6/19/18 that was completed by the Physician's Assistant recommended blood sugar checks three times daily. Resident 93's blood glucose levels documented were: a. 6/11/18 at 7:17 PM, 20.0 mg/dL (milligrams per deciliter) b. 6/12/18 at 7:59 AM, 245 mg/dL c. 6/13/18 at 7:29 AM, 163 mg/dL d. 6/13/18 at 9:38 AM, 88 mg/dL e. 6/13/18 at 4:01 PM, 37 mg/dL f. 6/14/18 at 7:47 AM, 144 mg/dL g. 6/14/18 at 6:21 PM, 45 mg/dL h. 6/15/18 at 7:55 AM, 176 mg/dL g. 6/16/18 at 8:10 AM, 578 mg/dL h. 6/17/18 at 7:01 AM, 279 mg/dL i. 6/18/18 at 8:38 AM, 400 mg/dL j. 6/19/18 at 8:02 AM, 344 mg/dL k. 6/20/18 at 7:55 AM, 295 mg/dL (Note: The above blood glucose levels were all the blood glucose levels obtained at the facility for resident 93. Resident 93's blood glucose was obtained in the evening were 20, 37, and 45. Resident 93's other blood glucose levels were obtained in morning and were elevated except on 6/13/18.) A Facility policy with a (YEAR) reference was retrieved by the CRN. Review of Policy entitled Nursing Care of the Resident with Diabetes Mellitus revealed, Glucose Monitoring: . 2. The physician will order the frequency of glucose monitoring. 3. Residents whose blood sugar is poorly controlled or those taking insulin may require more frequent monitoring, depending on the situation. .Management of [DIAGNOSES REDACTED] 2. For asymptomatic and responsive residents with [DIAGNOSES REDACTED] ( 3. For symptomatic and unresponsive residents with [DIAGNOSES REDACTED] ( On 6/20/18 at 9:19 AM, an interview was conducted with resident 93. Resident 93 reported that she had not had to use her glucose tablets at home except when she was doing extensive yard work. Resident 93 reported that since admission to the facility her low blood glucose levels were in the late afternoon and early evening. Resident 93 stated that her blood glucose levels were checked by facility staff mostly in the morning. Resident 93 stated that she had received her [MEDICATION NAME] and Invokana in the mornings, in addition to her antibiotics around 8:00 AM and 8:00 PM. On 6/20/18 at 10:55 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that signs and symptoms of [MEDICAL CONDITION] included headaches, dizziness, sweating, thirst, and high blood glucose levels. LPN 1 further stated that signs and symptoms of low blood glucose included dizziness, [MEDICAL CONDITION], nausea, lightheadedness, and low blood glucose levels. LPN 1 stated that she notified the physician when the blood glucose was outside parameters ordered ordered by the physician or if the blood glucose was over 500, or under 60. On 6/20/18 at 3:20 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that blood glucose should have been called to the doctor per order protocol and if glucose is over 400 or under 60. The DON stated that blood glucose less than 60 mg/dL the diabetic medications should be held per nursing discretion. The DON stated that nursing staff were to give a snack or juice, and recheck in an hour. The DON stated there should be a physician's orders [REDACTED]. The DON stated that the protocol for low blood sugar was to give glucose tablets, sternal rub, check vital signs, recheck blood glucose with a different monitor and check the residents code status. The DON stated that an unresponsive resident should not be administered beverages. The DON stated that she did not know if there was a policy to give IV medications, so facility staff would encourage the resident to eat. The DON reported that for Resident 93, we tried to get medication changes and IV [MEDICATION NAME] orders. The DON further stated that, We would get orders to check blood sugars more frequently. On 6/20/18 at 3:30 PM, an interview was conducted with the Corporate Resource Nurse (CRN). CRN stated that there has been no in-service about [DIAGNOSES REDACTED] or [DIAGNOSES REDACTED]. On 6/20/18 at 10:55 AM, an interview was conducted with LPN 1. LPN 1 stated that Resident 93's Invokana could definitely cause lower blood sugar levels along with her antibiotics. LPN 1 stated that resident 93's blood sugar levels should have been checked more often. LPN 1 stated that she notified the physician of a blood glucose on 6/19/18 of 344. LPN 1 stated Sometimes it takes a while for labs. I'll call (the doctor) a couple times a day. LPN 1 stated that the IV emergency kit had [MEDICATION NAME]. LPN 1 stated that resident 93's blood glucose levels were not controlled. LPN 1 stated when resident 93 admitted she was sent to a local hospital for low blood glucose. On 6/20/18 at 11:12 AM, an interview was conducted with LPN 2. LPN 2 stated that if a resident had [MEDICAL CONDITION], she would call the doctor if the blood glucose was over 400 mg/dL. LPN 2 stated that for [DIAGNOSES REDACTED], with blood sugar less than 60 mg/dL, she would follow the protocol to administer glucose tablets or glucose gel. LPN 2 stated that if the resident was not responsive, she would follow the POLST orders if we couldn't get her back up. LPN 2 further stated Now we have orders for D50. LPN 2 stated that Resident 93's blood sugar should be running high due to antibiotic prescriptions. LPN 2 stated that she thought blood glucose was monitored twice daily, but confirmed the order for once daily monitoring. LPN 2 stated that she had notified the Medical Director, who responded OK to the low blood sugars. LPN 2 stated that she did not keep the texts to the physician and did not document communication in a nurses' note. On 6/20/18 at 3:00 PM, an interview was conducted with LPN 3. LPN 3 stated that she contacted the physician regarding the high blood glucose. LPN 3 stated that she was unable to provide documentation and did not create a nurses' note that the physician was notified. | 2020-09-01 |