Other·February 21, 2024

REGULATION VIOLATION(S) § 72311 Nursing Services - General (a)Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. . . (C) Reviewing, evaluating, and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition. (3) Notifying the attending licensed healthcare practitioner acting within the scope of his or her professional licensure promptly of: . . . (B) Any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a patient. (c) Each facility shall establish and implement policies and procedures, including but not limited to: . . . (2) Nursing services policies and procedures which include: (D) Notification of the licensed healthcare practitioner acting within the scope of his or her professional licensure regarding sudden or marked adverse change in a patient's condition. The facility failed to provide the necessary care and services to maintain one of 130 (max capacity) resident's (Resident 1's) highest physical level of well-being. Despite knowledge of critical lab values, which alerted staff to a high possibility of bleeding, staff failed to follow policy and did not notify the physician of continued bloody stools in Resident 1. This failure further constitutes a failure by the facility to implement its Policy and Procedures detailing timely notification of healthcare practitioners with regards to adverse changes. Resident 1 started bleeding 9 hours prior to being transferred to the hospital. Resident 1 passed away within 30 minutes of arriving at the local acute care hospital. Resident 1 was a "Full Code" (patient/family want everything possible done to keep patient alive). During a telephone interview on 11/30/16 at 3:32 p.m. Complainant X stated Resident 1 had been admitted to the facility for therapy. Complainant X stated Resident 1 had started bleeding from the rectum in the morning of 10/21/16, and continued bleeding throughout the day. Staff had repeatedly told the family, who had been present throughout the day, Resident 1 was "fine." The family had not heard from Resident 1's attending physician. Complainant X stated the family had "relied on the professionals" to take care of Resident 1. Complainant X stated the Emergency Room was so close and questioned why Resident 1 was not sent to the Emergency Room sooner. Complainant X stated licensed staff had not paid attention to Resident 1 until Resident 1 had become unconscious. Review of a document titled "Resident Progress Notes" dated 10/16/16 at 16:04 (4:04 p.m.) revealed an entry by Licensed Staff G which indicated Resident 1 had been admitted on 10/16/16. The document identified Resident 1 as a 71 year old male with the diagnosis, among others, of "Left Middle Cerebral Artery Embolism (blood clot on the brain) with Stroke, Hypertension, History of intracranial hemorrhage (bleeding in the skull), hemiplegia and hemiparesis (one-sided paralysis/weakness), disorder of the circulatory system-visceral ischemia (decreased blood flow to intestines), old myocardial infarction, paroxysmal arterial fibrillation (irregular heart beat) and CAD (coronary artery disease). The entry revealed "Resident Code Status: Full Code." During an interview on 1/5/17 at 2:10 p.m., Unlicensed Staff A stated she had been taking care of Resident 1 during the day shift (6:30 am-2:30 pm) on 10/21/16 and noticed in the morning that "something was wrong." Unlicensed Staff A stated, Resident 1 had experienced 3-4 episodes of loose stools throughout the shift. The color of the stool had been brownish reddish [indicative of blood in stool], and then "changed to more reddish [indicative of substantial blood in stool]." Unlicensed Staff A stated she had notified Licensed Staff B. Licensed Staff B had witnessed the bloody stool in the morning. During an interview on 1/5/17 at 2:25 p.m., Licensed Staff B stated she had witnessed the bloody stool in the morning on 10/21/16. Licensed Staff B stated she had not spoken directly with Physician I regarding Resident 1's bloody stool. Licensed Staff B stated she had relied on Licensed Staff C (discharge nurse) to relay the information to Physician I. Review of a document titled "Resident Progress Notes" dated 10/21/16 at 13:22 (1:22 p.m.) by Licensed Staff B revealed "...noted resident had large amounts of loose BM (bowel movement), color is red and dark brown, ... notified ...discharge nurse (Licensed Staff C) to notify MD...VS (vital signs) at 0815 (8:15 a.m.): 124/76 (blood pressure) ... continues to have loose bloody stools, vs at 0945 (9:45 a.m.) 122/66..." The Resident Progress notes do not indicate any action was taken by Licensed Staff C after being informed by Licensed Staff B of blood in Resident 1's stool. During an interview on 1/5/17 