Other·June 9, 2022

F684 § 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility Patients. Based on the comprehensive assessment of a Patient, the facility must ensure that Patients receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the Patients’ choices, including but not limited to the following: T22 Section 72301. Required Services (a) Skilled nursing facilities shall provide, but shall not be limited to, the following required services: physician, skilled nursing, dietary, pharmaceutical and an activity program. (f) The facility shall ensure that all orders, written by a person lawfully authorized to prescribe, shall be carried out unless contraindicated. T22 Section 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. T22 Section 72313. Nursing Service -Administration of Medications and Treatments. (a) Medications and treatments shall be administered as follows: (2) Medications and treatments shall be administered as prescribed. (3) Tests and taking of vital signs, upon which administration of medications or treatments are conditioned, shall be performed as required and the results recorded. On 3/12/22, the Department of Public Health conducted a complaint investigation regarding Patient death. The facility failed to ensure Patient 1 who had diagnosis of hypertension (high blood pressure) received treatment and care in accordance with professional standards of practice and facility's policy and procedures by failing to: 1. Communicate, clarify and follow up with Patient 1's Physician regarding the physician progress note dated 2/25/22 to order a complete blood count (CBC, blood test that provides information about the cells in a person's blood), comprehensive metabolic panel (CMP, blood test that checks for fluid balance, levels of electrolytes, and how well the kidneys and liver are working), and urinalysis (UA, test to analyze urine) with culture and sensitivity (C&S, identifies organism that may cause infection) for Patient 1's complaint of burning upon urination. 2. Monitor and document Patient 1's blood pressure and pulse prior to administering Metoprolol (medication used to treat high blood pressure) as ordered by the physician on 3/1/22 at 5 PM, 3/2/22 at 9 AM and 5 PM, 3/3/22 at 9 AM and 5 PM, 3/4/22 at 9 AM and 5 PM, 3/5/22 at 9 AM and 5 PM, 3/6/22 at 9 AM, 3/7/22 at 9 AM and 5 PM, 3/8/22 at 9 AM, and 3/9/22 at 9 AM. 3. Assess and monitor Patient 1's condition after Patient 1 had low blood pressure and altered level of consciousness (change in condition) on 3/9/22 and required a bolus dose (a single dose of a drug or other substance given over a short period of time) of intravenous (IV, administered into a person's vein) fluids. 4. Recheck Patient 1's blood pressure after the patient received IV fluids and notify Nurse Practitioner 1 (NP 1) as ordered by NP 1. 5. Administer Eliquis (medication used to treat and prevent blood clots) to Patient 1 from 3/1/22 to 3/10/22 as ordered by the physician. 6. Develop a care plan to address Patient 1's hypertension, hypotension (low blood pressure), and use of Eliquis. As a result of these violations, on 3/10/22, at 9:37 AM, Patient 1 was transferred to a general acute care hospital (GACH 1) via 911 (emergency services) due to shortness of breath, chest pain, and hypotension. Patient 1 was admitted to GACH 1 for severe sepsis (body's overwhelming and life-threatening response to infection), acute respiratory failure (a condition that happens when the lungs cannot get enough oxygen into the blood), and urinary tract infection (infection in any part of the urinary system, the kidneys, bladder, or urethra). A review of Patient 1's Admission Record indicated the facility admitted the patient on 2/5/22. The patient was a 66-year-old male with diagnoses including acute kidney failure (the kidneys suddenly cannot filter waste from the blood), tachycardia (rapid heart rate), hypotension, and heart failure (a condition where the heart is not able to pump blood as well as it should). A review of Patient 1's Physician Order dated 2/5/22, indicated for the patient to receive Metoprolol 50 milligrams (mg, a unit of measurement) one tablet by mouth twice a day for hypertension and to hold the Metoprolol if the patient's systolic blood pressure (SBP, measures the force the heart exerts on the walls of the arteries each time it beats) is less than 110 millimeter of mercury (mm/Hg, unit of measurement) and pulse is less than 60. A review of Patient 1's Physician Progress Note dated 2/7/22, indicated the patient had essential hypertension, new onset atrial fibrillation (an irregular heart rhythm that can lead to blood clots in the heart), and was recently treated for a urinary tract infection (UTI). The note indicated Patient 1 was alert and oriented to person, place, and time and able to follow simple commands. A review of Patient 1's Minimum Data Set (MDS, a standardized assessment and care planning tool) dated 2/17/2022, indicated the patient was able to communicate and was cognitively intact (able to think, understand, learn, and remember). The MDS indicated the patient was assessed requiring extensive assistance with activities of daily living. The MDS indicated the patient was always incontinent (unable