72311 Nursing Service - General
(a) Nursing service shall include, but not be limited to, the following:
(1) Planning of patient care, which shall include at least the following:
(A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission.
72311 Nursing Service - General
(a) Nursing service shall include, but not be limited to, the following:
(3) Notifying the attending physician promptly of:
(B) Any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a patient.
An initial unannounced visit was made to the facility on 09/29/06 to investigate Complaints #CA00093655 and #CA00093791.
The Department determined that the facility failed to:
1) Identify Patient A's needs based on continuing assessment and
2) Failed to notify the attending physician of marked changes in the patient's condition.
These failures resulted in Patient A's condition rapidly deteriorating. On 09/14/06 at 8:00 p.m., he was found difficult to arouse and incoherent by a visiting family member who alerted staff about changes in the patient's condition. He was transferred to a hospital where he was diagnosed with renal failure and staphylococcus aureus septicemia (an overwhelming generalized infection caused by staphylococcus bacteria. The Patient Summary document listed multiple secondary diagnoses including sepsis (the presence of pus-forming bacteria of other toxins in the blood or tissues), Staph aureus pneumonia, acute respiratory failure, cardiogenic shock (circulatory shock), hyponatremia (abnormally low level of sodium in the blood) hyperpotassemia (higher then normal level of potassium in the blood associated with kidney failure or the use of diuretics) and hypotension (significantly low blood pressure). Patient A expired on 09/18/06. The death certificate listed the immediate cause of death as sepsis, listing pneumonia as secondary cause of death.
Patient A was a 62-year-old male, was admitted to the facility on 07/20/06. He had been discharged from the hospital to home on 07/18/06 but could not be supported there. He required inpatient skilled nursing care. The admission diagnoses included adult failure to thrive, advanced congestive heart failure, coronary artery disease, coronary artery bypass graft and renal insufficiency. The September 2006 physician orders indicated Patient A was taking multiple medications including the blood pressure medication (Lisinopril) and diuretic medication (Lasix). The September 2006 physician orders contained a 07/21/06 order for occupational and physical therapy to increase the patient's safety awareness and functional ability. It was anticipated that he would return home.
The 07/11/06 hospital History & Physical indicated that Patient A lived alone prior to the hospital admission. The patient had a long history of heart disease beginning more than 20 years ago, with a history of heart surgery and multiple cardiac catheterizations. The patient was had required a right below knee amputation for vascular disease and he had prior episodes of pneumonia. The 07/18/06 hospital Discharge Summary documented Patient A's condition was stable at the time of discharge.
The clinical record contained July 2006 through September 2006 facility's physician orders that indicated Patient A's "Rehab potential: marked improvement (was) anticipated." The monthly recapitulation of physician orders documented Patient A was "capable of understanding his rights, responsibilities, and rules governing conduct." Review of the most current Physician Orders Concerning Life Sustaining Treatment and Intensity of Care, signed by Patient A on 07/20/06, documented Patient A desired maximum care, CPR (Cardiopulmonary Resuscitation), and all supportive measures such as antibiotics, IV (intravenous fluids), naso-gastric fluids, and oxygen.
The admission MDS (an assessment tool) completed on 07/25/06 documented Patient A was cognitively intact, with no mood or behavioral problems. Patient A's assessment indicated he required a set-up to one-person assist with Activities of Daily Living (ADLs) such as bathing, toileting, ambulation and transfers.
Review of nurses' notes from the time of admission on 07/20/06 until 08/30/06 documented that Patient A was alert and oriented, continent of bowel/bladder, and required limited assistance of staff with ADLs, mobility and transfers. On 08/22/06 at 3:00 p.m., nurses documented Patient A had episodes of diarrhea and orders were received for Lomotil 5 mg one tablet as needed. On 08/30/06 at 11:00 p.m., a nurse documented that Patient A was able to verbalize needs to staff, was independent with transfers and bed mobility, required limited assistance with ADLs and was working with physical therapy on his goals.
On 09/10/06 at 7:30 p.m., a nurse documented Patient A refused dinner and was noted to have slightly jaundiced (yellow) skin. On 09/11/06 at 2:45 p.m. a nurse documented the patient "took 25% and 10% of diet" and refused substitutes. The note indicated the patient was resting quietly in bed with no shortness of breath, pain or discomfort.
