Citation Number: 060004611
Citation Date: 2/1/2008
Violation Date: 3/17/2007
Class: AA
Penalty: $ 75000.00

72313(a)(1)(2) Nursing Service-Administration of Medications and Treatments

(a) Medications and treatments shall be administered as follows:

(1) No medication or treatment shall be administered except on the order of a person lawfully authorized to give such order.

(2) Medications and treatments shall be administered as prescribed.

72311(a)(1)(A) 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.

The facility failed to ensure patient care was provided to Patient A based upon a continuing assessment of the patient's needs. On 3/17/07, Patient A choked on a piece of meat while eating dinner in her room. Patient A was transported to the acute care hospital, where she expired on 3/20/07. Toxicology screens obtained at the acute care hospital documented the obtunded state of Patient A was due to exogenous opiates. The aspiration of partially chewed meat and subsequent respiratory distress were due to Patient A being in a narcotized state at the time of the incident.

The facility failed to ensure only medications ordered by a person lawfully authorized to do so were administered to Patient A. Patient A was transported to the acute care hospital on 3/17/07, following a choking incident. Toxicology tests obtained on 3/17/07, confirmed the presence of opiates. However, according to documentation from the skilled nursing facility, Patient A was not prescribed opiate medications.

Patient A was admitted to the facility on 3/13/06, with diagnoses that included diabetes mellitus, esophageal reflux and dementia. A quarterly MDS (minimum data set) assessment dated 12/15/06, described Patient A with short and long term memory problems and "moderately" impaired cognition. Further documentation described Patient A as requiring "supervision, oversight, encouragement or cueing" at mealtime.

Documentation within a "Nutritional Assessment" dated 3/8/07, listed the patient's diet as "regular, no concentrated sugar, no added salt." According to assessment documentation, Patient A was able to feed herself, consumed 100% of her meals and usually ate in the dining room or her room.

On 3/17/07 at 1630 hours, Staff 1 documented "[Patient A] assisted back to station from activities by staff...staff stated she looks tired." Staff 1 further documented Patient A was asked how she was; Patient A told staff she was "ok." The patient's vital signs were documented as follows, blood pressure 128/78, pulse 88, respiratory rate 20, temperature 98.4, pulse oxygen saturation 94% and blood glucose 174. Staff 1 documented "denies pain or discomfort...frequent visual checks provided."

The next documented assessment was at 1700 hours. At that time, Staff 1 documented Patient A was observed lying diagonally in bed, with her feet hanging over the bedside. The following was documented "[Patient A] responsive to painful stimuli...respirations even/ wheezing slightly cool/moist to touch...blood sugar 230 mg/dl...oxygen saturation 84% on room air." "Visual examination of mouth shows no food/foreign objects...finger sweep food/foreign objects found...suctioned for possible food/foreign objects...none found." "Heimlich maneuver food/foreign object noted to project...oral examination and finger sweep performed again without food/foreign objects noted." Staff 1 further documented he initiated oxygen at 15 liters and summoned 911 emergency services. Patient A's vital signs were documented as follows, blood pressure 130/68, pulse 123, respiratory rate 28 and temperature 97.

According to Staff 1's documentation, Patient A was transported to the acute care hospital, via EMS (emergency medical services) transport, on 3/17/07 at 1730 hours.

On 4/9/07 and 5/30/07, interviews were conducted with facility staff. The following documentation was obtained from the interviews.

On 5/30/07 at 1515 hours, Staff 1 (licensed nurse) related details of the 3/17/07 incident. According to the documented interview, Staff 1 stated Patient A's dinner tray was discovered on her bedside table and a spoon "was soiled as if the resident had used it." Staff 1 stated he checked on the patient two to three times until approximately 1730 hours. At that time, Staff 1 stated Patient A was observed "wheezing." Staff 1 further stated he performed the Heimlich maneuver and a finger sweep." Staff 1 stated he called 911 approximately five minutes after noting the patient's change of condition.

Staff 1 stated the paramedics stated there was something "stuck in [Patient A's] throat...something about a piece of meat or steak."

Staff 1 stated Patient A was able to feed herself and usually ate in the dining room. However, Staff 1 stated the C.N.A. "probably brought the tray in her room because she [Patient A] was sleeping."

On 5/30/07 at 1640 hours, Patient B, Patient A's roommate, related the following. Patient B stated when Patient A was brought back to her room on 3/17/07 "she was choking, coughing a lot...when she was brought to the room, she threw up."

When asked about Patient A's medications, Staff 1 stated Patient A was not prescribed pain medications, however, Patient B, Patient A's roommate, received Dilaudid for sciatic pain. Staff 1 stated he did not administer pain medication to Patient B on 3/17/07, as she did not complain of pain and did not request pain medication.

Review of Patient B's MARs revealed the patient received Dilaudid 4 mg on 3/13/07 and not again until 3/21/07.

On 6/6/07 at 1445 hours, during an interview with an administrative nursing staff, staff was asked to provide the facility's investigation documentation for review, as well as the health records for Patient A and Patient B. In addition, the MARs (medication administration records) for Station II and controlled drug records were reviewed.

Staff reiterated the incident of 3/17/07. Administrative nursing staff stated she was told, by an activity staff, Patient A appeared sleepy during activities and "didn't look like herself."

