The facility must provide each resident with sufficient fluid intake to maintain proper hydration and health.
An unannounced visit was made to the facility on 02/08/08 at 9:50 AM to investigate a complaint regarding patient care.
Based on staff interview and record review, the facility failed to ensure sufficient fluids to prevent dehydration.
Record review revealed that Patient 1 was an 86 year old woman admitted to the facility on 12/13/07 with diagnoses that included dementia, depression and anemia. Review of the Minimum Data Set (MDS, an assessment tool ) dated 12/17/07 indicated that Patient 1 was moderately impaired for decision making and sometimes understood others as well as was able to make her own needs known. Patient 1 required full assistance with eating.
Record review revealed that an Advance Directives/Medical Treatment Decision form for Patient 1, signed on 12/13/07 indicated that there were no feeding restrictions and no treatment restrictions for Patient 1, and the Preferred Intensity of Care form, also signed on 12/13/07, indicated that Patient 1 preferred to receive treatments including intravenous fluids and nasogastric fluids.
Review of Patient 1's laboratory values from the acute care hospital prior to transfer to the skilled nursing facility dated 12/12/07 indicated that Patient 1 had a Sodium level of 142 (normal value is 137-145); a blood urea nitrogen (BUN) of 8 (normal value is 7-18); and a Creatinine level of 0.6 (normal values is 0.7-1.2) and a BUN/Creatinine ratio of 13. (Normal value is 10:1-20:1) All of the lab values were within normal range and showed that Patient 1 was hydrated prior to transfer to the skilled nursing facility.
Review of the nurse's admission assessment completed on 12/13/07 indicated that Patient 1's appetite was fair and had "no teeth." There was a physician's order dated 12/13/07 for a mechanically soft diet with a nutritional supplement (Carnation Instant Breakfast drink) (CIB) added to each meal tray, three times a day.
Review of the "Nutrition Assessment and Review" form dated 12/13/07 with no signature and date to show by whom and when the assessment was completed revealed that Patient 1 was 4 feet 10 inches tall and weighed 120.8 pounds. The assessment showed that the calculated fluid needs were between 1400 and 1600 cc's per day. The form showed no evidence that the patient's ideal body weight, or that food preferences were considered. There was no evidence that a nutritional or hydration care plan was developed for Patient 1 by the Registered Dietitian (RD) as of 12/13/07.
An interview was conducted on 4/2/08 at 11:00 AM with the Registered Dietician (RD). She stated that she completed the "Nutrition Assessment and Review" form on 12/13/07. She confirmed that the nutrition assessment was partially blank with no signature which indicated that the RD had assessed all aspects of the Nutritional Assessment Review. She stated that she should have been more accurate in her assessment of Patient 1. She stated that it has been a while and she could not remember what happened with the rest of the assessment. She stated that sometimes she would get side tracked from her work and would have to stop and then go back. She could not confirm why the portion of the form that indicated "Nutrition Assessment" was blank, which included areas such as food preferences, ideal body weight, and any issues that may contribute to Patient 1's nutritional enhancement or decline.
Review of the CNA notes of meal percentages and fluid intake indicated Patient 1 was eating from 80% to 100% at each meal from 12/15/07 through 12/17/07. The documentation of fluids showed water, milk and juice, but there was no quantification of the actual amount of fluids. There was a notation of the Carnation Instant Breakfast nourishment being given once from 12/15 to 12/17/07, on 12/15/07, but no record of the percent consumed.
From 12/18/07 through 12/26/07, Patient 1 consumed only 50% to 75% of her meal, 18% (5/27) of the time and was consuming below 50% of her trays 48% (13/27) of the times documented. 11% of the meal consumption entries were not recorded therefore making the information unavailable for the nurse staff to review and assess intake to ensure fluid intake. The documentation of fluids showed water, milk and juice, but there was no quantification of the actual amount of fluids. There was a notation of Carnation Instant Breakfast nourishment being given six times during the 12/18 to 12/26/07 period, but no record of the percent consumed.
