|§ 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.
Based on a review of clinical records and staff interviews it was revealed that the facility failed to timely identify and act upon a change in resident condition, including signs and symptoms of a serious head injury, to assure the resident received timely and necessary treatment and prompt medical intervention at the level required for a serious head injury for one resident out of three sampled (Resident CR1).
A review of the clinical record review revealed that Resident CR1 was 68 years old and admitted to the facility from the hospital on May 16, 2013, with diagnoses, which included cerebral infarction (is an area of dead tissue in the brain resulting from a blockage or narrowing in the arteries supplying blood and oxygen to the brain), seizure disorder, schizophrenia (mental disorder), anxiety disorder and macular degeneration (a progressive vision problem which leads to blindness).
An Annual Minimum Data Set assessment (MDS - a federally mandated standardized assessment process completed at specific intervals to identify resident care needs) dated November 7, 2018, indicated that the resident was cognitively intact and required the assistance of one person for transfers between surfaces, was not steady moving from a seated position to a standing position and had a history of falls.
Current physician orders dated February 2019, included the medication Plavix (an antiplatelet medication, that helps prevent red blood cells from clumping together; a noted side effect of this medication is increased risk for bleeding) 75 mg (milligram) daily for cerebral artery occlusion (blood clot causing a blockage resulting in a stroke) initially ordered August 4, 2018.
A review of the resident's February 2019 medication administration record dated February 2019, revealed that Resident CR1 received the Plavix 75 mg daily from February 1st through 4th, 2019.
Further review of the resident's clinical record revealed that Resident CR1 was under the care of a neurologist related to his seizure disorder.
A review of a facility investigation report dated February 2, 2019, at 8:45 PM revealed that Resident CR1 fell while in the shower room. The resident was lying on his right side with his head on a ceramic base, a raised block attached to the end of the bath tub. The report indicated that the shower room floor was wet and this resident had ambulation, balance and vision impairment.
The resident's physician and responsible party were notified and neuro checks (tests used to assess an individual's neurological functions and level of consciousness in order determine whether or not an individual is functioning properly and reacting appropriately to the tests being performed) were initiated. The resident had no apparent injuries noted at that time.
Nursing documentation dated February 3, 2019, revealed no indication of any neurological changes for this resident.
On February 4, 2019, at 10:00 AM nursing contacted the resident's attending physician to report a change in the resident's treatment status and to request therapy services and a change from transfer assistance of one staff member to two staff. The nursing documentation did not include any further information on the details relayed to the physician regarding the resident's need for a change in treatment status.
Nursing documentation dated February 4, 2019, at 10:03 AM revealed that nurse aides made the licensed nurse aware that Resident CR1 had a change in condition. The entry indicated that the resident was unable to sit up on the edge of the bed. Nursing noted that the facility was awaiting a return call from the physician to clear him (the resident) for physical therapy.
A nurses note dated February 4, 2019, at 2:59 PM indicated that the licensed nurse placed a telephone call to neurology and was awaiting a return call from same. The entry did not indicate why the neurologist was called.
An additional nursing assessment dated February 4, 2019, at 9:11 PM indicated that Resident CR1 had poor verbalizations (not speaking clearly) during the 3:00 PM to 11:00 PM shift, was incontinent of urine (the resident had been identified as continent or urine prior to this change) and tremors were noted while performing a neurological exam. The resident displayed right sided weakness, more than baseline, he was unable to transfer without extensive assistance of 2 staff and had increased lethargy.
Nursing documentation, a change in condition assessment, dated February 4, 2019, at 9:11 PM indicated that nursing staff had assessed Resident CR1 and noted decline in his condition. The attending physician was contacted and directed nursing to call the resident's neurologist. The neurologist was contacted and ordered that the facility send the resident to the hospital for evaluation. The resident was sent to the hospital at that time.
There was no documented evidence at the time of the survey ending February 20, 2019, that the facility had timely acted upon the resident's signs of neurological decline. The resident had a history of cerebral infarcts and stroke, was receiving Plavix and had struck his head during a fall on February 2, 2019. Nursing documentation revealed that this resident was exhibiting signs of a neurological decline February 4, 2019 at 10 AM, but the resident was not sent to the hospital until 9:12 PM on February 4, 2019.
Interview with the Director of Nursing during the survey ending February 20, 2019, confirmed that the resident was not sent to the hospital until approximately 11 hours after the noted change in the resident's condition. The resident was diagnosed with a subdural hematoma (a collection of blood outside the brain. Subdural hematomas are usually caused by severe head injuries. The bleeding and increased pressure on the brain from a subdural hematoma can be life-threatening), required a craniotomy (the surgical removal of part of the bone from the skull to expose the brain) and was admitted to the intensive care unit at the hospital.
28 Pa Code 211.12(a)(c) Nursing services
Previously cited 11/30/18, 12/27/17, 10/27/17
28 Pa Code 211.12(d)(1)(3)(5) Nursing services
Previously cited 11/30/18, 10/27/17
| ||Plan of Correction - To be completed: 03/27/2019|
Correction does not constitute an admission of or agreement with the facts and conclusions set forth on the survey report. Our plan of correction is prepared and executed as a means to continually improve the quality of care and to comply with all applicable state and federal regulatory requirements.
1.CR1 has since been discharged from the facility.
2.This was an isolated incident and there was no other residents identified in the facility to be at risk, for the same area of concern. There have been no further incidents of the same nature.
3.Licensed staff were in-serviced/educated on timely documentation and depicting actual times in nursing progress notes to ensure a clear concise picture of when care occurs. Facility protocol following any accidents/incidents with actual or suspected head injuries, and who are on anticoagulation therapy, has been re-evaluated and in addition to Neuro checks, an RN assessment will be done Q4H x 2 days then Q Shift x 3 days. MD will be made aware of any changes of condition to ensure prompt care is rendered, as it occurs.
4.DNS/Designee will do Audits of accidents/incidents x 3 months, to identify residents with actual/suspected head injuries and ensure facility protocol is being followed. Audit Results will be reported and reviewed by the QAPI committee monthly x 3 months to ensure compliance.