Class AA Citation - Patient Care
483.25 Quality of Care
Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care.
On 3/7/13, at 1:30 p.m., an unannounced visit was made to the facility to investigate a complaint regarding quality of care.
Based on interview and record review, the facility failed to provide Resident 1 with the necessary care and services in accordance with the comprehensive assessment, plan of care and physician's orders by failing to:
1. Ensure licensed nurses monitored the condition of a left heel wound for signs and symptoms of infection (such as odor, presence of fluid or drainage, and increased temperatu re of the area), response to treatment, changes in size and color, and presence of pain.
2. Follow the physician's order to obtain a wound consultation in a timely manner.
3. Implement the recommendation by the wound consultant physician to have a follow up evaluation a week after the initial evaluation.
4. Implement pain management interventions when the resident manifested pain to the affected left leg/foot and had increased behavioral manifestations of crying and continuous yelling for help.
On 1/16/13, Resident 1's left heel was evaluated by a wound consultant physician who diagnosed infected gangrene (dead tissue caused by an infection or lack of blood flow) on the left heel. On the same day, Resident 1 was transferred to a general acute care hospital (GACH) where she was diagnosed and treated for severe pain to the left heel, gas gangrene [potentially deadly form of tissue death caused by a bacteria. Gas gangrene causes very painful swelling, foul smelling discharge, and when the swollen area is pressed, gas can be felt as a crackly sensation (crepitus)] with foul smelling drainage, creamy-yellowish in color and, osteomyelitis (infection of a bone) of the left heel, urinary tract infection, and septicemia (blood poisoning, a life-threatening complication of an infection), which caused Resident 1's death on 1/27/13 at the GACH.
A review of the clinical record indicated the Resident 1 had been initially admitted to the facility on 5/11/12 and was transferred to GACH seven times, with the last readmission dated 11/12/12. Resident 1's diagnoses included chronic kidney disease Stage 4 (advanced kidney damage), diabetes mellitus (high blood sugar levels), anemia (deficiency of red blood cells), and dementia (a group of thinking and social symptoms that interferes with daily functioning). The admission nursing assessment documented the resident was readmitted with a Stage 2 (skin is broken) wound to the left heel measuring three centimeters (cm) by two (cm).
The Minimum Data Set (MDS -standardized assessment and care planning tool) dated 11/25/12, indicated the resident had memory problems, was able to communicate verbally, had daily behavioral symptoms not directed toward others, required extensive assistance with transfer, dressing, and walking, and required total assistance with toilet use, personal hygiene, and bathing.
A review of the readmission physician's orders included monitoring pain every shift, treatment to the left heel with Vitamin A & D ointment twice a day, and acetaminophen (pain medication) 325 milligrams (mg) orally one tablet as needed (PRN) for mild pain. The psychoactive (mind altering) medications ordered on readmission were Remeron 15 mg orally for depression manifested by poor appetite, Xanax 0.25 mg every six hours PRN for anxiety manifested by crying out, "Help me," and Haldol 0.5 mg orally at night for dementia with psychosis (mental disorder characterized by a disconnection with real ity) manifested by continuous yelling out, "Help me."
The plan of care developed upon readmission on 11/12/12, included the resident's problcm of potential for leg pain c;nd edema due to peripheral neuropathy (pain from nerve damage) due to diabetes. The approaches included assess when the resident complained of pain and check extremities for pulses, color, coolness, and swelling. The plan of care addressing the resident's psychoactive medications for behavioral manifestations included in the approaches to listen attentively and attempt to resolve or discuss area of upset. The approaches did not include determining if the behaviors were the result of pain.
On 11/13/12, the treatment order to the left heel was changed to cleansing the left heel would with normal saline solution salty water free from germs, apply triple antibiotic and cover with a dry dressing twice a day for 30 days.
