Citation Number: 250003781
Citation Date: 3/13/2007
Violation Date: 1/6/2006
Class: AA
Penalty: $ 75000.00

Title 22 # 72311 (a) Nursing service shall include, but not be limited to, the following: (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan.

On April 13, September 8, and October 24, 2006, unannounced visits were made to the facility for the purpose of investigation of a complaint. It was determined the facility failed to implement Patient A's care plan, which resulted in Patient A's death.

The following was noted: Patient A, a male 83 years of age, was admitted to the facility on March 29, 2004, with diagnoses including: 1. Pre-Senile Dementia; 2. Syncope and Collapse; and, 3. Anxiety State.

On April 13, 2006, Patient A's clinical record was reviewed at the facility. A Minimum Data Set (MDS) Quarterly Assessment dated September 12, 2005, contained documentation that Patient A's cognitive skill of daily decision making was severely impaired. Patient A's ability to walk, transfer, dress and bathe, was documented as requiring extensive assistance. Patient A was totally dependent on staff for toilet use and personal hygiene. Patient A had limited ability to communicate and understand communication. Patient A's ability to eat was documented as independent.

A plan of care dated March 2, 2005, titled "At risk for fall/injury" contained documentation that Patient A was found on the floor on December 13, 2005. Environmental adaptations included, low bed, roll guard for bed, non releasing seat belt, and lap buddy. The approach required nursing staff to provide and monitor the use of a wheelchair with non releasing seat belt.

An interdisciplinary progress note dated January 1, 2006, at 1230 hours, contained documentation that Patient A was found in the dining room sliding from the wheelchair. The "lap belt" was up to the patient's chest and neck area. When the belt was released, the patient slid to the floor.

A Physician's telephone order dated January 4, 2006, discontinued the non release seat belt, and changed to a lap buddy when the patient was up in the wheelchair.

A Change in Status-Fall form dated January 6, 2006, at 0540 hours, documented that Patient A was found on the floor mat next to his bed. There were no injuries documented.

An interdisciplinary progress note dated January 6, 2006, at 0700 hours, documented that Patient A had fallen from the wheelchair onto the floor and received a laceration over the right eye. Patient A was transferred to the hospital via ambulance.

Patient A's clinical record was reviewed at the acute care hospital on September 8, 2006. An emergency room report dated January 6, 2006, documented that Patient A had a laceration extending from his right eyebrow to the right temporal region measuring 6.5 centimeters (2 1/2 inches). The patient's lungs were clear. A Computerized Tomography (CT) scan of the head showed, "a 1.0 centimeter (approximately 1/2 inch) anterior right frontal area hemorrhage (bleeding). There are several other areas of hemorrhage, 1.5 by 0.5 area of hemorrhage adjacent to the high anterior falx. There is bleeding in to the right ventricle and lateral, and also there is bleeding lateral to the right side of the brain, brain step, and cerebellum, measuring 1 by 0.5 centimeters". He was intubated on January 7, 2006, at 0256 hours, diagnosed with a Closed Head Injury and Intracranial Bleed and admitted to the Intensive Care Unit of the acute care hospital.

A history and physical examination dated January 7, 2006, at 0954 hours, documented that Patient A's level of consciousness continued to deteriorate, and his blood pressure continued to elevate.

A consultation report dated January 7, 2006, documented that Patient A's temperature was 101.8 degrees Fahrenheit and breath sounds were decreased bilaterally and Rales and Rhonchi were audible. (Rales and Rhonchi are abnormal breath sounds). He was diagnosed with Acute Respiratory Failure.

A physician's telephone order dated January 9, 2006, at 2150 hours, contained documentation to extubate (remove the breathing tube inserted through the mouth and into the airway), discontinue tube feedings (a tube inserted into the stomach for feeding), and start a morphine (medication used for pain relief) infusion of 2 mg per hour. A ventilator monitor record contained documentation that Patient A was extubated on January 9, 2006, at 2215 hours. He continued to receive comfort care. Patient A was pronounced dead on January 13, 2006, at 0140 hours.

A discharge summary dated January 13, 2006, contained documentation that the attending physician had a thorough discussion with Patient A's family. They had requested Patient A be removed from life support. The patient's son was interviewed on February 13, 2007, and asked about the family's decision to remove life support. The son stated that the family had talked to the physicians and Intensive Care Unit nurses who stated the hemorrhage in the brain could not be stopped. The son stated, "The bleeding on my father's brain was inevitably going to cause death so we decided to remove the life support as not to prolong the inevitable".

On January 19, 2006, a certificate of death was signed. The cause of death included: A. Cardio Pulmonary Arrest B. Aspiration Pneumonia C. Alzheimer's Dementia

Other significant conditions contributing to the death, but not resulting in the underlying cause: Intracranial Hemorrhage was listed. The death was certified as caused by an accident at a nursing home during a mechanical fall.

On October 24, 2006, at 1130 hours, during an interview, the Assistant Director of Nursing (ADON) of the facility stated that Licensed Vocational Nurses (LVN1 and LVN2) and Certified Nursing Assistant (CNA1), involved in the January 6, 2006, incident with Patient A, were no longer working at the facility.

On October 24, 2006, at 1215 hours, during an interview, the ADON stated Patient A should have had a lap buddy on while he was in the wheelchair to prevent falls. The ADON stated Patient A had a history of falls and was a high risk for further falls.

On October 26, 2006, at 0815 hours, during a telephone interview, LVN 2 stated when she arrived at work on January 6, 2006, at 0630 hours; she noticed Patient A was sitting at the nurses' station without a lap buddy in place. She stated Patient A was, "lifting his hand and saying something about food". LVN2 stated she told LVN1 that Patient A needed to get a lap buddy on before he got hurt. LVN2 stated she sat down at the nurses' station and, a moment later, Patient A fell to the floor. LVN2 stated she "heard a loud crack" when Patient A hit the floor.

Patient A required extensive assistance from facility staff to walk or transfer. Patient A was totally dependent on staff for toilet use and personal hygiene. The patient had a diagnosis of Alzheimer's Dementia, with a limited ability to communicate and understand communication. Patient A required safety devices, a lap buddy, when in the wheelchair to prevent falls. Facility staff failed to provide the lap buddy, as ordered, while Patient A was in the wheelchair. Facility staff observed the lap buddy was not in place and failed to protect Patient A from falling, which resulted in Patient A's death.

The failure of the facility to protect Patient A from falling 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 was a direct proximate cause of the death of the patient.