Staff further stated the facility's investigation findings were inconclusive, as the facility was not able to determine how or when Patient A obtained opiate medications.

The following documentation was included within the EMS (emergency medical service) and acute care hospital records.

The EMS "Prehospital Care Report" listed an "alarm" time of 1812 hours. The alarm time identified the call received from the facility. At 1819 hours, EMS staff documented the following "chief complaint," "difficulty breathing secondary to eating dinner...duration time 10 minutes."

Under the heading "Treatment/Response" the following was documented "Pt. found sitting in strider with accessory muscle use while respirating...Heimlich/back blow with no poor, decreased tidal volume, decreased oxygen saturation by pulse oximeter at 82%...back blow with no production...visualized trachea with laryngoscope...removed foreign body with Magill forceps...SPO2 (oxygen saturation by pulse oximeter) increased."

The EMS staff documented the patient's time of arrival to the acute care hospital at 1833 hours.

The licensed nurse's notes pertaining to the patient's choking incident was not consistent with the EMS documentation. According to the licensed nurse's notes, paramedics were called at 1730 hours. However, EMS documentation identified the call time as 1812 hours.

The following was included within the "ED (emergency department) Physician Documentation." "Chief Complaint/History of Present Illness." "Pt. had been eating dinner at [facility]...developed difficulty breathing and sounded like she was trying to breathe through a straw." "Paramedics estimate that it was 8-10 minutes from the time of the alarm until they removed the foreign body from her [Patient A] throat." The foreign body was described as a piece of meat. "Patient immediately became pinker and had no trouble breathing anymore."

At 2230 hours, the emergency room physician documented "Coma panel shows opiates in urine-source unclear." "Narcan 0.4 mg (milligram) IV tried again-pt is more is acting and shows urine evidence of being on narcotics and responding to Narcan...plan: Narcan drip." The physician further documented "pt. is quite narcotized when she arose, which improved with Narcan temporally...we ordered Narcan drip to continue so that pt. is medicated with Narcan."

The following "Final Impression" was documented, "acute upper airway obstruction episode due to obstructed steak-prolonged time...comatose upon arrival in hospital, and coma has continued with abnormal Doll's eyes maneuver on physical exam." "Suspected hypoxic brain damage due to length of time before steak was removed...signs of occult opiate use with some positive response to Narcan administration."

A "Pulmonary and Critical Care Evaluation" dated 3/17/07, included the following, "Toxicology panel revealed her to be positive for opiates, although she was not receiving any opiates...remarkably, however, she is improving with administration of Narcan with respect to her mental status." The "impression" included respiratory failure, renal failure, diabetes mellitus, severe Alzheimer's' dementia, hypertension by history and "coma that seems to be responding to Narcan in a patient who had positive toxicology panel for opiates. She did not take opiates according to [skilled nursing facility] medication list."

Documentation included within the "Nephrology Consultation in Progress" dated 3/18/07, included the following. "Admitted for obstructed airway and altered mental status with suspected opiate overdose." "Further testing including urine drug screen was positive for opiates although no opiates noted on her regular medication list." "Due to possible opiate overdose, patient transferred to ICU for stabilization and Narcan infusion."

On 3/20/07 at 1410 hours, Patient A expired.

From 6/27/07 until 11/28/07, numerous telephone calls were made to the coroner's office to request a copy of the patient's death certificate and cause of death. However, a death certificate was not available as the case remained "pending investigation."

On 11/1/07, during a telephone interview, a detective from the Sheriff's Homicide Division stated the cause of death was expected to remain "undetermined," as it was not possible to ascertain how Patient A got the opiate medications and who administered them.

The coroner's case notes were forwarded for review.

On 5/2/07 at 1230 hours, two county toxicologists reported their findings. The following was documented, "the toxicology lab has found total morphine in very high levels...they will now quantitative the amount of free morphine."

On 5/30/07 at 1230 hours, the case review notes revealed the following, "the toxicology lab found free morphine in a very small level; therefore, the ratio of bound morphine to free morphine is very high." "This would be consistent with the decedent receiving morphine over a period of time prior to the choking incident." "There appears to be a high index of suspicion that the morphine played a significant role in the aspiration event, although its exact relationship is unclear."

On 12/4/07 at 1030 hours, a follow-up telephone call was placed to the coroner's office. Staff stated the death investigation was complete and finalized. A copy of the "verification of death" letter was forwarded to the Department. The following was documented, "cause of death: hypoxic/anoxic encephalopathy, clinical, due to upper airway obstruction, clinical, due to food bolus aspiration, clinical."

Under the heading title "Other Conditions" the following was documented, "mild cardiomegaly; mild coronary atherosclerosis; morphine present in system; clinical history of Alzheimer's disease, hypertension, diabetes mellitus and hypothyroidism. "Manner: Accident."

The facility failed to continually assess Patient A. Although Patient A was observed tired and lethargic, the patient's dinner tray was left at her bedside. Patient A was unsupervised during the dinner meal. Patient A choked on a piece of meat during a narcotized state, which lead to airway obstruction.

In addition, the facility failed to ensure Patient A was only administered medications prescribed by the physician. Patient A was not prescribed opiate medications; however, toxicology tests confirmed the presence of opiates.

These facility failures were a direct proximate cause of death to the patient or resident of the long-term health care facility.