Health inspection·August 26, 2024

AMENDED REGULATION VIOLATION: 483.35 Nursing Services The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at 483.70(e). 483.35(a)(3) The facility must ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. 70213 - Nursing Service Policies and Procedures (a) (c) (a)Written policies and procedures for patient care shall be developed, maintained, and implemented by the nursing service. (c) Policies and procedures which contain competency standards for staff performance in the delivery of patient care shall be established, implemented, and updated as needed for each nursing unit... 72311 Nursing Service - 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: (B) Development of an individual, written patient care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time limited. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. 72517 Staff Development (a) Each facility shall have an ongoing educational program planned and conducted for the development and improvement of necessary skills and knowledge for all facility personnel. FINDINGS: On July 12, 2024, at 8:12 AM, an unannounced visit was conducted at the facility to investigate a facility reported incident regarding Patient 1 receiving enteral feeding formula (liquid food designed to provide nutrition directly into the stomach) into his paracentesis drain (a catheter to remove fluid from the abdominal cavity) when Registered Nurse 6 (RN 6) connected the gastrostomy feeding (G-tube, a tube inserted through the abdominal wall that brings nutrition directly to the stomach) to the wrong tubing. This resulted in Patient 1 experiencing unnecessary abdominal pain requiring transfer to the general acute care hospital (GACH) and admission for septic shock and peritonitis (inflammation of the lining of the abdomen) which was a substantial factor in his death on July 14, 2024. Based on observation, interview, and record review, the facility failed to: 1. Have a Registered Nurse perform a comprehensive nursing assessment (a detailed physical examination of the patient's entire body, to gather information about the patient's status), upon admission on July 3, 2024, or upon change in condition, in accordance with the Registered Nurse's job description. 2. Have a Registered Nurse perform a readmission comprehensive nursing assessment on July 9, 2024, after Patient 1 was readmitted from the GACH where he was transferred earlier that day due to unresponsiveness. 3. Train the nursing staff and conduct competency testing on the care of a paracentesis drain as required by policy and procedure. 4. Implement the facility's Policy and Procedure entitled, "Competency of Nursing Staff," revised October 2017. These violations were a substantial factor in the death of a patient or a resident of a long-term health care facility. Patient 1 was a 72-year old male who was admitted to the facility on July 3, 2024, with diagnoses including cardiac arrest (when a person's heart stop pumping blood around the body), end stage renal disease (condition in which kidneys can no longer function adequately to meet the body needs) with hemodialysis (a treatment to filter wastes and water from the blood), liver cirrhosis (condition in which liver is permanently damaged), diabetes mellitus type 2 (a condition in which pancreas cannot produce enough insulin- a hormone that lowers the glucose in the blood), tracheostomy status (an artificial opening into the windpipe, that allows the insertion of a tube into the trachea, allowing a person to breathe), and gastrostomy status (a surgically created opening into the abdominal wall through which liquid nutrition and medication can be administered into the stomach). During a review of Patient 1's document titled, "Facility: [name of the facility]... History and Physical (H&P-information about a patient's health status and to establish diagnosis)," for Patient 1, dated July 5, 2024, the H&P indicated Patient 1 had diagnoses which included tracheostomy dependence, ventilator dependence (a machine that pumps air into the lungs when a patient is unable to breath independently), dependence on renal dialysis (a treatment to filter wastes and water from the blood), paracentesis with peritoneal drain placement (peritoneal drainage tube), and gastrostomy tube dependent. During a review of Patient 1's nursing "Progress Notes... Type: Transfer to Hospital Summary," dated July 9, 2024, at 10:06 PM, the "Progress Notes" indicated, "Wife asked CN [charge nurse] to connect drainage bag to paracentesis tube. When assessing the pt [patient] CN noted that the LTAD [Long Term Abdominal Drain] did not have the proper connection to connect the drain. CN noted that the tube appeared to have thick viscus cream/tan colored liquid in it. Informed RN supervisor to assess the resident [Patient 1]. After assessment RN called NP [Nurse Practitioner] at 2045 [8:45 PM] and informed him of the situation. NP gave order to send patient out for further evaluation..." The Licensed Vocational Nurse 5 (LVN 5) signed the "Progress Notes... Type: Transfer to Hospital Summary." Patient 1 was then