at 10:45 a.m., Licensed Staff C (discharge nurse) stated she had spoken on 10/21/16 in the morning with Physician I regarding Resident 1's bloody stool. Licensed Staff C stated she had notified the physician about Resident 1's lab result in the early afternoon on 10/21/16. Licensed Staff C stated that was "all the involvement" she had regarding Resident 1 on 10/21/16. Review of a document titled "Resident Progress Notes" dated 10/21/16 at 8:06 a.m. revealed the following entry by Licensed Staff C "...dark red blood in the stool. MD was notified and waiting for orders at this time. Patient did have a critical high (4.25 units) (indicating high risk for bleeding) PT (Prothrombin time - measure of how quickly blood clots)/ INR (International normalized ratio - standard unit used to report the result of a PT test - lab test to determine PT; target range for patients on blood thinners is 2-3 units) noted yesterday..." Review of a document titled "Resident Progress Notes" dated 10/21/16 at 8:16 a.m. revealed an entry by Licensed Staff C " Received a TO (telephone order) from MD and continue to monitor for blood in the stool." Review of a document titled "Resident Progress Notes" dated 10/21/16 at 14:08 (2:08 p.m.) revealed an entry by Licensed Staff C indicating notification to physician regarding lab results. The MD responded to recheck patients CBC in morning and continue with current PT/INR drawing. The entry did not mention continued bloody stools. During an interview on 1/18/17 at 1:45 p.m., Management Staff D stated he remembered Resident 1 had "coded" (experienced cardiopulmonary arrest) in the building. Management Staff D stated Licensed Staff C had been in contact with the physician and was asked to provide the documentation. During an interview 1/18/17 at 2:45 p.m., Management Staff E provided a copy of a lab result in response to a request for documentation showing staff had contacted the physician about Resident 1's continued bloody stools. The document titled " Diagnostic Laboratories and Radiology" dated 10/21/16 revealed results of a "CBC" (Complete Blood Count) (a laboratory test that measures several components of blood) laboratory report. The laboratory results indicated low RBC(Red Blood Count) ( a blood test to find out how many red blood cells a person has) 3.79 (normal rage 4.63-6.08 X10^6/ul (microliter)), low Hemoglobin (red cells responsible for transporting oxygen in the blood) 10.0 (13.7-17.5 g/dL(gram per deciliter)) , and low Hematocrit (ratio of the volume of red blood cells in the total volume of blood) 32.7 (40.1-51.0 % (percent)) (all low values indicating possible anemia or lack of blood). The document indicated on the bottom of the page "10/21/16 at 1:50 p.m. TO (telephone order) Dr (Name) Re-check CBC in AM 10/22/16". The document was signed by Licensed Staff C. The document did not reveal any discussion about the Resident 1's continued episodes of bloody stools. No other documentation was provided indicating staff had contacted the physician regarding the continued bloody stool after the initial physician order to "monitor for blood in the stool" was received at 8:16 am on 10/21/16. Record review of a document titled "Resident Progress Notes" dated 10/21/16 at 11:26 a.m. revealed an IDT (Interdisciplinary Team) note written by Licensed Staff F. The category titled "Events" revealed "10/20/16 Critical Lab.". The progress note revealed" PT/INR with critical high result: 4.25. MD notified and order received from Kaiser Coumadin clinic to hold Coumadin. Next PT/INR on 10/21/16 and do a stat CBC now"...." The note revealed " mont' (sic) (monitor) for s/s (signs and symptoms) of bleeding. Increased chance of bleeding, bruising, nosebleed, red or brown urine, black tarry stools. " The IDT note did not address the episodes of bloody stools during the morning of 10/21/2016. Review of a document titled "Event Report" dated 10/21/16 at 21:21 (9:21 p.m.) written by Licensed Staff H revealed the "Description" "Sudden Change in Condition" The document revealed under "Notes" dated 10/21/16 at 19:31 (7:31 pm) "Resident is Unresponsive to external stimuli (not responding to being touched or shaken). Appears to be weak. Abnormal vs taken: weak pulse PR (pulse rate) of 16, temp of 99.2 F (Fahrenheit), RR (respiration rate) of 8cpm (bpm) (breath per minute), BP (blood pressure) of 90/8, O2 (oxygen) 88. Primary Physician on (sic) the building and notify (sic) with the status of the patient and agreed to transfer on (sic) the ED thru 911. Resident leave (sic) the facility at 1730 (5:30 p.m.)" During an interview on 2/6/17 at 3:38 p.m., Licensed Staff H stated she had been taking care of Resident 1 during the pm shift (2:30pm-11pm) on 10/21/16. Licensed Staff H stated Resident 1 had been "totally fine". Resident 1's wife had notified Licensed Staff H that "something was wrong" with Resident 1 at approximately 4:00 pm. Licensed Staff H had found Resident 1 "unresponsive already." Review of a document titled "Pre-Hospital Field Notes; Agency: (Local) Fire Department" dated 10/21/16, and timed "Pt (patient) contact time 16:58 (4:58 p.m.)", revealed "Chief Complaint: Cardiac Arrest." The document revealed " Pt had a large amount of blood coming from rectum…” Review of a document titled "ED Summary Report" dated 10/21/16 reveals under "General Data" "Arrival Date/Time: 10/21/16 1735 (5:35 p.m.)