Other·February 11, 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. § 72523. Patient Care Policies and Procedures. (a)Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. § 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 (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. (B) Notifying the attending licensed healthcare practitioner acting within the scope of his or her professional licensure promptly of: (C) Any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a patient. (D) 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. The Department received a complaint on 9/16/2020 indicating the facility was not giving a resident (Resident 1) medication that was needed to prevent a stroke (an obstruction within a blood vessel supplying blood to the brain). The complainant alleged Resident 1 had a stroke 10 days after being admitted to the facility. On 9/30/2020 an unannounced investigation was conducted at the facility. The facility failed to: 1. Follow a physician’s discharge summary order from the general acute care hospital (GACH) to continue the use of Pradaxa (blood thinner used to prevent stroke and harmful blood clots if you have a certain type of irregular heartbeat) when the facility failed to properly assess the resident and show appropriate competencies upon admission of the resident. 2. Fully review the discharge summary and all physicians’ orders to create and implement a care plan to ensure the patient’s goals are achieved as required by above regulation and the policy and procedure titled “Admission of Resident.” 3. Implement its policy and procedure titled, “Admission of Resident,” which indicated nurses would review accompanying documentation from hospital/physician’s office for information, orders, etc. and contact the transferring facility to resolve any questions or to obtain clarification and contact the attending physician’s office as needed for orders and/or clarification; and the Licensed Nurse would contact the admitting physician regarding any orders that need clarification and transcribe orders according to facility’s policy. Resident 1, who had a history of heart failure and cardiovascular (relating to, or involving the heart and blood vessels) disease, was previously receiving Pradaxa while in the GACH and, upon discharge to the skilled nursing facility (SNF), the facility failed to continue the prescribed Pradaxa as per the physician’s discharge order for 10 days. As a result, Resident 1 had a change of condition (COC) of an altered mental status (AMS), which required a readmission to the GACH 10 days after admission to the SNF. Resident 1 was diagnosed with an acute right middle cerebral artery ([MCA] relating to the brain artery) stroke and was placed on comfort care (to ease suffering). Resident 1 expired within 24 hours of admission to the GACH of an ischemic (deficient supply of blood to a body part [such as the heart or brain] that was due to obstruction of the inflow of arterial blood) stroke. A review of Resident 1’s Face Sheet (admission record) indicated Resident 1, was an 86 year-old male, admitted to the facility on 1/10/2020. Resident 1’s diagnoses included unspecified diastolic (congestive) heart failure (occurs when the left ventricle [responsible for pumping oxygenated blood all over the body] can no longer relax between heartbeats because the tissues have becomes stiff), atherosclerosis (narrowing of the arteries by build-up of fat and calcium [plague]) on the aorta (the largest artery in the body and the heart’s muscular pumping chamber), paroxysmal atrial fibrillation (an irregular, often rapid heart rate that commonly cause poor blood flow), Type 2 diabetes mellitus (high blood sugar), hypertensive heart disease with heart failure (refers to heart problems that occur because of high blood pressure over a long time). During a review of Resident 1’s Minimum Data Set (MDS), an assessment and care-screening tool, dated 1/17/2020, Resident 1 had moderate impairment in cognitive skills (thought process) and required extensive assistance for transferring, bed mobility, walking, dressing toilet use and personal hygiene. During a review of Resident 1’s GACH discharge summary, dated 1/10/2020 titled “Medications to continue taking with no changes” indicated Resident 1 was to continue to receive Pradaxa 150 milligram ([mg] unit of measurement) one capsule two times daily. During a review of Resident 1’s SNF physician order summary report, dated 1/10/2020 indicated Pradaxa 150 mg two times daily was not included in the physician’s medication order. During a review of Resident 1’s Medication Administration Record (MAR), for the month of 1/2020 indicated Pradaxa 150 mg two times daily was not listed on the MAR and Resident 1 had not received Pradaxa for 10 days. During a review of Resident 1’s