Health inspection·October 15, 2021

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: (A)Identification of care needs based upon an initial written and continuing assessment of the patient’s needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. (2) Implementing of each patient’s care plan according to the methods indicated. Each patient’s care shall be based on this plan. (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. (b) All policies and procedures required of these regulations shall be in writing, made available upon request to physician and other involved health professionals, patients or their representatives, employees and the public shall be carried out as written. Policies and procedures shall be reviewed at least annually, revised as needed and approved in written by the patient care policy committee. (c) Each facility shall establish and implement policies and procedures, including but not limited to: (2) Nursing services policies and procedures which include: (A) A current nursing procedure manual. F693 §483.25(g)(5) A resident who is fed by enteral means receives the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers. On 7/22/2021 at 12:18 PM, an unannounced visit was conducted at the facility to investigate allegations of quality of care and neglect of Resident 1. The facility failed to ensure Resident 1 who was receiving enteral feeding (delivery of nutrients through a feeding tube directly into the stomach, duodenum [first part of small intestine], or jejunum [middle part of the small intestine]) received appropriate care and services, according to current standards of practice in maintaining and verifying tube placement to prevent tube feeding complications, to the extent possible including: 1. Failure to assess and identify the swelling in Resident 1’s left lower abdominal (stomach) area as a change of condition during the assessment of the gastrostomy tube (GT- a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications) site by the licensed nurses every shift (7 AM to 3 PM, 3 PM to 11 PM, and 11 PM to 7 AM shift) from 4/25/2019 to 4/26/2019. 2. Failure to implement interventions to address Resident 1’s redness and swollen left lower abdominal area which included monitoring the skin and GT site for irritation and infection such as redness and swelling and notifying the physician. 3. Failure to update and implement a policy and procedure titled “Confirming Placement of Feeding Tubes,” revised in December 2011, with current interventions according to the professional standards of practice for checking and maintain GT placement and assessments of Resident 1 during feedings. The facility had not updated the policy and procedure for confirming placement of feeding tubes since December 2011 (10 years), to ensure the safe practice of checking and maintain GT placement and assessments. As a result, Resident 1 was transferred to the general acute care hospital (GACH) with a diagnosis of pneumonia (an infection that inflames the air sacs in one or both lungs causing cough with phlegm), septic shock (a serious condition that occurs when a body wide infection leads to dangerously low blood pressure), abdominal abscess (swollen area within body tissue, containing an accumulation of pus), abdominal wall cellulitis (serious bacterial skin infection in which the affected skin appears swollen and red), and necrotizing fasciitis ([flesh eating disease] a serious bacterial infection that destroys tissue under the skin that can cause death) due to a dislodged gastrostomy tube with a large collection of tube feeds (a special liquid food mixture used to infuse in enteral feeding) found in the abdominal wall. Resident 1 received multiple antibiotics (medicines that fight bacterial infections), underwent a surgical procedure for g-tube dislodgment and necrotizing fasciitis, and to remove the large amount of tube feeds found in the abdominal wall. Resident 1 was placed in the GACH Intensive Care Unit (ICU; a unit in an acute hospital in which patients who are dangerously ill and require intensive medical care) for 25 days. On 5/23/19, Resident 1 was admitted to a long-term acute care (LTAC; a specialty care hospital designed for patients with serious medical problems that require intense, special treatment) hospital ICU from the GACH and died at the LTAC on 8/11/19 with final diagnoses that included sepsis due to Escherichia Coli (E. Coli., bacteria found in the environment, foods, and intestines of people and animals that can cause infection), aspiration pneumonia (occurs when food, saliva, liquids, or vomit is breathed into the lungs or airways leading to the lungs that can cause severe complications), acute respiratory failure, abdominal wall cellulitis, and necrotizing fasciitis infected with E. Coli. A review of Resident 1’s Admission Face Sheet indicated Resident 1 was admitted to the facility on 2/21/19. Resident 1’s diagnoses included cerebral infarction ([stroke] damage to tissues in the brain due to a loss of oxygen to the area), sepsis (a medical emergency caused by the body’s