Health inspection·July 10, 2023

F 686 Treatment/Services to Prevent/Heal Pressure Ulcer Section 483.25(b) Skin Integrity Section 483.25(b)(1) Pressure ulcers. Based on the comprehensive assessment of a resident, the facility must ensure that- (i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and (ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. On 9/21/21 at 10:02 a.m., an unannounced visit was conducted at the facility to investigate a complaint regarding the development of pressure ulcers (synonymous with pressure sore; injuries to the skin and underlying tissue, primarily caused by prolonged pressure on the skin), UTI (urinary tract infection) and sepsis (a life-threatening complication of an infection). Resident 1 was admitted to the facility in June 2021 and was cognitively intact and had no pressure sores. Due to a lack of turning, repositioning, and monitoring of the skin, Resident 1 developed eight pressure ulcers by September 2021 and was at risk for altered skin integrity upon admission. In addition, the resident developed confusion, drowsiness, inability to swallow medications, and changes in vital signs outside of normal parameters. Resident 1 was placed on an antibiotic (a medication to treat infection) for a suspected UTI and nurses were given instructions to transfer Resident 1 to a GACH (General Acute Care Hospital) if her condition worsened. A delay in treatment for worsening condition resulted in Resident 1 developing sepsis, which lead to multi-organ failure and the subsequent death of the resident. The facility failed to: 1. Ensure Resident 1 was free from neglect and harm, and 2. Provide preventative and maintenance care for the development of pressure ulcers. During a review of clinical record for Resident 1, the document titled, ?Face sheet? indicated Resident 1 was admitted to the facility in June 2021 with diagnoses including diabetes (a chronic condition that affects how the body processes blood sugar, which decreases the body's ability to heal), hyponatremia (a low level of sodium in the bloodstream), hypokalemia (low potassium), and hypertension (high blood pressure). A Minimum Data Set (MDS, an assessment tool), dated 7/3/21, indicated Resident 1 had no memory problems. A review of an admission note dated 6/29/2021 indicated, prior to admission, Resident 1 was living alone in an apartment, had normal cognition, behavior, mood, and had no depression. The MD (Medical Director) documented Resident 1 was admitted for, ?PT and OT, pain management and possible long term placement help.? The exam did not document any abnormalities for skin exam. A review of physician orders dated 8/6/2021 to 9/10/2021, indicated MD ordered a fluid restriction for Resident 1. There were no laboratory values or resident exams located in the chart that reflected a need for fluid restriction. 1. A review of a physician's order report, dated 6/26/21 through 9/6/21, indicated Resident 1 had the order, "Sepsis Prevention...Initiate the orders...if the resident has two or more of the following symptoms...Respiratory Rate greater than 20...Acute change in mental status ([Yes or No])... Systolic Blood Pressure less than 100 mmHg [(millimeters of mercury, a unit of measurement for pressure] ...Initiate and document vital signs every 4 hours for 72 hours...Notify physician of symptoms, any interventions carried out and if resident has a diagnosis of... Hyponatremia. Ask if following tests should be ordered and if fluids should be started...Consider transfer to ED [Emergency Department] (after consultation with physician) if resident has two or more of the following symptoms...Systolic Blood Pressure less than 100 mmHg...Acute Change in Mental status ([Yes or No]) ... [Assess this] Every shift; NOC [Graveyard shift], AM, PM." A review of the clinical record for Resident 1, the document titled, ?progress notes?, indicated the following: A progress note, dated 9/2/21 at 4:13 p.m., indicated, "...Appear drowsy today, responding in full sentences, vitals are okay...ER [Emergency Room] if symptoms worsen." A progress note dated 9/2/21 at 7:28 p.m., by Licensed Nurse (LN) 8 indicated, "... order per [physician] ... ciproflaxin [an antibiotic] 250 mg [milligrams, a unit of measure] PO [by mouth for] ... 5 days..." A progress note dated 9/3/21 at 10:49 p.m., by LN 2 indicated, "Monitoring [Resident 1] on [antibiotic]... showing difficulty to swallow [sic]..." There was no documented evidence the licensed staff notified the physician Resident 1 had difficulty swallowing the antibiotic. A progress note, dated 9/4/21 at 2:07 p.m., by LN 9 indicated, " [Resident 1] continues on [antibiotic] for possible infection... [Resident 1] having difficulty taking her medications..." There was no documented evidence the licensed staff notified the physician Resident 1 had difficulty swallowing the antibiotic. A progress note, dated 9/5/21 at 10:25 p.m., LN 7 indicated, " [Resident 1] continues on [antibiotic] for possible infection... [Resident 1] having difficulty taking her medications..." There was no documented evidence the licensed staff notified the physician Resident 1 had difficulty swallowing the antibiotic. A review of a facsimile (fax) transmittal sheet with the header, "To: [MD] From: [LN 7]," was in Resident 1's medical record, dated 9/4/21 and 9/5/21, and indicated, " [Resident 1] continues to decline. Unable to swallow pills whole... Very confused..." MD had written and signed a note dated 9/9/21 in the bottom right corner of the document that stated, "[on-call physician service] should have been called for this over the weekend." A review of a facility document titled, "Vitals Report,? indicated the following: 9/05/21 at 17:10 -Blood pressure- 159/78 mmHg (Millimeters of mercury, a unit of measure) ... 