transfer to the GACH. During a concurrent interview and record review on July 12, 2024, at 9:15 AM, with the Director of Nursing (DON), The DON reviewed Patient 1's "Admit/Readmit Screener V.2 (screener assessment - a basic health assessment)," effective July 3, 2024, at 2:01 AM. The "Admit/Readmit Screener V.2" indicated Patient 1 had a "PEG-TUBE (PEG - percutaneous endoscopic gastrostomy tube inserted surgically through the abdomen into the stomach)," received nutrition via tube feeding and received oxygen via tracheostomy. The "Admit/Readmit Screener V.2", did not include that Patient 1 had a paracentesis drainage tube. That document was signed by License Vocational Nurse 7 (LVN 7). The DON was not able to provide documented evidence that a Registered Nurse conducted Patient 1's comprehensive nursing assessment (a detailed physical examination of the patient's entire body, to gather information about the patient's status) upon admission on July 3, 2024, and readmission from the general acute care hospital, on July 9, 2024. The DON stated LVN 7 completed the screener assessment but a Registered Nurse had not done a comprehensive nursing assessment. During an interview on July 12, 2024, at 9:20 AM, with License Vocational Nurse 1 (LVN 1), LVN 1 stated she received training and education regarding drainage tubes in general, but not specifically on how to manage paracentesis drainage tubes. During an interview on July 12, 2024, at 9:55 AM, with the DON, the DON stated she received a call from Registered Nurse 2 (RN 2) on July 9, 2024, at approximately 10:00 PM, informing her that Patient 1's wife reported her husband complained of abdominal pain. The DON stated RN 2 noticed the enteral feeding formula was infusing through Patient 1's paracentesis drainage tube (a catheter to remove fluid from the abdominal cavity), which was the wrong port. The DON further stated Patient 1 transferred to the GACH earlier on July 9, 2024, at 1:45 AM, due to difficulty breathing and returned to the facility at 2:00 PM on the same day. The DON stated it was Registered Nurse 6 (RN 6)'s responsibility to assess Patient 1 upon his return from the GACH and to connect the enteral feeding formula to the G-tube (a tube inserted through the abdominal wall that brings nutrition directly to the stomach), but she did not. During an interview on July 12, 2024, at 10:37 AM, with License Vocational Nurse 2 (LVN 2), LVN 2 stated he received education on how to check residual and placement of a gastrostomy tube feeding but was not trained on how to differentiate between a gastrostomy tube feeding and a paracentesis drainage tube. During an interview on July 12, 2024, at 11:03 AM, with Registered Nurse 1 (RN 1), RN 1 stated she received training for gastrotomy tube feeding but was not familiar with the management of a paracentesis drainage tube. During an interview on July 12, 2024, at 11:35 AM, with Registered Nurse 2 (RN 2), RN 2 stated on July 9, 2024, at approximately 8:20 PM, Patient 1's wife reported to RN 2 that her husband was having abdominal pain. The RN 2 stated she assessed Patient 1 and observed the enteral feeding formula was infusing through the paracentesis drainage tube, which was on the floor. RN 2 further stated, she removed the feeding from the paracentesis drainage tube and called the physician. RN 2 stated she did not receive training or education for management of a paracentesis drainage tube. During a concurrent interview and record review on July 12, 2024, at 2:45 PM, with the DON, The DON reviewed the facility's policy and procedure (P&P) titled, "Managing Draining Tube," revised November 2018. The P&P indicated, "Purpose... To Ensure safe Monitoring of drainage tubes such as JP [Jackson Pratt - a thin flexible tube with a bulb at the end that drains fluid away from a wound] Drains, Nephrostomy [a tube that lets urine drain from the kidney through an opening in the skin on the back], Urostomy [an opening in the abdomen that directs urine from the bladder], Paracentesis, G-Tube, etc.... 1. All personnel responsible for monitoring drainage tubes will be trained, qualified and competent in his or her responsibilities... Preventing misconnection errors... 1. Assess all drainage tubes prior to treatment. 2. Regularly inspect tubing for proper and secure connections." The DON stated staff did not follow the policy. The DON further stated staff did not receive education or training on the management of a paracentesis draining tube until July 10, 2024, after the incident. During a review of the facility's P&P titled, "Competency of Nursing Staff," revised October 2017, the P&P indicated, "1. All nursing staff must meet the specific competency requirements of their respective licensure and certification requirements defined by state law. 2. In addition, licensed nursed and nursing assistants employed (or contracted) by the facility will: a. participate in a facility-specific, competency-based staff development and training program; and b. demonstrate specific competencies and skills sets deemed necessary to care for the needs of the residents, as identified through