The facility must also promptly notify the resident and, if known, the resident's legal representative or interested family member when there is a change in room or roommate assignment as specified in ß483.15(e)(2); or a change in resident rights under Federal or State law or regulations as specified in paragraph (b)(1) of this section.
The facility must record and periodically update the address and phone number of the resident's legal representative or interested family member.
F272 - Comprehensive Assessments - 483.20, 483.20(b) The facility must conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity.
A facility must make a comprehensive assessment of a resident's needs, using the RAI specified by the State. The assessment must include at least the following: Identification and demographic information; Customary routine; Cognitive patterns; Communication; Vision; Mood and behavior patterns; Psychosocial well being; Physical functioning and structural problems; Continence; Disease diagnosis and health conditions; Dental and nutritional status; Skin conditions; Activity pursuit; Medications; Special treatments and procedures; Discharge potential; Documentation of summary information regarding the additional assessment performed through the resident assessment protocols; and Documentation of participation in assessment.
The facility's staff failed to immediately consult with Resident A's physician when he had an accident resulting in injury that had the potential for requiring physician intervention; and failed to conduct periodically a comprehensive and on-going assessment of his injuries after the accident. The resident sustained an intracerebral/subarachnoid bleed and was in a coma. Surgical intervention was contra-indicated due to poor prognosis and he expired three days after the accident. The Department Of Coroner's report indicated death was natural due to natural diseases except the fall contributed to death. The resident may have suffered a stroke and then fell, the impact then may have contributed to the bleeding process. The trauma comments indicated the resident had evidence of severe forehead impact with history of fall. The Medical Report indicated the immediate cause of death was intracerebral hemorrhage due to or as consequence of blunt head trauma and arteriosclerotic cardiovascular disease. Other conditions contributing but not related to the immediate cause of death were cerebral stroke and seizure disorder.
The violations were determined during a complaint investigation completed on February 16, 2007.
Resident A was a 54 year-old male who was re-admitted to the Skilled Nursing Facility on August 2, 2005. His diagnoses included a history of cerebrovascular accident, seizure, chronic atrial fibrillation, and hypertension. The Minimum Data Set assessment dated August 15, 2005, indicated he had short and long term memory problems, with moderately impaired cognitive skills for daily decision making, and required supervision with set up help in ambulation, transfer, bed mobility, and locomotion on and off the unit.
A Physician's order dated August 2, 2005, prescribed Coumadin (Blood thinner) two milligrams, one tablet by mouth every afternoon, which was being given at 5 p.m., as recorded in his Medication Administration Record (MAR).
A History and Physical from the acute hospital dated July 30, 2005, indicated the resident's Coumadin dose for that day was to be held due to an elevated INR (International normalized ratio) of 3.6 (Reference ratio range was 1.0 - 2.0) and to repeat PTT (partial thromboplastin time) in the morning. The INR result done on August 2, 2005, was 1.3.
The Patient's Care Plan dated August 9, 2005, indicated the patient was at risk for falls/injuries due to the following factors such as: seizure disorder, history of cerebrovascular accident and transient ischemic attack, impaired cognition, visual limitation, use of psychotropic medications for psychosis, on coumadin therapy for atrial fibrillation, and was at risk for easy bruising and bleeding. The approaches included: patient may ambulate ad lib with oversight encouragement; remind him not to do sudden position changes such as from standing to bending down or sitting/lying to standing up; report any signs of bleeding/injuries/falls to the physician.
The Patient's Care Plan dated August 15, 2005, identified a problem of being at risk for easy bruising and skin discoloration related to Coumadin therapy. The approaches indicated to monitor for signs and symptoms of bleeding of gums and skin discolorations.
The Multidisciplinary Progress Record dated August 15, 2005, indicated the resident had a habit of picking up pieces of paper on the floors in the hallways.
A review of the Licensed Nurse Progress Record dated August 15,2005, and the facility's investigation report dated August 15 and 16, 2005, indicated that at approximately 1:00 p.m. on August 15, 2005, the resident was found on the floor in his room, lying flat on his back. He lost his balance when he attempted to reach for something on the floor and hit his forehead against the ground. He sustained a skin tear/laceration 2 by 1 centimeters in size with slight bleeding and a bump on the forehead. The Licensed Nurse Progress Record documentation dated August 15, 2005, read, "MD, Bob notified of incident." However, it did not include the name of the physician who was notified. Further record review indicated there was no documentation that the resident's Primary Physician was notified on August 15, 2005, of the resident's fall.
