Nursing Investigation Results -

Pennsylvania Department of Health
Patient Care Inspection Results

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Inspection Results For:

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TIMBER RIDGE HEALTH CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an abbreviated complaint survey completed on September 10, 2019, it was determined that Timber Ridge Health Care Center had findings of deficient practice identified as past non-compliance under the following requirements of 42 CFR Part 483 Subpart B Requirements for Long Term Care and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

 Plan of Correction:

483.25(h) REQUIREMENT Parenteral/IV Fluids:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.25(h) Parenteral Fluids.
Parenteral fluids must be administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences.

Based on a review of clinical records and staff interview, it was determined that the facility failed to provide intravenous fluids as prescribed for one resident out of 16 sampled (Resident CR1).

Findings include:

A review of the clinical record of Resident CR1 revealed that the resident was admitted to the facility on August 5, 2019. The resident was admitted with diagnoses including respiratory failure with hypoxia (a condition in which the body or a region of the body is deprived of adequate oxygen supply at the tissue level), end stage renal disease with dialysis (the process of removing excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally) and diabetes.

Resident CR1 had a physicians order on admission August 5, 2019 for a complete blood count (CBC), comprehensive metabolic panel (CMP), thyroid stimulating hormone (TSH), hemoglobin A1c blood test (A1C), and a lipid panel to be completed on August 12, 2019.

A lab results note dated August 12, 2019, at 12:19 p.m. indicated that the certified registered nurse practitioner (CRNP) reviewed the lab results, which indicated hyponatremia, dehydration and hyperkalemia. The CRNP ordered that the facility start an IV now, "start normal saline solution (NSS) 0.9% at 85 cubic centimeters (cc) per hour continous and to give a bolus (relatively large volume of fluid or dose of a drug or test substance given intravenously and rapidly to hasten or magnify a response) of 250 cc IV times one of NSS 0.9% first. "

The CRNP also prescribed Kayexalate 30 grams (gm) by mouth times one "STAT" (now), and a CBC and basic metabolic panel (BMP) in the morning of August 13, 2019.

Review of a "Medication Incident Report" dated August 12, 2019 at 5:00 p.m. indicated that a wrong IV dose was given to Resident CR1. Resident CR1 received 1000 cc of NSS bolus dose over 4 hours, instead of the 250 cc initial bolus ordered. The physician order was for 250 cc of NSS initial bolus then 85 cc per hour thereafter.

A written statement given by Employee 1 (RN) on August 12, 2019 (no time given) indicated that an order was received from the CRNP. Employee 1 and the CRNP went to the resident's room, with the resident's wife at bedside, and started the IV. Employee 1 programmed the IV pump thinking she could set it up for a bolus of 250 cc then for the IV to continue at 85 cc per hour continuously. In error, Employee 1 stated she set the pump for 250 cc per hour and put 999 cc as the volume to be delivered. Employee 1, in her statement indicated that this resulted in the IV running at 250 cc per hour until the bag (1000 ccs) was empty.

A nurses note dated August 12, 2019, at 1:06 p.m. indicated that an IV was inserted into right forearm with # 24 G needle with good blood return. IV 0.9% NSS at 999 hr for 250 ml bolus and then to be reduced to 85 ml/hr continuous.

A nurses notes dated August 12, 2019, at 5:00 p.m. indicated that the resident had increased lethargy and the resident was slow to respond. It also indicated that the resident had
agonal breathing (a specific type of respiratory pattern and might be mistaken for adequate breathing in an emergency. Agonal respirations are irregular, gasping breaths often seen during cardiac arrest) the CRNP gave orders to send the resident to the hospital.

Review of hospital documentation dated August 12, 2019, at 6:37 p.m. indicated that Resident CR1 had many co-morbidities and had a Hemoglobin (is in the blood and carries oxygen from the respiratory organs (lungs) to the rest of the body) of 6.9 and does appear to have some edema on a chest xray. It also indicated that the resident presented for what seemed to be a combination of fluid overload, hyponatremia, and hypoglycemia causing a change in his mental status.

Interview with the Administrator on September 10, 2019 at 1:30 p.m. confirmed that Resident CR1 received 1000 cc of NSS bolus dose over 4 hours in error.

This deficiency is cited as past non-compliance.

The facility's corrective action plan was to send the resident to the hospital for evaluation. Employee 1 was removed from medication pass and completed an IV/medication pass competency with the Staff Development Director. Education related to the 5 rights of medication pass, IV pump/administation competencies were completed with licensed staff on duty. Residents currently receiving IV fluids orders were checked and IV pump set up reviewed for accuracy. Licensed staff were given IV administration/medication pass competencies by the Staff Development Director. Nurses who do not meet competency requirements will be removed from the floor passing medications until reeducation with a satisfactory competency is completed with licensed staff. The Staff Development Director/designee will conduct random audits of residents receiving IV fluids/medications as they occur. Twice weekly times four weeks, then weekly times 1 month, then bi weekly times 1 month, then monthly times 2 with results to QAPI monthly.

The facility's immediate corrective action plan was completed August 13, 2019.

28 Pa. Code:211.12 (a)(c)(d)(1)(2)(3)(5) Nursing Services.
Previously cited 7/26/19

 Plan of Correction - To be completed: 09/30/2019

Past noncompliance: no plan of correction required.

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