On 09/12/06 at 11:00 a.m., LVN (Licensed Vocational Nurse) 4 documented the following: "Res (patient) c/o (complaining of) general malaise. Moist nonproductive cough noted. O2 sats (oxygen saturation) 77% on RA (room air). (Normal range is 93-100% on room air), O2 @ 2L/min (oxygen at 2 liters per minute) via NC (nasal cannula) administered with sats (up arrow) to 94 %. LS (lung sounds) with wheezing bilat UL (both upper lobes), diminished at bases. V/S (vital signs) 60/40 (blood pressure), 97.1 (temperature), 80 (pulse), 20 (respirations). MD (physician) called. Awaiting call back." On 09/12/06 at 11:30 a.m., the nurse noted second attempt to reach MD. On 09/12/06 at 2:00 p.m., the nurse documented an order was noted for Zithromax and Robitussin (antibiotic and cough medications).
On 09/12/06 at 11:45 p.m., LVN 4 documented Patient A's vital signs as follows: blood pressure of 60/40, temperature 97.1 (F) pulse 60 and respirations 24. The nurse noted the patient was alert, able to verbalize needs to staff and continued complaining of generalized malaise. The note indicated, "Productive cough continues. Robitussin as ordered. Refusing meals. Fluid intake (arrow down)." The nurse documented during the shift the patient remained in bed "by choice," was repositioned every two hours and skin color was slightly jaundiced. The O2 saturation was noted at 93% on 2 liters of oxygen. There was no indication the physician was notified about Patient A's refusal of meals and fluids, the low O2 saturation and that the blood pressure continued low at 60/40.
Laboratory results dated 09/12/06 documented Patient A's blood creatinine was 4.1 (his prior baseline was 1.4 and normal range was .5 - 1.3), his blood urea nitrogen was 65 (normal range is 6-21), serum sodium was 131 (normal range 134-143) and blood glucose was 56 (normal range 77-119). Laboratory record indicated that the physician was notified "per the facility" and "no new orders" were received.
The Department conducted an interview with LVN 4 on 11/21/06 at 3:30 p.m. regarding the care provided for Patient A and his condition on 09/12/06. The LVN stated she worked with Patient A frequently, mostly on the evening shift. The patient was usually alert, oriented, and independent with ADLs. Patient A was stable until 09/12/06, when other staff (did not recall name) reported to the LVN that the patient was complaining of cough and was not feeling well. LVN 4 confirmed she wrote the nursing notes on 09/12/06 at 11:00 a.m. and again at 11:45 p.m. The LVN stated that she notified the physician about the patient's first low blood pressure and his cough following the 11:00 a.m. assessment and received orders for Zithromax and cough medicine. The LVN stated she did not call the physician again after the 11:45 p.m. reassessment to notify the physician about Patient A's condition; the low O2 saturation or that the patient's low blood pressure continued.
In Nursing Notes on 09/14/06 at 3:10 p.m., RN (Registered Nurse) 1 documented the following: "VS (Vital Signs) = 82/45, 97.5, 60, 15 (blood pressure, temperature, pulse and respirations respectively). PT (patient) alert, respond well to commands, skin warm, pt pales, SOB (shortness of breath), lungs sounds decreased with crackles and wheezes bilaterally, abd (abdomen) with sounds normoactive, pt usually hypotensive, skin perfusion on extremities normal, he is on F/R (fortified) diet, no urine output present. Oncoming shift aware of it, no signs of distress at this time"-signed RN 1.
RN 1 confirmed in a 10/13/06 interview that Patient A's condition on 09/14/06 at 3:10 p.m. was as documented in the nursing notes. RN 1 did not comment when asked to explain how she considered the patient in stable condition, when the patient had shortness of breath, wheezes, decreased lung sounds and was hypotensive (lowered blood pressure) with no urine output. The RN stated that she was on a first or second day of orientation that day and she did not see Patient A before 09/14/06. The RN stated she assessed Patient A on 09/14/06 after CNA 2 called her to check on the patient. The RN stated she did not notify a physician regarding Patient A's condition on 09/14/06.