response to an infection and can be life threatening and is the consequence of widespread), and muscle wasting and atrophy (waste away). A review of Resident 1's Non-Pressure Sore Skin Problem Report, dated 2/21/19, indicated Resident 1 had a GT site located at the left abdomen (stomach area). The Non-Pressure Sore Skin Problem Report indicated monitoring (on the GT site at the abdomen) was conducted from 2/21/19 up to on 4/18/19 and indicated no significant changes and no signs and symptoms of infection were noted. A review of Resident 1’s care plan dated 2/21/19, indicated the resident had concerns/problems that included altered nutrition, on GT feeding related to dysphagia (difficulty swallowing), risk for aspiration related to the presence of tube feeding and dysphagia, and risk for GT site infection. The care plan goals indicated Resident 1 would be free from signs and symptoms of aspiration daily and would be free from signs and symptoms of GT site infection daily. The care plan interventions included monitoring tolerance to feeding like presence of “abdominal distention (bloating or swelling)” and notifying physician, monitoring and reporting signs and symptoms of redness, swelling, and pain to physician promptly. A review of Resident 1’s care plan dated 2/21/19, indicated the resident had an alteration in skin integrity with a goal that included wounds not developing secondary infection (an infection that occurs during or after treatment for another infection). The care plan interventions included performing skin assessments per protocol, turning and repositioning every two hours and as needed, monitoring for signs and symptoms of infection such as redness, swelling, etc., and monitoring skin and reporting red/discolored skin. A review of Resident 1’s Admission Minimum Data Set (MDS), a standardized resident assessment and care screening tool, dated 2/28/19, indicated Resident 1 was usually understood and usually understood others. The MDS indicated Resident 1 was severely impaired of cognition (thought process). The MDS indicated Resident 1 was totally dependent and required one-person physical assistance for bed mobility, dressing, and eating. A review of Resident 1’s Medication Administration Record (MAR) for April 2019 indicated the following information: 1. Resident 1 received Diabeticsource AD (a GT feeding formula) at 60 millimeters (ml, a volume measurement) for 20 hours via a tube feeding pump from 4/1/19 to 4/25/19. 2. Resident 1’s GT feeding order to decrease the tube feeding rate of Diabeticsource AD from 60 ml to 45 ml for 20 hours via a tube feeding pump on 4/26/19 during the 7 AM to 3 PM shift. 3. Resident 1’s GT residuals (volume of fluid remaining in the stomach at a point of time during the enteral nutrition feeding) were checked every shift (eight hours). The MAR indicated Resident 1 had zero GT residuals from 4/1/19 to 4/26/19. 4. Resident 1’s GT placement was checked every shift, from 4/1/19 to 4/26/19. 5. Resident 1 received 2.5 ml of Morphine Sulfate 10 mg/5 ml routinely, daily via GT during the 7 AM to 3 PM shift, 30 minutes before treatment of pressure injuries (areas of damage to the skin and underlying tissue caused by constant pressure or friction). Resident 1 had pressure injuries to the sacrococcyx (tailbone), right hip and left hip. A review of Resident 1’s 4/23/19 to 4/26/19 Nurses Notes indicated the following information: a. On 4/23/19 timed at 10:45 AM, indicated Resident 1's vital signs (a person’s signs of life; specifically the pulse rate, respiratory rate, body temperature, and blood pressure) were: temperature 97.0 (in older adults, the average body temperature is lower than 98.6) degrees Fahrenheit ([°F] a measure of temperature where 30 degrees is very cold and 100 degrees is very hot), heart rate was 110 beats per minute (normal range for adults age 18 and over is 60 – 100 beats per minute), respirations was 19 breaths per minutes, blood pressure was 95/66 (normal blood pressure in adults is below 120/80) millimeter per mercury (mm/Hg, unit of measurement for blood pressures), and a pain level 0 out of 10 (pain scale of 0 means no pain and 10 is severe/worst pain). The Nurses Notes indicated “Resident 1 did not have any cardiac or respiratory distress…tolerated the GT feeding and the GT site did not have signs and symptoms of infection.” b. On 4/24/19 timed at 11:10 AM, indicated Resident 1's vital signs were: temperature 97.5 °F, heart rate was 108, respiration was 17, blood pressure was 118/67 mm/Hg, and pain level of 0 out of 10. The Nurses Notes indicated “Resident 1 did not have any cardiac or respiratory distress, tolerated the GT feeding and the GT site was dry and intact.” c. On 4/25/19 timed at 1 PM, indicated LVN 7 noted Resident 1 with minimal cough and received a breathing treatment. The Nurses Notes indicated Resident 1’s vital signs were: blood pressure of 100/64 mm/Hg, heart rate was 70, respiration was 19, temperature 98.1°F, pain level of 0 out of 10, and the oxygen saturation was 98% (indicates that amount of oxygen traveling through your