Other·October 6, 2021

F684, § 483.25 Quality of Care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. On 1/22/2021, an unannounced visit was conducted at the facility to investigate complaints regarding Quality of Care/Treatment. The facility failed to obtain and implement medication orders from the acute hospital for Resident 1. In addition, the attending physician (AP, doctor assigned to the resident while the resident is in the facility) and nurse practitioner failed to identify that Resident 1 was not receiving the medication necessary to maintain his health and well-being. These failures resulted in Resident 1's hospitalization with conditions including, but not limited to, altered mental status, hypoglycemia (low blood sugar), seizures (electrical disturbances in the brain that cause changes in behavior, movements or feelings) and adrenal crisis (a life-threatening condition that occurs when there is not enough cortisol, which is secreted by the adrenal gland). Review of Resident 1's clinical record indicated he was originally admitted to the facility on 11/13/2014. He had the diagnoses of hypothyroidism (the thyroid gland does not produce enough hormones), hypopituitarism (the pituitary gland does not produce enough hormones), type 2 diabetes mellitus (DM, disease that impairs the body's ability to regulate blood sugar) and diabetes insipidus (disorder that causes an imbalance of fluids in the body). Further review of Resident 1's record indicated the facility sent him to the acute hospital on 11/18/2020, and he returned to the facility on 12/3/2020. Review of Resident 1's Discharge Summary, provided by the acute hospital and dated 12/3/2020, indicated Resident 1 was to continue taking Levothyroxine (also known as Synthroid, medication used to treat hypothyroidism) 0.1 milligrams (mg, unit of dose measurement) by mouth once daily. Review of Resident 1's medication administration record (MAR) indicated the facility did not administer levothyroxine from the time Resident 1 returned to the facility on 12/3/2020 to 1/10/2021. During an interview with the director of nursing (DON) on 3/5/2021 at 11:17 a.m., she explained that when Resident 1 returned to the facility on 12/3/2020, the acute hospital did not send Resident 1's medication orders. She explained that in this situation, the admitting nurse should contact the resident's AP to obtain medication orders. The DON stated that licensed nurse A (LN A) was the nurse who readmitted Resident 1 on 12/3/2020. Review of Resident 1's clinical record indicated there were no medication orders from the acute hospital when he returned to the facility on 12/3/2020. There was no documentation in the clinical record that the facility contacted Resident 1's AP to obtain the medication orders. Further review of the clinical record indicated there was no documentation explaining how the facility determined what medication orders to implement. During an interview and concurrent record review with LN A on 3/5/2021 at 11:28 a.m., she reviewed Resident 1's clinical record and confirmed there were no medication orders from the acute hospital when he returned to the facility on 12/3/2020. When asked if she attempted to contact the hospital to obtain Resident 1's medication orders, LN A stated she did not remember calling the hospital. LN A explained she was supposed to contact the resident's AP to obtain medication orders, but stated she did not remember if she did this. LN A reviewed Resident 1's clinical record and confirmed there was no documentation indicating she contacted the AP to obtain Resident 1's medication orders on 12/3/2020. When asked how she determined what medication orders to carry out and implement for Resident 1, LN A stated she did not remember. During a follow-up interview with the DON on 3/5/2021 at 2:00 p.m., she stated her "understanding" was that LN A called Resident 1's AP to obtain the medication orders and she did not call the hospital to obtain the orders. Review of Resident 1's record indicated nurse practitioner B (NP B) saw the resident on 12/10/2020, 12/29/2020 and 1/7/2021. The MD/NP/PA Progress Notes for the aforementioned dates were reviewed. On all of these Progress Notes, under the section titled "Impression & Plan," NP B documented, "Levothyroxine Sodium Tablet 100 MCG [100 micrograms, equivalent of 0.1 mg] PO [by mouth] QD [every day]." During an interview with NP B on 3/19/2021 at 1:37 p.m., she confirmed that when visiting residents in the facility, she should review what medications they are taking. When asked if she reviewed Resident 1's MAR when she visited him on the above dates, NP B stated, "I should review." When asked if she was aware the facility was not administering levothyroxine to Resident 1, NP B stated, "I don't think so." Review of Resident 1's 12/2020 Progress Notes indicated the AP documented a Physician History and Physical (H&P) on 12/6/2020. There was no documentation indicating the AP reviewed what medications Resident 1 was taking. Resident 1's 12/2020 Order Summary Report was reviewed. There was no order for Levothyroxine on this report. Further review of the report indicated there was a physician signature dated 1/1/2021. During an interview with the AP on 3/25/2021 at 12:46 p.m., he confirmed the Physician H&P documentation on 12/6/2020 indicated he saw Resident 1 on that date. The AP stated he would normally review medications when visiting his residents, but he did not remember if he was able to review Resident 1's medications on 12/6/2020. The AP acknowledged that if he noticed Resident 1 was not receiving levothyroxine, he would have started the medication. The AP stated he did not know why Resident 1's levothyroxine was not continued, but acknowledged the resident should have been receiving this medication. He stated he