Health inspection·January 21, 2022

T22 72311 (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. 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. F580 §483.10(g)(14) Notification of Changes. (i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is- (B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); The facility failed to ensure the physician was immediately consulted and notified when there was a change in the Patient 1’s condition, in accordance with the patient’s Emergency Room Discharge Instructions and the facility’s policy On 9/6/2021 at 11:00 PM, Patient 1’s head bandage dressing (a pad or compress applied to a wound) was noted to be dry and intact, but one (1) hour after on 9/7/2021 at 12:00 AM, Patient 1’s head bandage was noted to have been saturated with blood (indication of active bleeding from the wound) but Registered Nurse 1 (RN 1) did not call Patient 1’s attending physician to notify of the increase in bleeding from the wound on Patient 1’s head. This deficient practice resulted in a delay to care for Patient 1’s head wound. The patient was transferred to General Acute Care Hospital (GACH) on 9/7/2021 at 2:15 AM, requiring Patient 1 to receive blood transfusion (a medical procedure in which healthy blood is given to you through an intravenous line [IV, a soft flexible tube placed inside a vein, usually in the hand or arm]) at GACH emergency department due to a significant dropped in hemoglobin (HGB, oxygen-carrying component of blood) to a critical level. Patient 1 was admitted to the Intensive care unit (ICUs, specialist hospital wards that provide treatment and monitoring for people who are very ill) on 9/07/2021 for further monitoring and treatment and was subsequently discharged under hospice care (a comprehensive set of services to provide for the physical, psychosocial, spiritual, and emotional needs of a terminally ill patient) on 9/17/2021. An unannounced visit to the facility was conducted on 10:45 AM to investigate a complaint about the facility’s failure to recognize resident’s change of condition and to provide necessary care and services. A review of the Admission Record indicated Patient 1 was a 74 year old male who was admitted to the facility on 9/1/2021 with diagnoses of alcoholic cirrhosis of liver (advanced liver disease) with ascites (fluid builds up in the abdomen), peritonitis (an inflammation of the peritoneum, the tissue that lines the inner wall of the abdomen) and thrombocytopenia (low platelet [tiny blood cells that help your body form clots to stop bleeding] level in the blood). A review of Patient 1’s Minimum Data Set (MDS, standardized assessment and care screening tool) dated 9/07/2021, indicated Patient 1’s cognitive skills (ability to think and reason) were mildly impaired. Patient 1 required extensive assistance with one-person physical assist for bed mobility, transferring, dressing, toilet use and personal hygiene. A review of Patient 1's SBAR (situation-background-assessment-recommendation, a report form used by the facility as their Incident report form) report dated 9/06/2021, indicated at 5:30 AM, Patient 1 was found on the floor in prone position (laying on the abdomen) with significant amount of blood around his face. SBAR report indicated the patient was confused, disoriented, and had several skin lacerations (a deep cut or tear in skin) on his head, nose, and right elbow. Local emergency number was called (911) and Patient 1 was transferred to GACH. A review of Patient 1’s Emergency (ER) Documentation from GACH dated 9/06/2021, indicated Patient 1 noted with head lacerations (deep cut or tear on the skin), facial bruise (an injury appearing as an area of discolored skin on the body), and abrasions (wearing off the skin) on both arms. The laceration on Patient 1’s forehead (part of the face above the eyebrows) was measured at 5 centimeters (cm, a unit of measurement). The wound was reapproximated (to close a wound) and repaired using sutures. Moderate sharp debridement (removal of dead tissues in the wound) was required, and a dressing was placed. The laceration on Patient 1’s occiput (back of the head) was measured at 4 cm. The wound was reapproximated and repaired using 4 staples. Mild sharp debridement was required, and a dressing was placed. A review of Patient 1’s Emergency Department Discharge Instructions from the GACH dated 9/06/2021 printed at 2:32 PM, indicated to call the healthcare provider right away if any of the following occur: a. Fever of 100.4 degrees Fahrenheit or higher, or as directed by your healthcare provider b. Increasing pain, redness, swelling, or drainage from the wound c. Bleeding from the wound that does not stop after a few minutes of steady and firm pressure A review of Patient 1’s Nurses Progress Notes dated 9/06/2021, indicated at 3:45 PM, Patient 1 came back to the facility from the GACH, via private van accompanied by his son. Patient 1 was noted with laceration to forehead with 5 sutures, top of the head with 4 staples with minimal bleeding, bilateral multiple skin discoloration, and abrasion to upper arm. A review of Patient 1’s Nurses Progress Notes dated 9/07/2021 and time of 3:35 AM, indicated the following: a. On 9/06/2021 at 11:00 PM, Patient 1 head bandage dressing was dry and intact. b. One hour after on 9/07/2021 at 12:00 AM, Patient 1’s head bandage dressing was saturated with blood, dressing was reinforced with gauze pads (a bandage used to cover wounds). It did not indicate the Primary Physician (MD 1) was notified and there was no documentation of further assessment was done for the increase in bleeding from the wound site. c. On 9/07/2021 at 2:00 AM (two hours after), Patient 1’s head bandage dressing was saturated with blood, and the Blood Pressure (BP, a measure of the force that your heart uses to pump blood around your body) was 97/54 millimeter of mercury ([mmHg, unit of measurement] indicated a low blood pressure, normal is 120/80 mmHg). d. On 9/07/2021 at 2:10 AM, 911 was called for profuse bleeding on the wound site at the head and Patient 1 was transferred