to control excretion) of bowel and bladder. A review of Patient 1's Physician Order dated 2/23/22, indicated for the patient to receive Eliquis 10 mg by mouth twice a day for seven days and 5 mg by mouth twice a day (indication for use was not specified). A review of Patient 1's Physician Progress Note Daily Updates dated 2/25/22, indicated the patient complained of burning upon urination. The note indicated the physician ordered CBC, CMP, and UA with C&S. A review of Patient 1's Physician Order dated 3/9/22, timed at 11:23 AM, indicated for the patient to receive normal saline (NS, a sterile solution of sodium chloride in water) 500 cubic centimeter (cc, unit of volume) at 100 cc per hour (cc/hr, unit of flow rate) intravenously for low blood pressure. The order indicated for the staff to recheck the patient's blood pressure after 500 cc bolus and contact NP 1. A review of Patient 1's untimed Physician Order dated 3/9/22, indicated to complete a CBC and CMP stat (immediately) and for the patient to receive Bactrim DS (drug used to prevent or treat infection) 160 mg by mouth twice a day for 10 days for infection.  A review of Patient 1’s Intravenous Therapy Medication Record indicated Registered Nurse 1 (RN 1) hung normal saline 500 cc IV at 100 cc/hr as ordered by the physician on 3/9/22 at 11:30 AM. A review of Patient 1's Licensed Progress Note dated 3/9/22 at 5:04 PM, indicated Licensed Vocational Nurse 2 (LVN 2) did not give the patient's scheduled Metoprolol at 5 PM due to the patient's blood pressure of 90/58. The note did not include a documented physical assessment of Patient 1's change in condition. There was no documentation of continuous monitoring of Patient 1’s condition from 5:04 PM on 3/9/22 to 9 AM on 3/10/22. A review of Patient 1’s Licensed Progress Note dated 3/10/22, timed at 4:32 PM, indicated at 9:37 AM, the patient was transferred to GACH 1 for complaint of shortness of breath and chest pain. Vitals signs at 9:09 AM were 94/65, 61 (pulse rate), 16 (respiration rate), and O2 saturation (O2 sat, measures the amount of oxygen being carried by red blood cells) of 98% on room air. The note indicated upon examination of Patient 1, the oxygen flow rate was increased to 5 liters per minute (L/min) via nasal cannula (NC, device use to provide supplemental oxygen therapy) and breathing treatment was given. The note indicated Patient 1 was awake and oriented and lung sounds were clear (air is easily moving through airways). The note indicated NP 1 was notified and ordered to send Patient 1 to the hospital. A review of Patient 1’s GACH 1 record titled “ED General,” dated 3/10/22, timed at 10:02 AM, indicated Patient 1 presented to the Emergency Department (ED) for evaluation of shortness of breath and complaint of non-radiating burning sensation in the chest. The record indicated on scene, Patient 1’s blood pressure was noted to be low and his oxygen saturation on 3 L/min was fluctuating between 77% to 94%. Paramedics gave aspirin (drug used for pain, fever, inflammation, and blood clotting) in route and no other treatments were provided. The report indicated, Patient 1 was currently on blood thinners for atrial fibrillation and a left upper extremity DVT. The record indicated Patient 1 was admitted to the ICU (Intensive Care Unit, provides the critical care and life support for acutely ill and injured patient) for acute severe sepsis and respiratory distress. A review of Patient 1’s GACH 1 Death Discharge Summary dated 3/10/22, indicated Patient 1’s expired at 8:18 PM with primary cause of death of cardiopulmonary arrest with contributing factors of severe sepsis, acute respiratory failure, acute renal failure, and urinary tract infection. During an interview and concurrent review of Patient 1's Medication Administration Record (MAR) for March 2022 on 3/12/22 at 12:02 PM, Licensed Vocational Nurse 1 (LVN 1) stated he held Patient 1's Metoprolol dose on 3/9/22 at 9 am due to the patient's pulse being below 60 per min (specific pulse rate not documented). LVN 1 stated Patient 1's blood pressure was also low at that time, but he could not remember the exact reading. LVN 1 could not find documentation of Patient 1's BP at 9 am on the MAR or in the patient's clinical record. LVN 1 stated Patient 1's BP was 80/60 on 3/9/22 at 3:44 PM. LVN 1 stated on 3/10/22, Certified Nursing Assistant 1 (CNA 1) reported to him that Patient 1 was having difficulty breathing. LVN 1 stated when he entered Patient 1’s room, the patient’s nasal cannula was on the forehead. LVN 1 stated he checked Patient 1’s blood pressure and O2 sat, sat him up, and increased his oxygen flow rate (unable to recall oxygen flow rate). LVN 1 stated Patient 1’s blood pressure was 87/70 and pulse was 56 at 8:49 AM (not documented in Patient 1's clinical record). LVN 1 stated Patient 1’s hands were always cold, so it was hard to get an O2 sat reading. LVN 1 stated he gave Patient 1 a breathing treatment and the Patient said, “it’s getting better.” LVN 1 stated Patient 1 did not complain of chest pain until family member 2 (FM 2) came and asked the patient if he had pain. LVN 1 stated he notified NP 1 and NP 1 ordered to transfer Patient 1 to the hospital. During an interview and concurrent