A review of the MAR revealed that the resident was given Coumadin 2 mg on August 15, 2005, at 5 p.m. even though he had fallen at 1 pm that day and sustained a laceration with slight bleeding on the forehead.
A review of the medical record revealed a telephone order by the primary physician dated August 15, 2005, at 1:20 pm for treatment of the skin tear on the forehead with Normal Saline Solution, Bacitracin ointment, and steri-strips for 14 days, and neuro-check for 48 hours. However on March 8, 2006, at 3:15 p.m., a telephone interview was conducted with the resident's primary Physician, who stated the nursing home staff did not notify her on August 15, 2005, about the resident's fall and denied giving the above order.
The 48 Hours Neuro-Checklist revealed neuro-checks were done on August 15, 2005, at 2 p.m. through August 16, 2005, at 2:30 p.m. and were normal. However, there was no initial and ongoing assessment as to the color of the resident's skin tear/laceration and the size and color of the bump.
The Licensed Nurses Progress Notes on August 16, 2005, at 5:15 p.m., revealed the resident was non-arousable and his blood pressure (BP) was 160/110. The Physician Assistant, (PA) was paged. At 5:35 p.m., the PA called back and was informed of the resident's condition. At 6 p.m., the resident responded only to pain stimulus. The PA came to see the resident at 7 p.m. At that time the resident remained lethargic and at 7:45 p.m., he was transferred to an acute hospital.
The Emergency Department Nursing Assessment dated August 16, 2005, at 8:28 p.m., indicated the resident had a 2.5 cm. vertical lacerated wound on the frontal area. He was unresponsive to pain stimulus.
The Emergency Physician Record dated August 16, 2005, at 8:35 p.m., indicated the resident had a laceration on his mid forehead about 2 cm, with resolving hematoma and ecchymosis. The lab result dated August 16, 2005 revealed the INR was 3.1 (normal reference values are 1.0-2.0), PT (Prothrombin time) was 21.2 seconds (normal reference values are 11.0 to 15.0 seconds), and the PTT (partial thromboplastin time) was 48 seconds (normal reference range is 42-32 seconds). The Clinical Impression indicated intracerebral/subarachnoid bleed and coma.
A review of the Radiologist Preliminary Report of the Computerized Tomography of the head dated August 16, 2005, revealed the resident had extensive left frontal/parietal intraparenchymal hemorrhage 8 x 3 cm in size, right frontal intraparenchymal hemorrhage 2.5 x 2.0 cm., extensive bifrontal bitemporal subarachnoid hemorrhage, and "scalp STS/Hematoma frontal region." The Emergency Room Physician reading revealed huge cerebral bleeding.
On January 30, 2006, at 12:25 p.m., in an interview, Charge Nurse I stated Resident A's bump was the same size of the skin tear and was approximately 1/2 inch in size, and with slight redness. However, he failed to document his assessment on his shift.
On January 31, 2006, at 11:30 a.m., and March 1, 2006, at 6:35 p.m., respectively, the Director of Nurses (DON) stated the condition of the bump and color of the skin should have been continuously assessed to determine changes in size and color. She stated skin discolorations such as ecchymosis should be assessed to determine any bleeding for residents on Coumadin therapy and had head injuries.
On March 1, 2006, at 4:40 p.m., an interview with Charge Nurse II revealed the resident had a bump on the forehead from the fall on August 15, 2005, but she could not remember the size. She stated that she failed to document her assessment of the resident's skin tear and bump on the forehead during her shift. She stated that the color of the skin tear and bump should have been assessed because the resident was on Coumadin, a blood thinner, which could cause easy bruising. She stated that skin discoloration such as a bruise was a sign of bleeding.
A review of the Facility's Policy and Procedure on Skin Assessment and Documentation indicated, "the Licensed Charge Nurse shall document size, color, appearance, and bleeding for skin tear. Licensed Staff shall continuously monitor skin condition in the Licensed Progress Notes every shift for 72 hours, or until resolved or otherwise indicated."
A review of the facility's policy and procedure on Anticoagulation Therapy included monitoring the resident for any unusual bruising, bleeding and swelling and reporting to the physician promptly. However, there was no documentation in the resident's clinical record to indicate the aforementioned procedures were followed.
The facility's policy and procedure on head trauma, indicated to assess the resident for obvious signs of injury, which included ecchymosis and lacerations.