to GACH on 9/7/2021 at 2:15 AM. A review of Patient 1’s Physician Order form dated 9/07/2021 at 2:15 AM (over 2 hours when the patient’s head bandage was found saturated with blood), indicated a telephone order was given by Primary Physician (MD 1) to transfer Patient 1 to the GACH for profuse bleeding of the head. A review of Patient 1’s History and Physical (H&P) Report from GACH dated 9/07/2021, indicated Patient 1 returned due to constant bleeding from head wound despite holding pressure at the Skilled Nursing Facility. The H&P indicated laboratory result was a significant drop in hemoglobin from 8.1 grams per deciliter (g/dL, unit of measurement) to 5.9 g/dL (normal range for men is 13.5 to 17.5 g/dL), and Patient 1 was transfused with 1 unit of Packed Red Blood Cells (PRBC, a type of blood replacement product used for blood transfusions) in the GACH’s emergency department. On 11/03/2021 at 8:55 AM, RN Supervisor (RN 1) stated at the beginning of her shift on 9/06/2021 at around 11:00 PM, she went to visit Patient 1 in his room. RN 1 stated Patient 1 had a bulky dressing around his head stained with some blood. RN 1 stated at midnight, she went to see Patient 1 and found the dressing on his head saturated with blood. RN 1 stated she placed a new bulky dressing but after one hour, it was saturated again with blood. RN 1 stated when she checked Patient 1’s BP, his systolic bp (the top number, measures the force your heart exerts on the walls of your arteries each time it beats) was in the 90’s and heart rate was over 100 beats per minute. RN 1 stated that at around 2:00 AM, she called 911 to transfer Patient 1 to GACH due to profuse bleeding. On 12/14/2021 at 11:00 AM, LVN 2 stated on 9/06/2021 at 10:00 PM, Patient 1 complained that his head dressing was too tight. LVN 2 stated the head dressing was not saturated with blood and that there was only slight bleeding. LVN 2 stated she rewrapped the head with new dressing. LVN 2 stated she endorsed to the next shift nurse around 11:00 PM that she just placed a new dressing on Patient 1’s head wound. During a telephone interview on 12/14/2021 at 12:22 PM, RN Supervisor (RN 2) stated she endorsed to the next shift registered nurse that Patient 1 came back to the facility on 9/06/2021 at 3:45 PM and a new dressing was just placed on 9/06/2021 between 10:00 to10:30 PM. RN 2 stated, if a resident was admitted or readmitted from GACH, facility will review GACH’s discharge instructions and orders, notifies primary physician, and carry out orders and instructions from GACH records. RN 2 stated, it was important to follow discharge instructions from GACH to call the physician immediately for changes in wound condition of Patient 1 such as increase bleeding from the wound to make sure appropriate treatment, prompt action and to avoid worsening of condition. On 12/15/2021 at 11:15 AM, RN 1 stated Patient 1’s head wound was oozing (seeping out) with blood. RN 1 stated she did not call Patient 1’s physician after the dressing change on 9/7/2021 at 12:00 AM. RN 1 stated it was considered a change of condition and as per their policy, to notify the physician immediately if Patient 1’s head wound continues to bleed. RN 1 stated she only notified Patient 1’s primary physician on 9/7/2021 at 2:00 AM about the uncontrolled bleeding from patient’s wound on the head. A review of Patient 1’s SBAR dated 9/7/2021 and time of 3:25 AM, the SBAR indicated at 12 AM patient head bandage dressing was saturated with blood. The SBAR indicated at 9/7/2021 around 12:25 AM, MD 1 was called and under provider notification comment indicated transfer patient to the hospital. On 12/15/2021 at 12:15 PM, LVN 3 validated she entered Patient 1’s SBAR notes on 9/7/2021 at 3:25 AM. LVN 3 stated she just documented it, but she did not call or spoke at all with MD 1 on 9/7/2021 between12 AM to 12:25 AM when the head bandage was noted to have been saturated with blood. LVN 3 stated it was RN 1 who called 911 and talked with MD 1 on 9/07/2021, but LVN 3 was not sure what time RN 1 called MD 1 to transfer Patient 1 to GACH. On 12/16/2021 at 12:12 PM, the Director of Nursing (DON) stated if a patient had wound stitches, and the wound dressing has just had bloodstain, staff should continue to monitor the patient’s condition. DON stated if the wound continues to bleed, it warranted to call the physician for the change of condition and send the patient to acute hospital for further evaluation and treatment. A review of the Facility’s P&Ps titled “Change of Condition Notification” revised April 2015, indicated that the facility will promptly consult with the patient’s Attending Physician (primary physician) when the patient endures a significant change in their condition caused by, but not limited to a significant change in the patient’s physical, mental or psychosocial status. This deficient practice resulted in a delay to care for Patient 1’s head wound. The patient was transferred to General Acute Care Hospital (GACH) on 9/7/2021 at 2:15 AM, requiring Patient 1 to receive blood transfusion (a medical procedure in which healthy blood is given to you through an intravenous line [IV, a soft flexible tube placed inside a vein, usually in the hand or arm]) at GACH emergency department due to a significant dropped in hemoglobin (HGB, oxygen-carrying component of blood) to a critical level. Patient 1 was admitted to the Intensive care unit (ICUs, specialist hospital wards that provide treatment and monitoring for people who are very ill) on 9/07/2021 for further monitoring and treatment and was subsequently discharged under hospice care (a comprehensive set of services to provide for the physical, psychosocial, spiritual, and emotional needs of a terminally ill patient) on 9/17/2021. The facility failed to ensure the physician was immediately consulted and notified when there was a change in the Patient 1’s condition, in accordance with the patient’s Emergency Room Discharge Instructions and the facility’s policy. This violation had a direct or immediate relationship to the health and safety of Patient 1.