Record review revealed that from 12/13/07 to 12/26/07, showed staff failed to assess fluid consumption for all meals. There was no evidence that licensed staff notified the physician and the RD regarding the patient episodic poor food and fluid intake. There was no evidence that the facility had a plan other than encouraging fluids.
Review of physician's orders for Patient 1 dated 12/28/07 stated "urinalysis with culture and sensitivity if indicated, complete blood count and comprehensive metabolic panel on Monday (01/02/08)."
Review of Patient 1 laboratory values completed and dated 12/31/07 indicated that Patient 1's Sodium level was now 161 (normal value is 137-145), BUN was 48, normal value is 7-18, and BUN/Creatinine ratio was 50, normal value is 7-25. Further review of Patient 1's record showed a nursing note indicating that the laboratory results were reported on 12/31/07, but not to whom they were reported, and no new orders were obtained.
There was no evidence that nursing addressed Patient 1's hydration status after reviewing laboratory results that suggested possible dehydration on 12/31/07. There was no evidence that an assessment was conducted by nursing to determine hydration status. There was no evidence that nursing began to monitor Patient 1's hydration status once it was determined that she was at risk. There was no evidence that an Interdisciplinary Team met to discuss ways to improve Patient 1's hydration status such as pushing fluids, intravenous therapy or possible nasogastric or gastrostomy feedings. There was no evidence that a plan of care was developed on 12/31/07 to implement interventions to improve Patient 1's hydration status.
Review of the CNA meal percentage documentation showed there was no documentation from 12/27/07 through 12/31/07 (four days) in Patient 1's record for meal consumption.
An interview was conducted on 4/2/08 with the Director of Staff Development (DSD). The DSD stated she could not find the records from 12/27/07 through 12/31/07 of the nursing assistant notes where meal percentages are recorded.
Review of the CNA meal percentage documentation showed (there are two discrepant sets of percentages for this time period, both showing low meal consumption percentages) from 1/1/08 through 1/6/08, Patient 1 consumed less than 50 % of her meals 44% (8/18) of the time and refused her meals an additional 44% of the time (8/18).
1/1/08, patient refused her breakfast ate 20% for lunch and 30% for dinner eaten.
1/2/08 = 10% breakfast, 10% lunch and 50% dinner eaten.
1/3/08 = 60% breakfast, 40% lunch and 80% dinner eaten.
1/4/08 = Refused breakfast, refused lunch and 20% dinner eaten.
1/5/08 = Refused breakfast but took the nutritional supplement, 30% lunch and refused dinner. There was no evidence that the CIB nourishment supplement was given at lunch or dinner
1/6/08 = Refused breakfast but took the nutritional supplement, refused lunch but took the CIB nutritional supplement and refused dinner.
There was no further documentation in the clinical record from the RD following the incomplete initial assessment dated 12/13/07 to address Patient 1's poor food and fluid intake. There was no documentation regarding the percentage of Carnation Instant Breakfast nutritional supplement or other fluids consumed by the patient in order to assess if the patient was taking adequate amounts of fluids based on the calculated fluid goals.
Review of nurse's notes dated 1/2/08 and timed 2:00 PM stated "cath this pm for urine specimen for urinalysis and culture and sensitivity if indicated. Urine is clear and dark amber in color. (Dark urine suggest possible dehydration) There was no evidence that nursing developed a plan of care addressing the dark amber urine.
An interview was conducted with RN 1 on 6/11/09 at 1:45 PM. She stated that she was caring for Patient 1. She stated that she notified the physician of Patient 1's laboratory values. She stated that she did not address Patient 1's hydration status from a nursing perspective, but should have. She stated she did not monitor and document Patient 1's exact fluid intake in order to further monitor and further assess Patient 1's hydration status.