9/05/21 at 17:11- Pulse- 76/per minute ... 9/05/21 at 17:12- Respirations- 18/ per minute... 9/05/21 at 21:46- Blood pressure- 158/78 mmHg ... 9/05/21 at 21:46- Pulse- 76/per minute... [Respirations omitted] 9/06/21 at 02:13- Pulse- 74/ per minute... 9/06/21 at 02:13- Respiration- 18/ per minute.... 9/06/21 at 02:13- Blood pressure- 145/72 mmHg... 9/06/21 at 09:32- Pulse - 57/per minute (with indication alert) acceptable range 60-100 per minute... 9/06/21 at 09:32- Blood pressure- 98/67 mmHg... 9/06/21 at 09:33- Respirations- 20/per minute... 9/06/21 at 17:07- Pulse- 50/per minute (with indication alert) acceptable range 60-100 per minute... 9/06/21 at 17:08- Blood pressure- 95/60 mmHg... 9/06/21 at 19:13- Respirations- 32/ per minute... On 9/6/21 at 9:32 a.m., Resident 1's systolic blood pressure was 98 mmHg, respiratory rate was 22, and there was no documented evidence a change in mental status was assessed.; On 9/6/21 there was no documented evidence vital signs were obtained and documented approximately four hours after 9:32 a.m.; On 9/6/21 at 5:08 p.m. Resident 1's systolic blood pressure was 95 mmHg, there was no documented respiratory rate, and there was no documented evidence a change in mental status was assessed; and, On 9/6/21 at 7:13 p.m. Resident 1's respiratory rate was 32, a blood pressure was not documented, and a change in mental status was documented. Further review of the ?Vitals Report,? indicated the following weights for Resident 1: On 6/26/21, Resident 1 weighed 224 lbs (pounds) on admission, with a usual body weight of 230 lbs; On 8/18/21, Resident 1 weighed 192 lbs; On 8/30/21, Resident 1 weighed 181 lbs; and, On 9/5/21, Resident 1 weighed 172 lbs. This was a 23.21% total body weight loss between 6/26/21 to 9/5/21, or less than 3 months, and a 10.42% loss in total body weight over 18 days between 8/18/21 and 9/5/21. A review of progress notes for Resident 1 indicated the first entry made on 9/6/21 was at 7:28 p.m., by LN 5, and stated, "[Resident 1] noted with increased lethargy, [Resident 1] can barely open her eyes to sternal rub. [Resident 1] not responding to verbal command. vitals 94/60 [blood pressure] ... [heart rate] 50... [respiratory rate] 20... call placed to DR [physician] and left voicemail requesting call. Call placed to [Responsible Person (RP)] and informed her of resident's condition. [RP] stated she wants resident sent to ER. Nursing supervisor informed." A review of a progress note dated 9/6/21, at 8:03 p.m., by LN 4, indicated, ?...alerted around [5 p.m.] of residents condition. Upon assessment [Resident 1] would not wake up with a sternal rub. [Resident 1] was lethargic and was not able to be arouse [sic], [Resident 1] is usually alert and oriented. Informed bedside nurse that the doctor needed to be called immediately and possibly sent out. Around [7:30 p.m.] I was made aware of residents [sic] daughter calling and stating she wanted [Resident 1] sent out to the [ED]. Bed side nurse then called and notified the MD [Medical Director] via voicemail about the change of condition. Spoke with MD myself and he stated [Resident 1] can be sent out. I then called EMS [Emergency Medical Service] ...and [Resident 1] was taken to the ER." A review of an "ED to Hosp-Admission ..." note dated 9/6/21, at 11:24 p.m., by a hospital physician, indicated, "Clinical Impression: 1. Sepsis with encephalopathy [a brain disease that alters brain function or structure, commonly caused by infection, tumor, or stroke] and septic shock, due to unspecified organism ..." A review of Resident 1?s laboratory values (labs) from the GACH on 9/6/21, indicated Resident 1 was malnourished and dehydrated due to: Protein 5 - low (normal 5.9 ? 8.2 g/dl, normal range is 6.0 to 8.3 grams per deciliter (g/dL) and a marker for malnutrition). Albumin - 2.5 low (normal 3.2 -4.7 g/dl, and serum albumin <3.4 g/dl and marker for malnutrition). Serum Creatine - 2.23 g/dl (normal 0.5 ? 