CLASS AA CITATION -- PATIENT CARE
The inspection was limited to the specific facility event investigated and does not represent the findings of a full inspection of the facility.
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.
72315 - Nursing Service - Patient Care
(h) Each patient shall be provided with good nutrition and with necessary fluids for hydration.
On 6/26/08, an unannounced visit was made to the facility to investigate Complaint #CA00153502 regarding care and treatment.
The Department determined that the Facility failed to:
1. Continually assess Patient 1 for adequate hydration and urinary tract infection.
2. Provide Patient 1 with the necessary fluids for hydration.
These failures resulted in Patient 1 developing dehydration and a urinary tract infection (UTI) twice in the five weeks she lived at the facility. The second UTI resulted in transfer to a hospital, alteration in consciousness, sepsis (infection or infectious toxins in the blood or tissues) and septic shock (life threatening low blood pressure (shock) due to sepsis), that lead to cardiac arrest. She died on 4/14/08, less than nine hours after transfer to the general acute care hospital.
Review of Patient 1's health record indicated that Patient 1, 86 years old, was admitted to the facility on 3/5/08 at 8:00 p.m., after sustaining a mechanical fall that resulted in a fracture to her 4th lumbar vertebrae. The admitting physician ordered physical and occupational therapy, a back brace and determined her rehabilitation potential as 'good'. The patient's diagnoses at the time of admission included a closed fracture to the fourth lumbar vertebrae, personal history of fall, hypertension and pre-senile dementia.
On 3/5/08 at 8:20 p.m., the admission nursing assessment described Patient 1 as able to transfer with 1 person assist, bear full weight and ambulate with a wheel chair. Patient 1 ate independently and was continent of both bowel and bladder. The nurse described Patient 1 as alert, friendly, cooperative and answered questions readily. Under the discharge evaluation section, the nurse documented that the discharge plan was for short term care in the facility and discharge back to her previous assisted living facility.
On 3/5/08 an initial bowel and bladder assessment was completed and determined Patient 1 to have occasional and/or frequent bladder incontinence with no signs or symptoms of a urinary tract infection (UTI). The nurse assessed Patient 1 as able to participate in bladder retraining and initiated the training on 3/14/08.
On 3/7/08, the Facility developed a care plan for Malnutrition-Risk for Dehydration. The care pl an referenced the medi cati on, Hydrochlorothiazide 25 mg 1/2 tab per day (HTCZ, a medication to eliminate excess fluids from the body), as the primary component for the potential of dehydration. The goal marked on the care plan was to "show good evidence of hydration daily" as evidenced by:
> Normal vital signs
> Good skin turgor.
> Normal urinary output .
> Normal mucous membranes.
The interventions marked on the care plan were listed as:
> Allow sufficient time for resident to eat meal.
> Encourage fluids.
> Monitor daily for hydration.
On 3/11/08, the Registered Dietician (RD) provided a nutritional screening for Patient 1 and documented her assessment on the Dietitian's Assessment form. The RD determined Patient 1's body weight as 132 lbs and calculated her fluid needs as 1500-1800cc per day. The RD documented, ">1800 cubic centimeters (cc) fluids in diet per day, plus, ad lib fluids." The RD also documented that Patient 1's diet intake was not adequate to meet her needs as she consumed 0-50% of meals. The RD documented, "Weight at low end. Intake poor. At risk for malnutrition, weight loss and skin breakdown. Labs suggest anemia of chronic disease. Will alert nursing to monitor weights and skin closely".
On 3/20 at 4:20 p.m., the physician saw the patient and ordered a urinalysis with culture and sensitivity, "Now!" At 8:00 p.m. nursing received orders from the physician for intravenous (IV) fluids at 100 cc/hr for 12 hours, then 80 cc/hour for 72 hours and antibiotic (Rocephin) for a UTI. The 3/26/08 urine culture and sensitivity report (specimen collected 3/20/08) showed the urine was positive for two types of bacteria, proteus vulgaris and escherica coli, both from bowel system. On 3/20/08, a nurse documented, in the daily skilled nurse's notes, "IV hydration. Rocephin. Continues with strong, foul odor in urine. Fluids encouraged".
On 3/21/08, a nurse practitioner documented in the progress notes (no time indicated), "WBC's increased" (increased level of white blood cells indicative of infection) "Urine dirty. More confused last 2 days. Can't do therapy. UTI, dehydrated, hyponatremia".