On 10/13/06 at 1:00 p.m., CNA 2 confirmed that on 09/14/06 she asked RN 1 to evaluate Patient A because the patient's blood pressure was very low and the patient had difficulty talking which was a change in condition for the patient.
Nursing notes documented that on 09/14/06 at 8:00 p.m., Patient A's visiting family member alerted a nurse regarding Patient A's condition. The note indicated Patient A was "difficult to arouse, unable to speak coherently or focus eyes." The note indicated the patient's "breath sounds decreased with upper airway rhonchi, color jaundice; sclera jaundice. No urine output. Call placed to Dr (name) - reported COC (change of condition), jaundice, anuria (no urine) x 22 hours, lethargy, (arrow down) B/Ps. Orders received to transfer to (name of hospital) ER (Emergency Room) for evaluation."
An interview was conducted on 11/21/06 at 11:00 a.m. with Patient A's physician. The physician stated that he was the admitting physician on 09/14/06. The physician stated he recalled nursing staff had called him on 09/12/06 about Patient A having signs and symptoms of pneumonia. The physician did not recall nurses notifying him about Patient A's low blood pressure of 60/40 on 09/12/06. The physician stated that he remembered his frustration that he was not notified about Patient A's decline timely. The physician stated that if he had known Patient A's condition had worsened and the blood pressure was low, he would have ordered Patient A to be sent to the ER on 09/12/06, especially since the patient was a full code.
The Emergency Room (ER) record showed that Patient A presented to the ER on 09/14/06 at 10:22 p.m., with a chief complaint of altered level of consciousness. The ER report showed the patient was somnolent, dehydrated and hypoglycemic (low blood sugar at 54). The ER report contained in part the following assessments: hypotension, hypoglycemia, abdominal pain, hyperbilirubinemia (high bilirubin level in blood), renal failure, questionable right lower lobe infiltrate.
The 09/14/06 hospital H&P (History and Physical) noted hypotension, a heart rate of 104 with atrial fibrillation (an irregular heart rhythm). The section "plan" indicated the patient was to be started on intravenous medication to improve his blood pressure and improve vascular flow to avoid further deterioration of his kidneys. A physician documented in a 09/15/06 consultation done for "critical illness. Respiratory insufficiency": "When I came to the bedside this afternoon, I found him (Patient A) to have unresponsiveness and weak respirations. I heard coarse upper airway sounds and so, after confirming with family that they were willing to have him undergo intubation (insertion of a tube into the air passages to support artificial ventilation), I went ahead and asked anesthesia to intubate him. Intubation was done without anesthetic and it was found that there were copious secretions in the upper airway that were purulent (containing puss) and thick brown."
The Patient Summary documented that Patient A expired on 09/18/06. The summary noted the admitting diagnosis was renal failure, the principal diagnosis was "staph aureus septicemia" and it listed multiple secondary diagnoses including sepsis, Staph aureus pneumonia, acute respiratory failure, cardiogenic shock, hyponatremia, hyperpotasemia and hypotension.
The Department determined that the facility failed to identify Patient A's needs based on continuing assessment and failed to notify the attending physician of marked changes in the patient's condition for Patient A when:
1. The staff failed to adequately assess Patient A and notify the physician for interventions when on 09/12/06 Patient A became hypotensive twice with shortness of breath and the patient's condition progressively worsened.
2. The nursing staff again failed to notify the physician of Patient A's condition when on 09/14/06 at 3:15 p.m. Patient A was noted with decreased lung sounds with wheezes, low blood pressure and no urine output.
Failure to notify the physician of a significant change in condition on 09/14/06 of symptoms which began on 09/12/06 and progressed on 09/14/06 at 3:00 p.m. resulted in a lack of medical advocacy for the patient, delay of acute care assessment and early treatment of beginning renal failure and sepsis.
These violations presented either (1) imminent danger that death or serious harm to the patients or residents of the long-term health care facility would result therefrom, or (2) substantial probability that death or serious physical harm to patients or residents of the long-term health care facility would result therefrom and were a direct proximate cause of death of the patient or resident.