did not remember facility staff calling him to obtain medication orders for Resident 1 on 12/3/2021. The AP confirmed if facility staff informed him that the acute hospital did not send Resident 1's medication orders, he would have advised the facility to contact the hospital to obtain the orders. He did add, however, that it is sometimes hard to contact the hospital. When asked about Resident 1's signed 12/2020 Order Summary Report, the AP stated he did not remember seeing that there was no order for Levothyroxine. He stated that most likely he did not notice. Further review of Resident 1's Discharge Summary from the acute hospital, dated 12/3/2020, indicated that in addition to continuing levothyroxine, Resident 1 was to do the following: 1) Continue Exenatide (medication used to treat DM) 2 mg injected subcutaneously (SQ, into the tissue layer between the skin and the muscle) once every week; 2) Continue Hydrocortisone (medication used to reduce inflammation) 10 mg 4 tabs (40 mg) by mouth every morning; 3) Continue Hydrocortisone 10 mg 2 tabs (20 mg) by mouth every evening; 4) Continue Insulin Glargine (long-acting medication used to control blood sugar) 15 units (u, unit of dose measurement) injected SQ every evening; 5) Discontinue Insulin Lispro (rapid-acting medication used to control blood sugar) 100 units per milliliter (u/ml, unit of dose measurement) injected SQ three times daily with meals; and 6) Discontinue Insulin Detemir (also known as Levemir, long-acting medication used to control blood sugar) 100 u/ml SQ every evening. Further review of Resident 1's MAR indicated the following from 12/3/2020 to 1/10/2021: 1) Resident 1 did not receive Exenatide 2 mg injected SQ once every week; 2) Resident 1 received Hydrocortisone 10 mg 2 tabs (20 mg) by mouth every morning instead of 40 mg by mouth every morning; 3) Resident 1 received Hydrocortisone 10 mg by mouth every evening instead of 20 mg by mouth every evening; 4) Resident 1 did not receive Insulin Glargine 15 units injected SQ every evening; 5) Resident 1 continued to receive insulin aspart (another rapid-acting medication used to control blood sugar) 100 u/ml 18 units injected SQ before meals; and, 6) Resident 1 continued to receive insulin Detemir 100 u/ml 82 units injected SQ at bedtime. Review of Resident 1's Situation, Background, Assessment, Recommendation (SBAR, a communication tool) documentation, dated 1/10/2021, indicated Resident 1 had a fall. He was also noted to have "altered level of consciousness" and "personality change." Review of Resident 1's Progress Note, dated 1/10/2021, indicted the AP gave an order to send the resident to the acute hospital. Review of Resident 1's ED (emergency department) Physician Notes from the acute hospital, dated 1/10/2021, indicated Resident 1 had altered mental status and had a possible seizure in the ambulance prior to arriving at the ED. The notes further indicated, "Per EMS [emergency medical services], the patient's blood sugar was 52 when they picked him up." According to ED Physician Notes, Resident 1 was unresponsive and snoring when he came into the ED. Review of Resident 1's H&P from the acute hospital, dated 1/10/2021 indicated, "I carefully reconciled meds comparing discharge med list from [acute hospital] to SNF [skilled nursing facility] med list. I no longer see levothyroxine, insulin has changed significantly (levemir [detemir] 82 up from 15 u, premeal insulin 18 u added)." The H&P further indicated, "#Hypoglycemia #Type II DM - I no longer see Exenatide on home med list. Current insulin regimen markedly up from Nov [November] discharge - hypoglycemia could be related to adrenal insuff[iciency]." "#Hypothyroid - unclear why not on levothyroxine, will resume and check tsh [thyroid stimulating hormone, determines whether the thyroid gland is functioning properly]." The H&P had an addendum, dated 1/11/2021, that indicated Resident 1 had a repeat 1-minute seizure overnight during hypoglycemic periods (periods of low blood sugar). Review of Resident 1's Discharge Summary from the acute hospital, dated 1/29/2021, indicated he was an inpatient (stayed in the hospital) from 1/10/2021 to 1/29/2021. The Discharge Summary indicated Resident 1's seizure was likely hypoglycemia related. The Discharge Summary also indicated, "#Central Hypothyroidism - presentation likely due at least significantly due to lack of Synthroid for about 2 months resulting in relative adrenal crisis." Review of the facility's policy titled "Admission Process," revised 9/2012 indicated, "Conduct an admission assessment (history and physical), including: d. Current medications and treatments." The policy further indicated, "Verify medication orders with the Attending Physician as necessary." Review of the facility's undated policy titled "Physician Visits and Services" indicated, "The Attending Physician must perform relevant tasks at the time of each visit, including a review of the resident's total program of care and appropriate documentation." The policy further indicated, "Non-physician practitioners (Physician Assistant, Nurse Practitioner) may perform required visits (initial and follow-up), sign orders and sign certifications/re-certifications as permitted by state and federal regulations." In violation of the above cited standards, the facility failed to obtain and implement medication orders from the acute hospital for Resident 1. Also, the attending physician and nurse practitioner failed to identify that Resident 1 was not receiving the medication necessary to maintain his health and well-being. These failures resulted in Resident 1's hospitalization with conditions including, but not limited to, altered mental status, hypoglycemia, seizures and adrenal crisis. 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 harm would result.