On 11/26/12, the psychiatrist evaluated the resident and ordered to increase the Haldol to twice a day and added Trazadone (antidepressant) 50 mg for depression manifested by crying and tearfulness. On 12/5/12, Haldol was increased to three times a day. On 1/10/13, the psychiatrist discontinued Haldol (not effective) and ordered Depakote Sprinkles (mood stabilizer) 125 mg twice a day for continuous yelling for help.
On 12/19/12, a telephone physician's order was obtained to change the left heel wound treatment to cleanse the wound with normal saline solution, apply Santy! ointment (debridement agent that removes dead tissue from wounds) twice a day and cover with a dry dressing for 21 days due to non-healing wound. The physician also ordered to have a wound care consultation which was not done until 1/1/13, 13 days after it was ordered on 12/19/ 12. The reason for the licensed nurse to call the physician and obtain new orders related to the wound was not documented in the clinical record. From readmission to 12/19/12, there was no documentation of the progress of the left heel wound; there was no description of the wound condition such as size, depth, pain, color, swellin·g, temperature, drainage, and response to the treatment. There was no documentation the wound had deteriorated from a Stage 2 (superficial) to having presence of dead tissue [Stage 3, 4 or undetermined (UTD - the base of the sore cannot be seen due to dead tissue])
On 1/1/13, Wound Consultant 1 documented on 1/1/13, the left heel wound measured 6 cm in length, 3 cm in width and UTD depth; 100 percent black necrotic (dead) tissue; no evidence of active infection; no drainage; pulses were not present (blood flow was not detected though pulse sensation). Wound Consultant 1 documented there was no need of debridement (removal of dead tissue) at the time, recommended vascular study on the left lower .e~remity, and to monitor the wound for visible or expressible liquid drainage or other signs of infection under or around the eschar (dead tissue) which would require debridement. Wound Consultant 1 documented to arrange another wound consultation for the following week, which was not done until 15 days later, on 1/16/13.
Between 1/1/13 and 1/16/13, there was no documented evidence the licensed nurses monitored the condition of the wound for presence of drainage, presence of pain to the wound or other signs of infections as recommended by Wound Consultant 1.
On 1/16/13 would consultant documented ... wound measured 9 cm in length, 10cm in width and ... depth (the would increased in size since 1/1/13); had 100 percent black necrotic foul odor and diagnosed infected gangrene.
According to the licensed nursing noted dated 1/16/13, timed at 3 p.m., Resident was screaming and yelling without apparent reason. At 3:30 p.m., another nurse documented the resident continued to yell repeatedly and complaining of severe pain to the left heel, pain medication not effective, and the attending physician (Physician 1) was called. At 4 p.m., the same nurse documented Physician 1 ordered to transfer the resident to a GACH due to uncontrollable pain. At 4:30 p.m., the same nurse documented the family was at Resident 1's bedside trying to control the resident. Residen t 1 was transferred to a GACH on the same day 1/16/13, at 5:30 p.m., where according to the GACH clinical record review, the resident arrived in severe pain and was given Morphine Sulfate intravenous (IV), was diagnosed with gas gangrene ori the left heel, and the wound was described as having foul smelling drainage, creamy-yellowish in color. The resident was admitted to the GACH and was further diagnosed with osteomyelitis (infection of a bone) of the left heel, urinary tract infection, and septicemia. The resident underwent surgical debridement of the left heel wound on 1/20/13. Resident 1 expired on 1/27/13 at the GACH.
