Other·July 26, 2022

§T22 DIV5 CH3 ART3 - 72311(a)(3)(B) (a) Nursing service shall include, but not be limited to, the following: (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. The facility failed to ensure that a physician (Physician A) was notified of a change in condition for one of three sampled residents (Resident 1), causing a delay in treatment. This may have contributed to Resident 1's death. Resident 1, a 61-year-old female was admitted to the facility on 2/6/19, with medical diagnoses including Surgery on the Digestive System, Nutritional Deficiency, Chronic Obstructive Pulmonary Disease (A chronic inflammatory lung disease that causes obstructed airflow from the lungs), Dysphagia (Difficulty swallowing) and Muscle Weakness, according to the facility's Face Sheet. Nursing Care Plans indicated Resident 1 was incontinent of feces and urine, and at risk for aspiration due to Dysphagia. A Nursing Note, dated 2/22/19 at 8:33 a.m., indicated Resident 1 received a physician order to send her to an Emergency Department after being notified of a blood pressure of 72/46, and complicating factors related to her low blood pressure. Resident 1's MDS (Federally-mandated process for clinical assessment of all residents in Medicare or Medicaid certified nursing homes), dated 2/20/19, indicated Resident 1's BIMS (Brief Interview for Mental Status-a structured evaluation aimed at evaluating aspects of cognition in elderly patients) score was 12, which indicated Resident 1's cognition was moderately impaired. Resident 1's MDS also indicated she required extensive assistance with bed mobility, transfers, eating, and toilet use. The Nutritional Risk Assessment, dated 2/20/19, indicated Resident 1's intake was 26-74% of meals which came to 1,000 to 1,499 calories per day, of a pureed diet. Resident 1's blood pressure was recorded as 108/64, and pulse as 88, on 2/19/19 at 4:19 a.m. According to the book, "Medical-Surgical Nursing Critical Thinking in Client Care Fourth Edition," by Priscilla LeMone and Karen Burke, Septic shock is part of a progressive syndrome called systemic inflammatory response syndrome, which is often the result of gram-negative bacterial infections (i.e., Pseudomonas, E. coli, Klebsiella). The book indicated that early manifestations of Septic Shock include, "Blood pressure: normal to hypotension (Blood pressure that is lower than 90/60 millimeters of mercury)." Late manifestations of Septic Shock include, "Blood pressure: hypotension ...Pulse: Tachycardia (an abnormally rapid heart rate, usually over 100 beats per minute) ... Respirations: rapid (More than 20 breaths per minute) ...Skin: cool, pale ... Mental Status: lethargic (a state of tiredness, weariness, fatigue, or lack of energy) ... Low urine output (less than 400 ml/day), and fluid and electrolyte depletion status (decreased input)." A Nursing Note documented on 2/18/19 at 1:58 a.m., indicated, "Client is on charting for reduced PO (By mouth) intake. Her BP (Blood pressure) has been low. MD was contacted and gave LVN orders to push fluids, hold her Lasix (Furosemide - a diuretic medicine to treat excess accumulation of fluid or swelling of the body) and monitor VS (Vital Signs)." Earlier on 2/18/19 at 4:22 a.m., Resident 1's blood pressure had been recorded as 88/62 and her pulse as 86. According to Resident 1's Medication Administration Record (MAR) for February of 2019, Resident 1 had an order for three tablets of Lasix 20 mg to be administered daily by mouth at 8 a.m. The MAR indicated this medication was withheld on 2/18/19 from 6:55 a.m. to 8 a.m., and from 2/20/19 through 2/21/19, starting at 7:38 a.m. (on 2/20/19) to 2:21 a.m. (on 2/21/19), becoming active again for the scheduled dose on 2/21/19 at 8 a.m. Documentation in the MAR indicated the scheduled Lasix was withheld on 2/18/19, administered on 2/19/19, withheld again on 2/19/19, and administered on 2/21/19. A Nursing Note documented on 2/19/19 at 10:59 p.m., "As per aide, resident has not voided (urinated) on shift. MD notified." A Nursing Note on 2/20/19 at 1:05 a.m., indicated, "Called MD. Received order to straight cath (A procedure in which a catheter is introduced through the urethra into the bladder to relieve retention of urine) x1 if no void in 12 hours." Nursing Notes on 2/20/19 at 1:56 a.m., indicated a urinary catheterization was performed on Resident 1, obtaining 700 milliliters of amber-colored urine. During an interview on 3/25/19 at 4:45 p.m., Physician A confirmed he was contacted on 2/19/19 and 2/20/19, with regards to Resident 1 not voiding for several hours. A Nursing Note, dated 2/20/19 at 4:30 a.m., indicated, "VS 86/44 (Systolic/Diastolic Blood Pressure. Normal Blood pressure is 90-120 milligrams of mercury for the systolic reading and 60-80 milligrams of mercury for the diastolic reading), 97.7 (Temperature in degrees Fahrenheit) 80 (Pulse) 20 (Respirations).” There is no indication the physician was contacted because of Resident 1's low blood pressure reading. During an interview on 3/25/19 at 4:45 p.m., Physician A stated he should have been notified of Resident 1's low blood pressure reading on 2/20/19 at 4:30 a.m., but he was not contacted. A Nursing Note, dated 2/21/19 at 6 a.m., indicated Resident 1's blood pressure was 94/48 