On March 2, 2006, at 11:30 a.m., during an interview, the Registered Nurse (Supervisor) stated the resident's skin tear was slightly raised and the color was reddish. She described a skin tear as a tear on the skin and a laceration as a deep cut, which involves the muscle. She stated she failed to document her assessment of the resident at the time of the fall incident.
On March 8, 2006, at 12:40 p.m., a telephone interview was conducted with the PA. He stated that he and the primary physician were not notified of Resident A's fall on August 15, 2005, nor did he give treatment orders. He stated that the physician's office had no record of contact or call from the nursing home staff on August 15, 2005, regarding the resident's fall. The PA stated he was first notified of the fall incident when the facility staff found the resident lethargic on August 16, 2006; He subsequently went to the facility and found the resident extremely lethargic. He ordered to transfer the resident to the acute hospital.
On March 8, 2006, at 3:10 p.m. and on March 14, 2006, at 10:35 a.m., in a telephone interview, the DON stated that according to her investigation of the fall incident, Charge Nurse I did not notify the Primary Physician but notified the Physician Assistant (PA), who gave the treatment order on August 15, 2005.
On March 8, 2006, at 3:15 p.m., a telephone interview was conducted with the resident's primary Physician, who stated the nursing home staff did not notify her on August 15, 2005 about the resident's fall. She stated she was first notified of the incident on August 16, 2005, when the PA came to the facility to assess the resident. The Physician stated that if a resident was on Coumadin and had a fall incident sustaining a skin tear or bump, the resident was to be transferred to the closest acute hospital for evaluation.
On March 10, 2006, at 11:15 a.m., in a telephone interview, Charge Nurse I stated he called the Physician's Exchange on August 15, 2005, and left a message regarding the resident's fall. He did not talk to the resident's primary Physician or PA (Bob) at that time (referring to his documentation on August 15, 2005). He could not remember if he talked to the Primary Physician or the PA after he called the Physician's Exchange and who gave the telephone order on August 15, 2005. Charge Nurse 1 also stated that he usually documents the physician notification, including the time and the physician's name in the Nurse Notes and to follow up to make sure the primary physician was notified of the incident. He further stated that it was considered a telephone order when providing the facility's in-house treatment protocol for skin tear.
A review of the resident's medical record and facility documentation revealed no evidence of a follow-up or about the physician calling back with orders.
A review of the facility's policy and procedures on Documenting Physician Notification indicated, "The Licensed Nurse in charge of the patient's care shall be responsible for immediate notification of the resident's Primary Care Physician for any aspect of the resident's care, which may require physician and/or medical intervention including change in status or condition. Changes in a resident's status or condition include any incident or accident involving the resident, which results in injury or which has the potential for requiring physician intervention. If alternate physician was notified in lieu of the primary care physician, document date, time, and name of the alternate physician that was notified. Licensed nurse shall document in the resident's clinical record the date and time notification was made to primary care physician. Also document any follow up made to the initial call and outcome of such follow up."
A review of Resident A's Discharge Summary from the second acute hospital, where he was transferred for surgical intervention on August 17, 2005, revealed he expired on August 18, 2005, with the principal cause of death as, "intercerebral hemorrhage with herniation, left 3 x 5 x 14 peri-sylvian and a right tempoparietal 1 x 1.5 x 4 hemorrhage extension to the left occipital horn with small midline shift."
The Death Memorandum record revealed the resident died on August 18, 2005, and the cause of death included massive bilateral intracerebral hemorrhage contributory to head trauma.
The Department Of Coroner's report dated August 25, 2005, indicated death was natural due to natural diseases except the fall contributed to death. The resident may have suffered a stroke and then fell, the impact then may have contributed to the bleeding process. The trauma comments indicated the resident had evidence of severe forehead impact with history of fall. The Medical Report dated August 25, 2005, indicated the immediate cause of death was intracerebral hemorrhage due to or as consequence of blunt head trauma and arteriosclerotic cardiovascular disease. Other conditions contributing but not related to the immediate cause of death were cerebral stroke and seizure disorder. Under the section of how did the injury occurred it indicated the resident fell to the ground and struck his head.
Failure of the facility to immediately consult with Resident A's physician when he had an accident resulting in injury which had the potential for requiring physician intervention and failure to conduct periodically a comprehensive and on-going assessment of his injuries after the accident, met the standard for a class "A" citation and was a direct proximate cause of death of the resident.