." Review of a document titled "Emergency Department Report" dated 10/21/16 1839 (6:39 p.m.), revealed "When paramedics arrived the patient was nonresponsive and reportedly had a rapid pulse. Notably there was dark blood in the bed which appeared to be coming from the rectum. There is a copious amount of blood, as much as 1 liter according to the paramedics." The document revealed in the subtitle "Physical Exam" General Appearance: "unresponsive" Rectal: "bloody stool noted". In the subtext of "Medical Decision Making" the text revealed"... He (Resident 1) was pronounced dead at 6 PM." During a phone interview on 2/16/17 at 3:08 p.m., Physician I stated he did not recall Resident 1. Physician I stated he had not been the admitting physician and had therefore not been familiar with Resident 1. Physician I stated he did not recall the conversation regarding bloody stool. Physician I stated brighter bloody stool would indicate "there is a problem". Physician I stated he "would have notified the facility to call 911 if there had been any changes like red blood." Review of the facility policy and procedure titled "Acute Condition Changes" dated 2001 (revised October 2010) revealed under section "Assessment and Recognition" 5. a. "Phone calls to attending or on-call physicians should be made by an adequately prepared nurse who has collected pertinent information, including the resident's current symptoms and status." 6. The nursing staff will contact the Physician based on the urgency of the situation. For emergencies, they will call or page the Physician and request a prompt response." The document revealed under section "Cause Identification" 2. "As needed, the Physician will discuss with the staff and the resident and/or family the benefits and risks of diagnosing and managing the situation in the facility or via hospitalization" b. "The discussion should consider the resident's overall condition, prognosis, and wishes." Review on 2/21/17 of the Local Law Enforcement's Coroner's report dated 10/21/16 at 18:21 (6:21 p.m.) revealed during an interview conducted by Local Law Enforcement on 10/21/16 at the local acute care hospital, Physician K stated, "he believed the decedent (Resident 1) possibly bled (sic) (bled) out." The document revealed an interview with family members who had been "concerned due to the large amount of blood found in the decedents stool throughout the day" ..." (Family member name) had brought it to the attention of care staff who stated it was "ok." (Family member name) stated "at some time during the morning (family name) had initially advised the care home staff of the blood. (Family name) had mentioned it twice more. The staff stated it was "ok." The document revealed during an interview on 10/21/16 conducted by Local Law Enforcement, Licensed Staff B stated her "main concern was the decedents frequent loose bowel movements containing blood throughout the day." Licensed Staff B stated, "the decedent needed to be changed at least 8 times that day and each time the stool was very dark and bloody." Review of Resident 1's Death Certificate on 2/23/17 at 8:30 am revealed in section "Cause of death" "subsection: other significant conditions contributing to death "acute gastrointestinal (stomach) hemorrhage (bleeding)." The facility failed to respond to Resident 1's critical lab value which indicated high possibility of Resident 1's hemorrhaging. The facility staff failed to alert the physician of the resident's continued bleeding and failed to take timely appropriate action in response. The resident was not taken to the local acute care facility until 9 hours after the resident continued to have bloody stools episodes. The resident passed away within 30 minutes of arriving at the local acute care hospital. The above violations presented either imminent danger that death or serious harm would or did result or a substantial probability that death or serious physical harm would or did result and was a direct proximate cause of death for Resident 1.