body; normal oxygen saturation is usually between 95% and 100%). d. On 4/25/19 timed at 6:45 PM, indicated RN 1 wrote, “Physician 1 evaluated Resident 1 and was notified about chest x-ray results.” The Nurses Notes indicated Physician 1 ordered to decrease Resident 1’s GT feeding rate to 45 ml per hour (from 60 ml per hour). e. On 4/26/19 timed at 3 AM, indicated LVN 3 wrote, Resident 1 was on monitoring for congestion. Resident 1’s “breathing was even, unlabored, did not have shortness of breath, and was not in any acute distress.” The Nurses Notes indicated Resident 1’s vital signs were: blood pressure was 123/61 mm/Hg, heart rate was 87, temperature 97.8°F, and respiration was 19. f. On 4/26/19 timed at 8:30 AM, indicated Director of Nurses (DON) 1 wrote “received new orders (CBC [Complete Blood Count] a group of tests that evaluate that cells that circulate in the blood) stat (immediately), CMP ([Comprehensive Metabolic Panel] blood test that measures your sugar level, electrolyte [essential minerals] and fluid balance, kidney function, and liver function) stat. UA ([urinalysis] test of urine to diagnose or monitor several diseases and conditions) from Physician 1 and carried it out.” g. On 4/26/19 timed at 1:40 PM, indicated LVN 7 wrote, Resident 1’s breathing was “Even, unlabored, did not have shortness of breath, and was not in any acute distress.” The Nurses Notes indicated Resident 1 did not have a fever and was not congested. The Nurses Notes indicated Resident 1’s GT feeding was tolerated well and was flushed with water as per Physician 1’s orders. The Nurses Notes indicated Resident 1’s vital signs were: blood pressure was 140/80 mm/Hg, heart rate was 105 beats per minute, temperature was 99.8° F, oxygen saturation was 92%, and pain level 0 out of 10. h. On 4/26/19 timed at 4 PM, indicated that during “nursing rounds” Registered Nurse (RN) 1 noticed Resident 1’s breathing fast and appeared to look weak. Resident 1’s vital signs were: blood pressure 79/60 mm/Hg, heart rate was 143, temperature of 99.9 °F, respirations was 30, and oxygen saturation was 94%. The Nurses Notes indicated Resident 1 was able to respond, but in a very soft voice and chest congestion was noted. The Nurses Notes indicated Resident 1’s GT feeding was held, and Physician 1 was notified and ordered to transfer Resident 1 to the GACH. The Nurses Notes indicated Resident 1’s family member (FM 1) was at the resident’s bedside and RN 1 called “paramedics” via 9-1-1 (emergency services). i. On 4/26/19 timed at 4:12 PM, the Nurses Notes indicated paramedics arrived at the facility and at 4:20 PM, Resident 1 was transferred to a GACH. A review of Resident 1's "OT (Occupational Therapy) Daily Treatment Note," dated 4/25/19, indicated Resident 1 verbalized to Occupational Therapist Assistant (OTA) 1 that he did not feel well and declined to transfer out of bed for therapy. The OT Daily Treatment Note indicated that OTA 1 “notified the nursing staff (unknown).” A review of Resident 1’s Final Chest X-ray result dated 4/25/19 for congestion indicated an enlarged heart and congestive heart failure. The x-ray result indicated there was a small left pleural effusion (an unusual amount of fluid in the lung) and a clinical correlation (a medical process physician use to make a diagnosis) follow up was suggested. A review of Physician 1’s pre-typed Progress Notes dated 4/25/19 timed at 6:45 PM indicated “AVSS” (abbreviation for Afebrile, Vital Signs Stable). The Progress Note indicated a handwritten note indicating the tube feeding was decreased to 45 ml per hour for 20 hours (from 60 ml per hour). The Progress Note indicated Resident 1’s oral diet was between 40% to 60%. The Progress Note indicated under gastrointestinal (GI) physical assessment indicated soft, nondistended, no hepatosplenomegaly (enlargement of the liver and spleen), no hernia (an obvious swelling beneath the skin of the abdomen or the groin), and no masses (a lump in the body that can be caused by the abnormal growth of cells). A review of Resident 1’s Certified Nursing Assistant (CNA) Skin Detail Report (per facility policy and procedure Skin Inspection [Form C]) for 4/2019 indicated CNA 3 wrote there were no new skin problems observed from 4/26/19 timed at 2:09 AM. The Report indicated that CNA 4 wrote there were no new skin problems observed on 4/26/19 timed at 11:22 AM. A review of the Ambulance Report – Prehospital Care report Summary dated 4/26/19 indicated the local Fire Department emergency services arrived at the facility on 4/26/19 at 4:12 PM and left the facility with Resident 1 at 4:27 PM. The Ambulance Report indicated the dispatch reason was hypotensive (relating to or suffering from abnormally low blood pressure) of “less than 90 mm/Hg of systolic blood pressure (the top number indicated the pressure when your heart pushes blood out) and chief complaint of congestion.” The ambulance report indicated rhonchi (type of lung sounds often caused by secretions in larger airways or obstructions and can be heard in patients with pneumonia) was heard to the left and right l