care plan, dated 1/10/2020 indicated Resident 1 had a potential for bleeding due to receiving antiplatelet (are medicines that stop cells in the blood [platelets] from sticking together and forming a clot) medications for cardiovascular protection. The staff’s intervention included to administer the medication as prescribed, assess for bleeding and notify physician for any unusual observation. During a review of Resident 1’s nursing progress note, dated 1/20/2020 and timed at 9:30 a.m., indicated the resident was in bed, lethargic (feeling of tiredness), less responsive and speaking slowly with a right facial droop (loss of facial muscle tone; usually caused by an impairment of nerve function that supply the facial muscles; could be a sign of a stroke) and left upper extremity flaccid (not firm or stiff) and weak. The physician (Physician 1) was made aware of Resident 1’s condition and ordered to transfer the resident to the nearest hospital via paramedics. According to the nursing progress note, at 9:32 a.m., 911 (emergency service) was called and the paramedics arrived at 9:42 a.m. and took over the care of Resident 1. During a review of Resident 1’s SNF transfer order report, dated 1/20/2020 and timed at 10 a.m. indicated Resident 1 was sent to the GACH due to AMS and lethargy (a state of weariness that involves diminished energy, mental capacity, and motivation). The transfer report indicated Resident 1 had right facial droop. During a review of the Paramedic Run Sheet (Prehospital Care Report Summary) dated 1/20/2020, it indicated the paramedics were dispatched at 9:51 a.m. on 1/20/2020 and arrived at the facility at 9:57 due to Resident 1 having an altered level of consciousness (ALOC) unrelated to low blood sugar and or seizures (sudden, uncontrolled electrical disturbance in the brain). According to the paramedic run sheet, Resident 1’s blood pressures were recorded as 123/79 and 129/83 millimeters of mercury ([mm Hg] unit of measurement, Normal Reference Range 120/80 mmHg), had rapid labored breathing with facial droop and an abnormal ECG ([electrocardiogram] records the electrical signals of the heart) of atrial fibrillation/flutter (abnormal heart rate, or arrhythmia). Resident 1 was transferred to a comprehensive stroke center to rule out a stroke. During a review of Resident 1’s GACH history and physical, dated 1/20/2020 indicated Resident 1 had a history of atrial fibrillation and being anticoagulated (agent that is used to prevent the formation of blood clots) on Pradaxa [sic] and had an ALOC with an inability to speak and right facial droop at the nursing home. The CTA was positive for a complete occlusion of the right (internal carotid artery [ICA] ([Ischemic stroke] occurs when a blood clot blocks or plugs an artery leading to the brain) origin of the right MCA and placed in intensive care unit and due to poor prognosis care was discussed with Resident 1’s family for comfort care only and Resident 1 died on 1/21/2020 with family at the bedside. During an interview, on 9/30/2020 at 10:03 a.m., Resident 1’s family member (FM 1) stated Resident 1 was not receiving Pradaxa 150 mg medication two times daily as prescribed by the GACH physician from 1/10/2020 until 1/20/2020. During a telephone interview on 11/16/2020 at 3:57 p.m., a supervisor, Registered Nurse 2 (RN 2) stated, “Our practice in this facility is to carry out orders that are written in the discharge summary and should be reflected on the MAR, the facility cannot write any order based on what the residents’ family are telling us and it should be approved by the admitting doctor.” RN 2 stated, “If a family persist, we must clarify and verify the order with the doctor.” On 11/16/2020 at 4:45 p.m., during a telephone interview, RN 3 stated, “When doing admissions, I always verify the discharge summary order to the admitting doctor, and I talk to my director of nursing (DON) before doing anything.” RN 3 stated if a resident missed a dose of a blood thinner it could cause a stroke or a heart attack. During a telephone interview on 12/9/2020 at 8:51 a.m., RN 1 stated when the facility admitted new residents from the GACH, the facility must carry out the discharge summary orders. RN 1 stated it was the admitting nurse’s responsibility to verify the GACH orders with the physician of which medications to continue or discontinue. During a telephone interview on 12/9/2020 at 3:30 p.m., Resident 1’s GACH physician (Physician 2) stated when the resident was discharged from the GACH on 1/10/2020, as per the discharge summary, Pradaxa 150 mg twice day was to be continued in the SNF. During a telephone interview on 12/10/2020 at 10:45 a.m., RN 1 stated if any resident missed dosages of a blood thinner it can lead to stroke. During a telephone interview on 12/28/2020 at 3:15 p.m., RN 