resident assessments and described in the plans of care." During an interview on July 12, 2024, at 3:00 PM, with Registered Nurse 1 (RN 1), RN 1 stated she "saw" Patient 1 in his room on July 9, 2024, at 3:30 PM, when she [RN 1] was "doing rounds." RN 1 stated she did not conduct a comprehensive nursing assessment of Patient 1. RN 1 further stated she should have performed an assessment of Patient 1 after he [Patient 1] returned from the general acute care hospital. During a follow up interview on July 12, 2024, at 3:20 PM with the DON, the DON stated when the license vocational nurse who admits or readmits from the GACH performs the "Admit/Readmit Screener," they do not do a "comprehensive nursing assessment." The DON stated the expectation is for the Registered Nurses to complete a comprehensive nursing assessment within 24 hours of admission. During a record review of the Registered Nurse job description, undated, the job description indicated, "...4. Collect resident pre-admission and/or admission information and assist Director of Nursing Service to determine appropriate level of care... 19. Assess resident upon admission/readmission, change of condition, resident equipment, and supply needs, and make recommendations to the DON." During an interview and record review on July 12, 2024, at 4:23 PM with the Subacute Manager (SM), the SM reviewed Patient 1's medical records. The SM stated she was not able to find documented evidence that demonstrated a Registered Nurse performed a comprehensive nursing assessment on Patient 1 upon his admission on July 3, 2024, or upon his readmission on July 9, 2024. During a concurrent interview and record review on July 12, 2024, at 9:15 PM with the DON, the DON reviewed Patient 1's medical records and was unable to find documented evidence that a comprehensive nursing assessment for Patient 1 was performed after his admission on July 3, 2024, or upon his re-admission on July 9, 2024. During a concurrent interview and record review on July 12, 2024, at 9:48 PM, with the DON, the DON reviewed the facility's policy and procedure (P&P) entitled, "Admission Evaluation/Assessment & Follow Up: Role of Nurse" revised September 2012. The P&P indicated, "The purpose of this procedure is to gather information about the resident's physical, emotional, cognitive, and psychosocial condition upon admission or readmission for the purpose of managing the resident, initiating the care plan and completing the required assessment instruments..." The DON stated the P&P did not identify the staff responsible for performing the assessment. During an interview on July 12, 2024, at 9:58 PM, with Registered Nurse 3 (RN 3), RN 3 stated it is the responsibility of the Registered Nurses to perform a comprehensive nursing assessment of the patients upon admission or readmission to the facility. The RN 3 further stated the registered nurses have 24 hours from admission or readmission to complete a comprehensive nursing assessment and would need to endorse to the next shift if unable to complete a comprehensive assessment during admission. The RN 3 stated the admission comprehensive nursing assessment must be documented in the patients' medical records. During a review of Patient 1's nursing "Progress Notes... Type: Admission Summary," dated July 9, 2024 at 2:00 PM, the nursing "Progress Notes" indicated, "Resident [Patient 1] returned from [name of the GACH] ER [emergency room] via gurney and [Name of ambulance] transport, without incident or injury, no new orders noted at this time from ER visit, resting in bed, no s/s [signs or symptoms] of distress to note, patient's wife at bedside, charge nurse aware, call light within reach, cooling measures implemented, all needs met by staff, will continue to monitor, bed in lowest position." The Subacute Manager (SM), who is a Licensed Vocational Nurse signed the "Progress Notes... Type: Admission Summary." During a review of Patient 1's nursing "Progress Notes," entitled, "Type: Transfer to Hospital Summary," dated July 9, 2024, at 10:06 PM, the "Progress Notes" indicated, "Wife asked CN [charge nurse] to connect drainage bag to paracentesis tube. When assessing the pt [patient], CN noted that the LTAD [Long Term Abdominal Drain] did not have the proper connection to connect the drain. CN noted that the tube appeared to have thick viscus cream/tan colored liquid in it. Informed RN supervisor to assess the resident [Patient 1]. After assessment, RN called NP [Nurse Practitioner] at 2045 [8:45 PM] and informed him of the situation. NP gave order to send patient out for further evaluation..." The Licensed Vocational Nurse 5 (LVN 5) signed the "Progress Notes" entitled, "Type: Transfer to Hospital Summary." During a record review of Patient 1's general acute care hospital H&P, dated July 9, 2024, the H&P indicated Patient 1 "...presents w [with]/ 1d [one day] severe, constant, diffuse abdominal pain after received tube feeds though the peritoneal drain instead of his PEG tube [Percutaneous endoscopic gastrostomy - a feeding tube inserted through the skin and the stomach wall directly to the stomach]