and her pulse 86. There was no indication Physician A was contacted for this low blood pressure reading. During an interview on 3/25/19 at 4:45 p.m., Physician A stated that he did not recall being notified of this blood pressure reading taken on 2/21/19. According to, "PRENTICE HALL NURSE'S DRUG GUIDE 2008," the drug Furosemide (Lasix) is contraindicated in people with increasing oliguria or anuria. This drug guide also indicated Furosemide could cause acute hypotensive (Blood pressure that is lower than 90/60 millimeters of mercury) episodes. In other words, the guide cautions against administering Furosemide to a patient with a history of low blood pressure because it could cause a dangerous drop in blood pressure. According to Resident 1’s Medication Administration Record (MAR), administration of Lasix was withheld on 2/18-20/19, but not on 2/21/19. Consequently, Resident 1 was administered three 20-milligram Furosemide tablets for Chronic Obstructive Pulmonary Disease at 8 a.m. on 2/21/19, even though her blood pressure was documented at 94/48 two hours prior, and she had been having episodes of poor oral intake and reduced episodes of voiding for several hours. The administration of Furosemide was documented in Resident 1’s MAR by Licensed Staff B. During an interview on 3/25/19 at 4:45 p.m., Physician A stated the Furosemide 20 mg tablet should have been withheld, or he should have been contacted, after Resident 1's blood pressure was noted to be 94/48 on 2/21/19 at 6 a.m. Physician A stated that he was always open for staff to check with him. A few hours after staff administered Furosemide on 2/21/19 at 8 a.m., to Resident 1, her blood pressure dropped. Nursing Notes documented by Licensed Staff B on 2/21/19 at 12:29 p.m., indicated for Resident 1: "vs. (Vital signs) 74/42 (Blood pressure), 98.0 (Temperature), 90 (Pulse)...Continues on charting for hypotension. BP still low." There was no indication Licensed Staff B contacted the Physician to notify him of Resident 1's critically low blood pressure. There was no documentation of interventions to attempt to increase Resident 1's blood pressure. There was no documentation Resident 1's blood pressure was re-checked by Licensed Staff B on 2/21/19. There were no follow-up Nursing Notes by Licensed Staff B on 2/21/19. There was a follow-up nursing note (not written by Licensed Staff B) on 2/21/19 at 8:47 p.m., which indicated, "VS 84/68. T(Treatments) refused ...resident continues to refuse food, cannot swallow crushed meds in pudding ...alerted DON (Director of Nurses) and NOC (Night shift) nurse to continue to monitor, possible send to ER (Emergency room) in AM (Morning).” During an interview on 3/12/19 at 12:25 p.m., Licensed Staff B stated, after documenting Resident 1's blood pressure as 74/42 on 2/21/19 at 12:29 p.m., she probably re-checked the blood pressure and noted it to be at normal levels. However, no evidence of such a re-check appeared in Resident 1’s file, and Licensed Staff B confirmed she did not document a follow-up note. Licensed Staff B further stated she did not know if she notified the Physician of Resident 1's low blood pressure reading. No evidence of such a notification appeared in Resident 1’s file. During a second interview on 3/28/19 at 10:20 a.m., Licensed Staff B stated the blood pressure of 74/42, had been taken by a Certified Nursing Assistant, but recorded by her (Licensed Staff B) in the computerized documentation system. She stated the expectation, when obtaining a low blood pressure reading, was to re-check the blood pressure and document a follow-up note. No such follow-up note was documented in this instance. During an interview on 3/12/19 at 12:45 p.m., the Director of Nursing (DON) stated the expectation was to take immediate action after a blood pressure check had a result of 74/42, and the failure to do so was out of character for Licensed Staff B. A Progress Note, documented by the DON on 2/21/19 at 10:11 p.m., indicated, "The resident had Lasix held for a low b/p (Blood Pressure). Contacted [Physician A] to update on resident's status of poor po (by mouth) intake and continued oral candida (oral fungal infection). Also informed of complaints of nausea today ...Informed [Physician A] that despite our efforts, the resident has been a failure to thrive post small bowel obstruction. Requested the charge nurse get a new set of vitals to determine if the blood pressure remains low." There was no indication Physician A was informed of Resident 1's low blood pressure reading recorded on 2/21/19 at 6 a.m., 12:29 p.m. and 8:47 p.m. No further DON notes were found. A Nursing Note, dated 2/22/19 at 6 a.m., indicated, "80/42 (blood pressure), 97.6 (temperature), 102 (pulse), 24 (respirations) continues charting for low BP, poor intakes ...No void for night shift." There was no indication the Physician was contacted because of Resident 1's abnormal vital sign readings and lack of voiding episodes throughout night shift. A Nursing Note, dated 2/22/19 at 8:33 a.m., indicated, "BP 72/46, P=98, T-99.5, client is lethargic, unable to drink or eat, and cannot respond to questions. She is in WC with head hanging down and mouth open. MD contacted, order to send to ER." During an interview on 3/25/19 at 4:45 p.m., Physician