Since Resident 1's admission to the facility on 11/12/12 to the date of transfer on 1/16/13, the weekly licensed nursing notes lacked documentation of the progress of the left heel wound and a description of its condition; presence or absence of pain to the wound area was not addressed. There was no documentation pain management related to the wound was provided. There was no new order for pain medication since admission. On 1/11/13 Tylenol #3 (acetaminophen and codeine, a narcotic pain medication) one tablet orally twice a day PRN was ordered for severe pain. On 1/14/1 3, the physician added Tylenol # 3 three times a day routinely for pain management. A review of the Medication Administration Record (MAR) since the month of 12/2012 until1/16/13 indicated for the pain monitoring every shift the resident had no pain, 0/10 (in a pain scale from zero to ten, zero indicating no pain and 10 the worst possible pain). However, the MAR also had documentation the nurses administered Tylenol 325 mg 11 times during the month on 12/2012 for pain rated 3/10-4/10 on the head or the back; three times from 1/1/13 to 1/8/13 for leg pain rated 5/ 10; Tylenol #3 ten times from 1/11/13 to 1/16/13 for left heel pain rated 7/10-8/10.
Since Resident 1's admission to the facility on 11/12/12, to the date of transfer on 1/16/13, there was no documentation the interdisciplinary team (IDT) including the psychiatrist and the attending physician, addressed as possible causative factors for the resident's increased behavior manifestations the deterioration of the wound to the left heel and possible presence of pain. Since admission, the resident was given routinely the antipsychotic medication Haldol for crying out for help. The behavior increased despite increased of the Haldol dosage. Haldol was changed to the mood stabilizer Depakote on 1/10/13. The antidepressant Remeron was given every night since admission for poor appetite. The antianxiety medication Xanax (Aiprazolam) was given PRN crying out for help during the month of 11/2012 a total of four times, during the month of 12/2012 a total of 25 times, and from 1/1/13 to 1/16/13, Xanax was given 11 times. The antidepressant Trazadone for crying out for help and tearfulness was added to the medication regimen on 11/26/12. The lDT did not rule out the behaviors were related to pain from the left heel wound which was not responding to treatment.
On 3/7/13, at 1:30 p.m., during an interview, the director of nursing (DON) stated the resident needed multiple transfers to the GACH and had several skin break down during the different admissions.
On 3/7/13, at 3:40p.m., during another interview, the DON stated on 1/1/13, Wound Consultant 1 explained to Responsible Party 1 the condition of the wound and it was not gangrenous. The DON stated the facility did not learn Resident 1 had gangrene until Wound Consultant 2 evaluated the resident on 1/16/13.
On 6/20/13, at 10:30 a.m., during another interview, the DON explained the delay in obtaining the wound consultations was related to the fact the provider of wound consultants did not have enough physicians to visit residents and the facility had to change providers. The DON could not explain the lack of documentation by the licensed nursing staff regarding the progress of the wound and pain management.
The facility failed to provide Resident 1 with the necessary care and services in accordance with the comprehensive assessment, plan of care and physician's orders by failing to:
1. Ensure licensed nurses monitored the condition of a left heel wound for signs and symptoms of infection such as odor presence of fluid drainage and increased temperature of the area response to treatment changes in size and odor and presence of pain.
2. Follow the physician 's order to obtain a wound consultation in a timely manner.
3. Implement the recommendation by the wound consultant physician to have a follow up evaluation a week after the initial evaluation.
4. Implement pain management interventions when the resident manifested pain to the affected left foot and had increased behavioral manifestations of crying and continuous yelling for help.
On 1/16/13, Resident 1's left heel was evaluated by a wound consultant physician who diagnosed infected gangrene (dead tissue caused by an infection or lack of blood flow) on the left heel. On the same day, Resident 1 was transferred to a general acute care hospital (GACH) where she was diagnosed and treated for severe pain to the left heel, gas gangrene [potentially deadly form of tissue death caused by a bacteria. Gas gangrene causes very painful swelling, foul smelling discharge, and when the swollen area is pressed, gas can be felt as a crackly sensation (crepitus)] with foul smelling drainage, creamy-yellowish in color and, osteomyelitis (infection of a bone) of the left heel, urinary tract infection, and septicemia (blood poisoning, a life-threatening complication of an infection) which caused Resident 1's death on 1/27/13 at the GACH.
The above violation presented either 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 Resident 1's death.