The documentation on the intake and output record indicated from 3/7/08 through 3/20/08, Patient 1 received an average fluid intake of 1700 cc/day (within the RD recommendation of 1500-1800 cc/day), yet Patient 1 developed dehydration (requiring IV fluid replacement) and a UTI. Patient 1's output was not measured in fluid amounts; instead, staff recorded the number of times a day she urinated (usually 2-3 times a shift). There was no documentation that Patient 1's fluid needs were reassessed by the RD or nursing, after she was diagnosed with dehydration and a UTI. There was no change in fluid recommendations and there was no documentation that nursing or the RD considered the patient's response to HTCZ as a contributing factor to dehydration. Until 3/23/08, there was no documentation for the need for catheterization or to closely monitor Patient 1's urine output.
On 3/23/08 at 1:50 p.m. a nurse documented in the daily skilled nurses notes, "Abdominal distention. Urine, dark yellow, hazy, strong odor. Complain of severe lower abdominal pai n...unabl e to empty bl adder completely...Indwelling (brand name) catheter due to urinary retention. Rocephin was discontinued. Resident was then placed on Cipro 500 mg 1 Tab PO BID (twice a day) X 5 days."
From 3/21 through 3/24/08 Patient 1 received an average daily intake of 2700 cc (which included intravenous fluids). On 3/24 at 3:45 a.m. a nurse documented in the daily skilled nurses notes, "Temperature 99" and at 10:45 a.m., "Received order to DC IV once dose completed. IV discontinued as ordered. Antibiotics for UTI." In the "G.U." section nursing documented, "pinkish urine".
On 3/25 at 4:00 a.m. a nurse documented vital signs of, "BP: 87/62, (normal is 120/80), Temperature: 99, Heart rate: 90." There was no documentation of what interventions were done for the abnormally low BP. On 3/25/08, (no time indicated), a nurse documented, "Consumed 60% for lunch, 75% for breakfast...Indwelling catheter hazy yellow with sediment and blood also noted in bag and tube." At 11:55 p.m., nurses documented that Patient 1's vital signs were B/P: 126/72, P: 74, Temp: 97.3.
On 3/25/08, (no time indicated), an interdisciplinary team conference (IDT) was held regarding Patient 1. The IDT conference notes described Patient 1 as a new admit with a lumber fracture, on OT and PT, a full code, regular diet with no added salt, and in her room (1:1) for activities 2X's weekly. There was no indication that the IDT reviewed the nursing assessments for Patient 1 over the previous 2-week period or whether the care plans still addressed Patient 1 needs. There was no documentation in the conference notes that referenced the care plan for dehydration, the effects of the medication (HTCZ), the UTI, or the antibiotics and IV therapy. There was no note that referenced the RD's assessment on 3/11/08 or whether the diet was still appropriate for Patient 1. The IDT notes did not reflect a summation that addressed all areas of discipline or if the desired outcomes were being attained.
From 3/25/08 through 3/31/08, after the IV fluids were discontinued, Patient 1 received an average daily intake of 1550 cc. Intake & Output was not documented after 3/31/08.
From 3/26/08 through 4/2/08 nursing documented daily that the urinary catheter was patent. Descriptions of the urine included, "amber urine with sediment still noted in tube", "dark amber urine", "continues with hematuria (blood) in urine", "yellow urine with some red noted", and "yellow urine with small amount of sediment noted in tube".
From 4/1/08 through 4/5/08, (5 days) there was no documented recording of Patient 1's intake and output even though she maintained the indwelling catheter until 4/5/08. On 4/5/08, the Nurse Practitioner (NP) ordered the indwelling catheter to be removed. However, there was no documentation that Patient 1 was evaluated for the bladder retraining program or how the facility would ensure fluids were encouraged to maintain adequate hydration.
From 4/1/08 through 4/4/08 (4 days) on the Daily Skilled Nurses Note form, the nurses marked "Dehydration/Fluid intake" in the Services Provided section. The nurse's notes for this time period did not reflect the amount of fluids Patient 1 consumed, what measures were implemented to ensure adequate hydration or how the diuretic medication may have affected Patient 1's fluid status. On 7/12/10 at 12:35 p.m., an interview was conducted with the DON regarding the form for Daily Skilled Nurses Notes and what services were provided when the nurses marked the area for Dehydration/Fluid intake. The DON stated, "When nurses mark the area, it means the nurses are observing for signs and symptoms of dehydration. The nurses will document, on the I&O sheet, the amount of fluids the patient is consuming as well as urinary output. The nurses will check the patient's skin turgor (the rigidity of the cells due to the absorption of water). Our expectation is for nurses to document this information on the I&O sheets or in the nurses progress notes."