A confirmed having been contacted by the Licensed Staff who documented the note on 2/22/19 at 8:33 a.m., and ordering the transfer of Resident 1 to an acute care facility. A facility's document titled, "SBAR Communication Form," dated 2/22/19, indicated, "The change in condition, symptoms, or signs observed and evaluated is/are: Abnormal vital signs (low/high BP, heart rate, respiratory rate, weight change), Altered mental status, Food and/or fluid intake (decreased or unable to eat and/or drink adequate amounts) ...client is markedly declined since 2/20/19. She can barely speak, cannot close her mouth and her skin is sallow." During an interview on 3/27/19 at 2:42 p.m., Unlicensed Staff C, who provided care to Resident 1 during her stay at the facility, stated she was familiar with Resident 1. She stated that upon admission, Resident 1 voided every two to four hours. Unlicensed Staff C stated, on her last days at the facility, Resident 1 did not void for a period of eight hours. She noticed Resident 1 was eating less and voiding less. Unlicensed Staff C stated she remembered notifying the Licensed Nurses assigned to Resident 1, that Resident 1 was nauseous and voiding less, but could not remember which Licensed Nurses she notified. Resident 1 was transferred to an acute care facility the morning of 2/22/19. The acute care facility documented her arrival as 2/22/19 at 9:26 a.m. Hospital Progress Notes, dated 2/22/19 at 7:02 p.m., indicated, "In addition to clinical appears to be concerning she was brought into the emergency department regarding the symptoms. In the emergency room she was found to be hypotensive she was started on fluid resuscitation addition to intrajugular line was placed in pressure support was started. Patient is currently being admitted for septic shock and hypotensive shock." Lactate levels obtained on 2/22/19 at 9:58 a.m., were 2.7 millimoles per liter (normal range is 0.4 to 2.0). The acute care facility performed a urine test on 2/22/19 at 11:20 a.m. The results indicated, "Greater than 100,000 cfu/ml (Colony forming units per milliliter-greater than 100,000 colonies/ml represents urinary tract infection) Escherichia coli (bacteria found in the environment, foods, and intestines of people and animals)." The acute care facility also performed an endotracheal aspirate test (A method of obtaining tracheal secretions for culture and microbiological diagnosis) on 2/24/19 at 8:30 a.m. The results showed heavy growth of Pseudomonas Aeruginosa (A common bacterium which can cause disease), which could have caused the infection that led to Resident 1’s symptoms or diagnosis and could have been indicative of a septic shock. A Nursing Note dated 2/24/19 at 4:15 p.m., from the acute care facility, indicated, "At 1529 [3:29 p.m.] (with daughter at bedside) pt (patient) went into ventricular asystole (rate 80). Daughter escorted to waiting room. SBP at 40/. No pulses palpable and code blue called at 1529 and stopped at 1539 [3:39 p.m.]." The acute care facility's Discharge Summary, dated 3/9/19 at 11:18 a.m., indicated, "Patient is a 61 year old female who presented to the hospital on 2/22/2019 with altered mental status and hypotension. Was found to be in septic shock with likely pulmonary source, received fluid resuscitation, IV (intravenous) antibiotics, pressors (drugs increase heart rate and cardiac contractility) and CVC (Central venous catheter-a tube placed in a large vein in the neck, chest, groin, or arm to give fluids, blood, or medications or to do medical tests quickly) on day of admission ...Despite the above therapies her clinical status declined ...She was pronounced dead at 1539 [3:39 p.m. on 2/24/19]." During an interview on 3/25/19 at 4:45 p.m., Physician A stated he should have been called to notify him immediately of Resident 1's blood pressure reading of 74/42 on 2/21/18 at 12:29 p.m. He stated he did not recall having been notified. Physician A also stated, if he had been notified of Resident 1's blood pressure of 74/42, he would have ordered IV fluids or sent her out to an acute care facility. Physician A was asked if anything could have been done differently with regards to Resident 1's situation during her last days at the facility. Physician A stated, retrospectively, staff should have contacted him earlier in regards to Resident 1's deterioration. He confirmed there had been some issues with nurses not notifying him of residents' changes of condition in the past. The facility's policy titled, "Change in a Resident's Condition or Status," last revised in May of 2017, indicated, "The nurse will notify the resident's Attending Physician or physician on call when there has been a (an): d. significant change in the resident's physical/emotional/mental condition ...A "significant" change in condition is a major decline or improvement in the resident's status that: a. Will not normally resolve itself without intervention by staff by implementing standard disease-related clinical interventions." Therefore, the facility failed to notify the physician promptly of a change in condition, causing a delay in treatment, and administered the medication Lasix improperly, which may have contributed to Resident 1's death. 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.