Review of the plan of care titled "Nutritional Approach" implemented on 1/2/08 indicated Patient 1 was to receive a pureed diet and a very high calorie (VHC) nutrition drink 60 milliliters (ml) three times a day during medication pass. There was no evidence that nursing monitored how much VHC fluid Patient 1 was receiving at each medication pass. In addition, the VHC would have only provided 180 cc of product for the day of which 120 ml would be available as free water for fluid purposes. There was no "measurable" fluid goal on the plan of care to make sure Patient 1 was receiving the correct amount.
Review of the Interdisciplinary team meeting (IDT) conducted on 1/4/08 showed no evidence that the IDT team discussed Patient 1's laboratory values from 12/31/07 to address Patient 1's hydration status. There was no evidence that an assessment identifying the reasons and issues regarding Patient 1's hydration status was conducted by the IDT. There was no evidence in the clinical record that the family was notified regarding Patient 1's hydration status despite the fact that Patient 1's record contained a signed preferred intensity of care that showed that Patient 1 was to receive antibiotics, intravenous fluids, nasogastric fluids, hospitalization and oxygen.
Review of Patient 1's Rap Summary from the Minimum Data Set (MDS) significant change dated 1/4/08 indicated under nutrition that "Patient 1 is refusing to open her mouth. There was no evidence that nursing addressed Patient 1 refusing to open her mouth. There was no evidence that a plan of care was developed to address Patient 1 refusing to open her mouth. There was no evidence that the IDT team discussed Patient 1 refusing to open her mouth on 1/4/08. There was no evidence that the family was notified regarding Patient 1 refusing to open her mouth.
Review of nurses' notes dated 1/7/08 at 6:00 AM documented that the patient's blood pressure was 56/22 , pulse 74, respiration 38 and that the patient had a change in condition color of face "mottling" (skin discoloration suggesting a decrease in circulation) and that staff were unable to obtain an oxygen saturation. Oxygen at 10 liters per minute via a non-rebreather mask was given; the physician was called and ordered to transfer Patient 1 to the acute hospital.
Review of the admission record at the acute care hospital for Patient 1 indicated that Patient 1 weighed 97 pounds; therefore, the patient has had a 23.8 pound weight loss during the 25 days that she was at the skilled nursing facility since the admission weight was 120.8 pounds.
Acute hospital assessment indicated Patient 1 was in "severe hypernatremia, severe dehydration and acute renal failure. The "History and Physical" notes dated 1/7/08 at the acute hospital indicated that "the patient has cachexia and malnutrition, skin tugor 3+ (Skin turgor is a sign commonly used by health care workers to assess the degree of fluid loss or dehydration) and severe dehydration.
Review of the laboratory report from the acute care hospital 1/7/08 showed that the patient's Blood Urea Nitrogen (BUN) was 97, normal value is 7-18, a BUN test is done to see how well the kidneys are working and an elevated BUN suggests dehydration. The creatinine ratio was 4.0 (Normal value is 0.7-1.2) blood creatinine ratio is also indicators of how well the kidney is functioning and is elevated when kidneys are failing due to causes such as dehydration. Patient 1's Sodium level was 189 (normal value is 137-145) this lab value is also an indicator of dehydration.
Review of the physician History & Physical notes at the acute care hospital dated 1/7/08 indicated that the patient was non-responsive except to painful stimuli that Patient 1 was noted to have cachexia (loss of weight, muscle atrophy, fatigue and significant weight, appetite loss) and malnutrition.
Review of the discharge summary from the acute care hospital indicated that the patient expired on 1/15/08 at 2:00 PM, 8 days after admission to the acute care hospital. The cause of death was listed as terminal illness, acute renal failure, and hypernatremia.
Review of the death certificate listed the causes of death as hypernatremia, dehydration and included Alzheimer's dementia, malnutrition and pneumonia.
The facility failed to:
Ensure that Patient 1 was provided sufficient fluids to prevent dehydration.
The facility's failure to ensure that the patient received sufficient fluids caused the patient to develop dehydration. The patient subsequently expired on 1/15/08. The cause of death was listed as hypernatremia, malnutrition and dehydration..
These violations jointly, separately or in any combination presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result.