CLASS AA CITATION -- PATIENT CARE
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 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 plan Patient A's care based on an initial and continuing assessment. The facility failed to continually assess Patient A, with input from other health professionals involved in the patient's care. Patient A was admitted to the facility on 5/12/09, with a history of status post subdural hematoma, which resulted in two craniotomy procedures, in 2008. In addition, Patient A sustained a fall prior to his admission to the facility. Patient A sustained three falls during his two month facility stay; the falls occurred on 5/13/09, 5/26/09 and 7/14/09 . Followin~ the patient's fall on 7/14/09, Patient A was transferred to the acute care hospital, via EMS (emergency medical services). Patient A subsequently died on 7/18/09. The cause of death included, "Subdural hemorrhage, right side of brain, mechanical fall ."
On 10/27/09, Patient A's daughter forwarded a letter to the Department. Documentation referred to the course of events that took place during Patient A's facility stay. The daughter documented the facilitywas advised of the patient's prior fall and history of two surgeries to release the pressure on the patient's brain, secondary to a subdural hemorrhage. Patient A's daughter documented after the patient's fall on 5/13/09, facility staff advised her a personal alarm device would be attached to the patient; the alarm would activate and alert staff if Patient A attempted to get out of bed unassisted. However, the patient's daughter reported during her daily visits, the personal alarm was not attached to Patient A.
On 11/9/09, Patient A's health record was reviewed. Patient A was admitted to the facility on 5/10/09, with diagnoses that included coronary artery disease, congestive heart failure and anemia. Patient A was admitted to the facility for physical rehabilitation , following his 5/09 acute care hospital stay.
An H&P (history and physical) dated 5/11/09, listed the following operations: "ICD (implantable cardioverter defibrillator) placement, CABG (coronary artery bypass graft), craniotomy." Documentation showed Patient A had two craniotomy (burr holes placed to allow blood and fluids to drain) procedures in 2008 for subdural hematoma (blood clot) evacuation.
A plan of care dated 5/09 addressed the patient's history of falls. The following approaches to care included, "Assess new admit resident with history of falls, will be in falling star. .. provide safety devices such as: low bed, tab alarm in bed and wheelchair."
Although the plan of care did not identify the exact date, interview with the DON (director of nurses) stated the plan of care was started on admission; 5/10/09.
However, review of the physician's orders showed the personal bed and wheelchair alarm was not ordered until 5/13/09.
An undated "Bed Safety Evaluation" noted the rationale for the use of 1/4 bed rails. The "evaluation" form listed the following "less restrictive measures" tried prior to the use of bed side rails, "low bed (and) personal alarm."
On 5/13/09, a "Falls Risk Evaluation" determined Patient A was at "high risk" for repeat falls.
On 5/13/09 at 1935 hours, the licensed nurse documented Patient A was found on the floor of his room, by the foot of his bed. According to the licensed nurse's documentation, Patient A attempted to get out of bed without assistance and fell. Patient A sustained a skin tear to his right elbow, which was described as approximately 1 cm. (centimeter.) There was no documented evidence of a personal alarm in place, or a padded mattress next to the bed.
On 5/13/09, the licensed nurse documented a telephone physician's order for a personal bed alarm and a "blue pad mattress." The mattress would be placed on the floor, beside the patient's bed to help prevent injuries in the event of a fall.
On 5/26/09 at 1245 hours, the licensed nurse documented Patient A was found sitting on the mattress pad/mat by his bed. Documentation showed Patient A sustained an abrasion to his right lower back. Additional documentation showed the patient's personal alarm was activated prior to the fall; the alarm alerted the CNA (certified nurse assistant). Patient A reportedly told the CNA, "Oh, I don't know what happened."
"Weekly Physical Therapy Progress Notes" dated 5/11/09 through 7/9/09, referred to Patient A's continued poor safety awareness as well as a continued risk for falls, general weakness and gait disturbance.
On 6/4/09, the PT (physical therapist) documented Patient A's gait showed "heavy leaning to left ... high risk for fall ... balance, standing poor."
On 7/2/09 and 7/9/09, the PT documented Patient A was making "steady progress overall with physical therapy." However, the patient's "general weakness, gait disturbance and fall risk" remained a concern.