review of Patient 1's MAR for March 2022 on 3/12/22 at 1:15 PM, LVN 1 stated there was no documentation of Patient 1 receiving Eliquis from 3/1/22 to 3/10/22. During an interview on 3/12/22 at 3:25 PM, LVN 2 stated Patient 1 refused all his medications on 3/9/22 during the 2 PM to 10 PM shift because he was sleepy. LVN 2 stated Patient 1 was arousable but said "No" when he offered his medications. LVN 2 stated Patient 1's blood pressure was 80/60 on 3/9/22 at 3:44 PM. LVN 2 stated the RN gave the normal saline IV bolus. LVN 2 stated Patient 1's blood pressure was 90/58 at 5:05 PM. LVN 2 stated he was not concerned about Patient 1's blood pressure because the Patient's blood pressure would sometimes be on the low side. LVN 2 stated Patient 1 was not in distress. During an interview and concurrent review of Patient 1's clinical record on 3/12/22 at 5:20 PM, Medical Records Director 1 (MRD 1) stated she could not find documentation of Patient 1's change in condition and continuous monitoring of Patient 1's vital signs (blood pressure, pulse, temperature, respiration, and O2 sat) on 3/9/22. During an interview on 3/31/22 at 2:47 PM, Family Member 1 (FM 1) stated she was with Patient 1 at the facility on 3/9/22 from about 9 am to 4 PM. FM 1 stated Patient 1 slept all day, was not very communicative, and not himself on 3/9/22. FM 1 stated she informed the staff about her concern and the staff told her that Patient 1 was dehydrated. FM 1 stated Patient 1's blood pressure was 80/40 at that time and his O2 sat was 67%. FM 1 stated NP 1 saw Patient 1 and ordered IV hydration. FM 1 stated 2 weeks prior to 3/10/22, Patient 1 complained to her of burning in his penis. FM 1 stated she informed four different staff about Patient 1's complaint and requested for a UA. FM 1 stated the staff did not do a UA. During a follow-up telephone interview on 4/26/22 at 12:21 PM, LVN 1 stated he would check patients’ (in general) blood pressure and pulse rate and document the reading on the MAR prior to giving any blood pressure medication. LVN 1 stated if the physician order indicated specific parameters to hold the medication, then he would follow the physician order. During a concurrent review of Patient 1's MAR for March 2022, there was no documentation of Patient 1's blood pressure and pulse rate on 3/1/22 at 5 PM, 3/2/22 at 9 AM and 5 PM, 3/3/22 at 9 AM and 5 PM, 3/4/22 at 9 AM and 5 PM, 3/5/22 at 9 AM and 5 PM, 3/6/22 at 9 AM, 3/7/22 at 9 AM and 5 PM, and 3/8/22 at 9 AM and no documentation of Patient 1's blood pressure on 3/9/22 at 9 AM. LVN 1 stated Patient 1 had a physician order for Eliquis but was unsure if the medication was discontinued. LVN 1 stated he was not aware of any urinary concern from Patient 1 or FM 1. During a telephone interview on 4/27/22 at 1:06 PM, NP 1 stated on 3/9/22, there was a concern about Patient 1 being confused. NP 1 stated she ordered some laboratory tests to check what was going on with Patient 1. NP 1 stated she could not recall if Patient 1 had low blood pressure at that time. NP 1 stated if she gave an order for IV fluids then that was probably the reason for the IV fluids. NP 1 stated Patient 1 was on Eliquis for deep vein thrombosis (blood clot in a deep vein). NP 1 stated she could not recall discontinuing the Eliquis. NP 1 stated she was not aware of any urinary complaints from Patient 1 or FM 1. NP 1 stated she could not recall ordering any laboratory tests on 2/25/22 or getting any UA results. NP 1 stated she could not recall writing a provider note on 2/25/22. NP 1 stated if she received a positive UA results then she would order antibiotics (drug used to prevent or treat infection). NP 1 stated untreated urinary tract infection can lead to sepsis and death. NP 1 stated she ordered Bactrim, a broad-spectrum antibiotic (targets many types of bacteria), on 3/9/22 to cover whatever was happening to Patient 1 because “he did not look right”.   During a follow-up telephone interview on 4/29/22 at 8:30 AM, LVN 2 stated he was not aware of any urinary complaint from Patient 1 or FM 1. LVN 2 stated if he saw a physician progress note about ordering laboratory tests but did not see a transcribed order, he would call the physician and ask if the physician wanted to order the laboratory tests and would carry out the order (to carry out an order as prescribed by the physician). LVN 2 stated he does not remember seeing a physician progress note from 2/25/22. LVN 2 stated it was difficult to read physician progress notes because he has a lot of patients. During a telephone interview and concurrent review of Patient 1's medical record on 5/2/22 at 12:19 PM, the current director of nursing (DON) stated there was no documentation that the physician progress note to order CBC, CMP, and UA with C&S was transcribed as a physician order, therefore laboratory draws were not done for the patient. The DON stated the licensed nurse from 11 PM to 7 AM shift should have checked the physician progress notes during nightly chart checks and communicated, clarified, and followed-up with the physician if the physician wanted to order the laboratory tests, then transcribed and carried out the order. The DON stated prior to giving a blood pressure medication, the licensed