On 4/4/08, a Patient Care Coordinator (PCC) representing Patient 1's health insurance plan issued a notice to the facility that Patient 1 no longer required the services of skilled nursing after 4/6/08 (Noti ce of Medi care Non-coverage). An interview conducted with the PCC on 4/22/10 at 2 p.m. explained, "Patient 1 no longer qualified for skilled nursing care after 4/6/08, because she met the expected goals for physical and occupational therapy. Patient 1 did not require specific skilled nursing care (i.e. intravenous fluids, wound care). The decision whether a patient requires skilled nursing care following the time frame Medicare allows is a team decision (PCC, physician, therapists) and when the desired objectives have been met, the patient is transitioned from skilled nursing to 'custodial care'. When this occurs, the information is documented on an authorization form and provided to the Director of Nurses (DON) and the Discharge planner".
On 4/5/08, the facility decreased the daily nursing assessments for Patient 1 to weekly assessments. The nurse's Weekly Summary dated 4/5/08 indicated Patient 1 was alert and verbally responsive. However, the weekly summary form did not contain a summation of the events that occurred with Patient 1 between 3/28/08-4/5/08. The area designated for "Significant Medical Events", i.e. antibiotics (for the UTI), oxygen administration (O2), oxygen saturation (O2 sat) and/or baseline vital signs, was left blank. There was no documentation discussing the care plan for dehydration, whether the ATB therapy for the UTI was effective, consideration of the impact of the medication (HTCZ) on the patient's hydration status or how Patient 1 was monitored daily for evidence of hydration (per the dehydration care plan).
On 11/6/09 at 2:30 p.m., an interview was conducted with the DON regarding the decision that Patient 1 no longer qualified for skilled nursing level of care and that daily skilled nursing notes (assessments) were no longer required. The DON stated, "The decision was based on Patient 1's progress and the team decision on 4/4/08. On 4/5/08 we initiated weekly nursing summary notes rather than daily assessments."
From 4/8/08 - 4/14/08 (7 days), there were no nurse's notes, IDT notes or documentation of a nursing assessment regarding Patient 1 except on 4/13/08 at 3:30 p.m., when a nurse described Patient 1 as having, "Poor appetite, fluid intake". There was no further documentation regarding the patient's mental status, reference to the care plan for dehydration, the diuretic (HTCZ) or how Patient 1 was monitored daily for evidence of hydration or risk for UTI. The weekly nursing summary, due 4/11/08, was not completed.
On 4/14/08 at 10:00 a.m., a change in condition in Patient 1 was identified which required a transfer to an acute care hospital. The nurse documented on the progress notes the following assessment, "Patient assisted to use the bathroom and was able to void more than 200 cc of dark amber, very cloudy urine. Patient noted to have circumoral (around the mouth) cyanosis (blue in color), but still verbally responsive. Assisted back to bed and vital signs check 99/60 (blood pressure) 98 (temperature) 72 (heart rate) and 20 (respirations) O2 (oxygen) saturation 56% on room air started O2 inhalation @ 2 LPM (liters per minute), titrated and O2 saturation fluctuating 70-80% @ 4 LPM. Increase 5 LPM [unreadable word or symbol] O2 saturation 84%. Patient still verbally responsive and denied any pain. Abdomen noted distended, straight cath done and able to get urine output of more than 1000cc and still draining dark, amber urine, and after 1000cc output, started to drain cheesy-like, cloudy urine. Patient still verbally responsive and answers yes and no but very lethargic and looks pale. At 10:55 a.m., MD informed and new order noted to send patient to ER for evaluation."
On 4/14/08 at 11:10 a.m., Patient 1 was transported to the general acute care hospital (GACH) and admitted to the emergency room for "Alteration in consciousness and low blood pressure". The emergency room physician documented under assessment and plan, "Septic shock, secondary to urinary tract infection, hyponatremia (low sodium level), and acute renal failure". The patient's vital signs upon admission read: Blood pressure: 76/50, heart rate: 106 and respirations: 16. The physician ordered intravenous fluids, antibiotics, laboratory studies and for Patient 1 to be admitted to the intensive care unit (ICU).