3, who was Resident 1’s admission nurse, stated, “It’s always my practice to clarify and verify physicians order especially if the resident is being discharged from the hospital.” When RN 3 was asked why there was no documentation written in the progress notes of Physician 2 (GACH discharging physician) being notified for clarification of Resident 1’s medications orders. RN 3 stated, “Maybe I did not write it in the progress notes or possibly forgot to properly verify/clarify the admission orders as per the facility’s policy”. RN 3 stated she could not remember. During a telephone interview on 12/29/2020 at 9:11 a.m., RN 1 stated Pradaxa medication was not included in Resident 1’s SNF admission order, although it was listed as part of Resident 1’s home medication to receive from the GACH. RN 1 was asked why Pradaxa was not verified and clarified with the admitting physician based on the GACH discharge summary order. RN 1 stated she did not know. During a telephone interview on 12/29/2020 at 11:46 a.m., the SNF Administrator stated, “I saw the documentation that our staff spoke to the discharging physician from the hospital (Physician 2) regarding the medication Pradaxa, as it was put on hold but there was no documentation in the progress notes regarding holding Pradaxa.” The Administrator confirmed there was no documentation Physician 2 ordered to discontinue Pradaxa. During a telephone interview on 12/30/2020 at 9:53 a.m., the facility’s Pharmacy Consultant (PC) stated Pradaxa was an anti-coagulant (blood thinner) medication. The PC stated if the medication would be discontinued abruptly it could cause deep vein thrombosis ([blood clots] DVT), stroke and or a heart attack (occurs when the flow of blood to the heart is blocked). During a telephone interview on 12/30/2020 at 3:19 p.m., Physician 2 stated if the medication Pradaxa was discontinued abruptly there was a high risk of an ischemic stroke or heart attack could occur. Physician 2 stated it required a physician’s order to discontinue the Pradaxa medication and Physician 2 did not order to discontinue the medication. During a review of Resident 1’s Certification of Death, the certificate indicated the resident expired on 1/21/2020 at 3:08 p.m. Resident 1’s death was listed as an ischemic stroke within days as an onset. During a telephone interview on 2/11/2021 at 11:45 a.m., Resident 1’s family member (FM 1) stated she was not aware the resident was not receiving the Pradaxa medication as prescribed until the resident was transferred to the GACH on 1/20/2020. FM 1 stated the physician and the nurses at the GACH asked her when the last time Resident 1 received Pradaxa and she stated she thought the resident was receiving it. During a review of the facility’s policy and procedure (P/P), dated for the year 2018 and titled, “Admission of Resident” the P/P indicated the facility’s purpose was to obtain timely physician admission orders including, medications, diet, activity etc. The P/P indicated the nurses would review accompanying documentation from hospital/physician’s office for information, orders, etc. The nurse would contact the transferring facility to resolve any questions or to obtain clarification and contact the attending physician’s office as needed for orders and/or clarification. According to the P/P, the Licensed Nurse will contact the admitting physician regarding any orders that need clarification and transcribe orders according to facility’s policy. Specifically, “Licensed Nurse will contact admitting physician regarding any orders that need clarification…” The facility failed to: 1. Follow a physician’s discharge summary order from the general acute care hospital (GACH) to continue the use of Pradaxa (blood thinner used to prevent stroke and harmful blood clots if you have a certain type of irregular heartbeat) when the facility failed to properly assess the resident and show appropriate competencies upon admission of the resident. 2. Fully review the discharge summary and all physicians’ orders to create and implement a care plan to ensure the patient’s goals are achieved as required by above regulation and the policy and procedure titled “Admission of Resident.” 3. Implement its policy and procedure titled, “Admission of Resident,” which indicated nurses would review accompanying documentation from hospital/physician’s office for information, orders, etc. and contact the transferring facility to resolve any questions or to obtain clarification and contact the attending physician’s office as needed for orders and/or clarification; and the Licensed Nurse would contact the admitting physician regarding any orders that need clarification and transcribe orders according to facility’s policy. Resident 1, who had a history of heart failure and cardiovascular disease, was previou