On 7/14/09 at 0340 hours, the licensed nurse documented Patient A was found on the floor in his room. Patient A was lying on his back, between bed A and bed B. An assessment showed Patient A sustained two lacerations on the back of his head (occipital area). The licensed nurse documented, "moderate amount of blood." According to the documentation, no other injuries were noted and Patient A did not complain of pain. However, the licensed nurse documented Patient A's oxygen saturation was 79 %. The licensed nurse administered oxygen and telephoned 911/paramedics.
According to the facility's investigation documentation, a personal alarm and floor pad/mattress was not in use at the time of the patient's fall.
The EMS (emergency medical services) - documentation_ showed an arrival tjme Of 0345 hours. According to EMS documentation, Patient A was found in bed, with a dressing in place to the patient's head. EMS paramedics administered Albuterol (bronchodilator) , secondary to audible wheezing, prior to transporting Patient A.
Patient A left the facility, via EMS transport, to the acute care hospital emergency room, at 0358 hours.
On 11/09/09, the patient's acute care hospital record copies were forwarded to the Department. The following information was obtained.
On 7114109 at 0415 hours, the ER (emergency room) physician documented an assessment of Patient A and services rendered. Patient A's head laceration was repaired with eleven sutures, laboratory blood tests and a CT (computed tomography) scan of the head was obtained. As the patient's blood test revealed abnormally low hemoglobin, hematocrit and platelet count, as well as an elevated INR (international normalized ratio-for anticoagulant monitoring) of 1.6, one of two units of FFP (fresh frozen plasma) was infused. Additional emergency room orders included Vitamin K (to assist with blood clotting).
The results of the head CT revealed the following, "Positive extensive subdural bleed with a 5 mm (millimeter) midline shift."
On 7/14/09 at 0850 hours, Patient A was admitted to the intensive care unit.
An H&P (history and physical) dated 7/14/09 , included the following. "(Patient A) presents now having suffered a fall at his place of residence creating an occipital laceration which has now been closed ." "Based upon this mechanism of injury, a CT scan of the brain was acquired demonstrating evidence of his previous burr holes but also the presence of an acute right sided holohemispheric and tentorial acute subdural hematoma with minimal shift .. . his basilar cisterns are open." "Impression: acute subdural hematoma in an elderly gentleman with multiple medical co-morbidities."
On 7/18/09 at 2214 hours, documentation showed Patient A was observed in respiratory arrest. Patient A subsequently died at 2218 hours.
A "Discharge Summary" dated 7/18/09, described the patient's hospital course. Documentation showed Patient A became "increasingly dyspneic" "possib ly secondary to pulmonary edema and noted also the patient was suffering acute renal failure as well as having the presence of a subdural hematoma and the multiple medical problems."
A "Certificate of Death" listed the cause of death: "Anoxic encephalopathy, subdural hemorrhage, right side of brain, mechanical fall." On 11/9/09 at 1400 hours, an interview was conducted with the DON (director of nurses) at the skilled nursing facility. The DON was asked what preventative measures were initiated upon Patient A's admission to the facility, as the patient's admission information included two prior subdural hematomas and a current fall at the acute care hospital. The DON stated preventative measures were initiated on 5/13/09. In addition, the DON was unable to provide documented evidence of preventative measures in place during the patient's falls, on 5/13/09 and 7/14/09.
On 11/12/09 at 1415 hours, a telephone interview was conducted with Patient A's daughter. The daughter reiterated the concerns outlined in her letter, which was forwarded to the Department on 10/27/09. The daughter further stated she did not understand why facility staffs were unable to ensure Patient A's safety, especially since staffs were aware of the patients history of falls and "brain surgeries to drain blood from a subdural hemorrhage." Patient A's daughter stated, "We went over and over this with the facility staff members .... they knew how important it was that he (Patient A) did not fall."
Based on the information obtained, the facility failed to plan Patient A's care based on an initial and continuing assessment, as well as input from other health professional's involved in the patient's care. The facility failed to implement preventative measures to help prevent falls and injuries until after Patient A fell on 5/13/09. In addition, the facility failed to consistently implement preventative measures, which included a personal alarm and floor pad/mattress.
These failures resulted in three falls with injuries; the last fall resulted in Patient A being transferred via 911/EMS on 7/14/09, which resulted in the patient's death four days later.
The violation was a direct proximate cause of death of a patient or resident.