1.30, indicates muscle break down; can indicate dehydration). Sodium - 148 high (normal 134 - 143 mmol/L; An elevated level can indicate dehydration and insufficient body fluid). Lactic acid 6.9, critical (normal 0.5- 1.9 mmol, elevated levels indicate poor tissue blood flow in dehydration). Urea Nitrogen (BUN)/Creatine ratio - 32.3 (normal 7.3 to 21.7 mg/dl, elevated BUN and creatinine ratio can indicate decrease blood flow to the kidneys and decrease in kidney function). BUN - 72 (normal 6-21 mg/dl, elevated BUN and creatinine levels can indicate decrease blood flow to the kidneys and decrease in kidney function). e-GFR - 22 (estimated glomerular filtration rate normal > 60. It is a test that measures kidney function and blood flow. Decreased levels may indicate kidney failure and/or dehydration). A review of a publication in the National Library of Medicine, titled, ?Nutritional Laboratory Markers in Malnutrition,? dated 5/31/19, indicated malnutrition results from a mismatch of nutritional requirements with intake. Eating and swallowing problems increase the risk of malnutrition. The study showed that serum albumin and prealbumin levels were maintained even in the presence of distinct weight loss, and they were lowered only during extreme starvation (BMI < 11 kg/m2). Serum Albumin is the most abundant protein in human serum. It has been used for decades as an indicator of malnutrition in residents. There is a clear relationship between serum albumin concentrations and all-cause mortality in elderly subjects. Creatinine is the end product of creatine which consists of 3 amino acids and is mainly present in muscle. Provided that renal function is intact its excretion reflects creatinine production which in turn is a mirror of skeletal muscle turnover. Each mmol (millimole, a unit of measure) of creatinine in urine is derived from 1.9 kg skeletal muscle A review of a GACH admitting note on 9/7/22, by the admitting physician, stated Resident 1 had, ?severe protein calorie malnutrition. A review of a hospital record titled, ?Initial Nutrition Assessment,? dated 9/10/21, indicated Resident 1 was Consulted by a Registered Dietician (RD). The RD indicated the following diagnoses based on her assessment: 1) Severe malnutrition in the context of chronic illness (failure to thrive) related to inadequate oral intake as evidenced by </=[less than or equal to] 75% of estimated energy requirement for >/= 1 month [greater than or equal to], 20% weight loss 4 months. 2) Inadequate oral intake related to altered mental status as evidenced by NPO [(take) nothing by mouth]. 3) Increased nutrient needs related to impaired skin integrity as evidenced by unstageable PI to coccyx, multiple DTIs [deep tissue injuries]. During an interview on 6/20/22 at 2 p.m., with the Assistant Director of Nurses (ADON), when asked about the low systolic blood pressure taken on 9/6/21 at 9:32 a.m., ADON stated, "I don't think the nurse realized it was a low blood pressure for [Resident 1] ... [nurse] unaware of [Resident 1] baseline. A drop in blood pressure was a sign of sepsis. The resident could go into multisystem failure. The nurse failed to notify the doctor of changes." During an interview on 7/14/22 at 3:28 p.m. the MD stated, "I suspected UTI [Urinary Tract Infection] and started [Resident 1] on antibiotics. I wrote the order if patient [sic; resident] deteriorated to transfer to ER. I was pretty upset. We have [an on-call physician service] for [medical insurance] patients which [the] facility had access 24 hours to report any change in patient's condition... It was a long weekend... Friday, Saturday, and Sunday no one called [the on-call physician service]. They just wrote on the paper. It was the weekend... They should have called. They ignored it completely... The facility told me they had a lot of registry nurses. This patient could have been saved if they notified the doctor and followed my order to transfer the patient to the ER. The patient should have gone a couple days before. [Resident 1] was not taking oral antibiotic. I was never informed. How could a patient improve if the patient was not taking the oral antibiotic? The patient could have been sent to the hospital and received IV [intravenous] antibiotic. She continued to deteriorate because she did not receive the treatment which she needed. The patient could not have gone into sepsis if she received the antibiotic. Low blood pressure and confusion was already a sign of sepsis but neither me nor [the on-call physician service] was notified. Every hour, every minute counts in sepsis and they missed three days on this patient. Septic shock and death could have been prevented in this instance with timely interventions." A review of the American Medical Directors Association (AMDA) Clinical Practice Guidelines for Long Term Care Facilities, published 2011, indicated, "Because frail elderly patients are at a higher risk of death and complications from infectious diseases, prompt recognition, assessment, and treatment of infections are imperative...For example, in patients with UTI, complications...sepsis; unstable pulse or blood pressure; or serious illness, combined with uncertain diagnosis, may warrant a hospital transfer... Direct-care staff should closely monitor each patient who is being treated for an infection... A nurse should evaluate the patient who has an infection at least once during every shift as long as the patient is unstable or significantly symptomatic... The practitioner should be notified promptly if the patient's condition worsens...If the patient's condition shows no improvement... reconsider the treatment