Patient 1 developed tachycardia (increased heart rate) and septic shock before transfer to the ICU. Cardiopulmonary Resuscitation (CPR) was administered on 2 occasions in the emergency room with Patient 1 responding both times. Patient 1 was then transferred to the ICU, where she coded a 3rd time and passed away during the evening of 4/14/08 at 7:49 p.m., nine hours after transfer to the hospital.
The admitting physician wrote in the discharge summary the events that occurred with Patient 1 while in the emergency room. "By the time patient was seen, she was given the fourth liter of normal saline. She was awake, but not answering any questions. The nurses noted that her urine when she initially arrived was thick and purulent. She was diagnosed to be in septic shock. She was tachycardic (heart rate 106). The decision was made to intubate her based on a low oxygen saturation level (40 (normal=80-100). Patient 1 became asystolic (decreased heart contraction) and both times she responded with CPR. When she arrived in the ICU, she coded again and no heroics were implemented (measures to save her life) based on the family's wishes for comfort care. The patient passed away that night." The diagnoses the physician documented on the discharge summary sheet were dehydration, urosepsis and altered level of consciousness.
On 11/9/08 at 10 am, a phone interview was conducted with a family member regarding Patient 1's care. The family member stated, "Initially, we thought mom would return to the assisted living facility after she completed her therapies. Then we were told she needed to be reevaluated for the level of care she required and would still need skilled nursing. My brother and/or I visited every day and we were unaware that mom was having a problem. On 4/14/08, I walked in to see mom and saw the assistant taking her blood pressure. Mom was on oxygen and I was told to speak with the nurse as this was an emergency situation. The nurse said, 'Your mom was assisted to the bathroom and turned blue in color. She was given oxygen and the physician ordered a transfer to the emergency room'. When I arrived at the hospital, I spoke with one of the nurses in the ER who was very upset. He told me, 'I should be very angry because they had to increase fluids and antibiotics, because mom was so dry'. They had a difficult time inserting a central line and her urine was like sludge. There was blood in her urine and blood clots in the line'. He said, 'Mom had a terrible bladder infection".
On 12/10/09, a copy of Patient 1's death certificate was obtained and the immediate cause of death was stated as, "Septic shock with underlying causes from sepsis and urinary tract infection".
On 4/22/10 at 1:30 p.m., an interview was conducted with the Director of Nurses (DON) regarding nursing documentation and nursing assessments. The DON reviewed Patient 1's medical record and stated, "Patients receive skilled nursing, physical and occupational therapies until the patient reaches the expected goals and are then transitioned from skilled nursing to custodial care. Daily nursing assessments are not required since the patient is considered stable and has fulfilled the expectations or, if the patient refuses care." The DON reiterated, "The decision to transition a patient from skilled nursing care to custodial care is based on the case manager representing the patient's health insurance, the IDT and ultimately determined by the physician. When it is determined by the IDT that a patient has met the anticipated goals, and does not require skilled nursing, a notification form is given to the staff involved in the patient's care."
Following further review of Patient 1's medical record, the DON concurred, "The input/output form was not complete and, the care plan for Malnutrition/Dehydration was not updated to reflect Patient 1's needs". The DON was unable to provide evidence of a notification form, documentation that the IDT collaborated or documentation that the physician ultimately determined Patient 1 no longer required skilled nursing care. The records failed to document that the IDT considered that the patient had been dehydrated, needed IV fluids and needed skilled nursing assessments & monitoring to maintain her hydration status before discontinuing skilled nursing care & services and transitioning her to custodial care.
The Facility failed to continually assess Patient 1's condition to ensure adequate hydration following the transition from skilled nursing care to custodial care. From 4/5/08 through 4/13/08, there was no documentation of an assessment or evaluation to determine Patient 1's hydration status even though she was still receiving the diuretic (HTCZ) and her food and fluid intake was poor (as documented on 4/13/08). On 4/14/08, Patient 1 required transfer to the acute care hospital where she was diagnosed with dehydration, urosepsis, altered level of consciousness and septic shock. Patient 1 experienced cardiac arrest three times. The third time, Patient 1 expired.
These violations presented either an imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result and were a direct proximate cause of Patient 1's death.