Chittenango Center for Rehabilitation and Health Care

Based on staff interviews and record review conducted during an abbreviated survey (NY #00086747), it was determined the facility did not provide the necessary care and services to maintain the highest practicable physical well being for 1 sampled resident (Resident #1) reviewed for a change in status. Specifically, the facility did not obtain immediate medical attention when Resident #1 was non-responsive. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

Resident #1 was admitted to the facility on September 4, 2009 with weakness, diabetes, and hypertension.

The February 24, 2010 Minimum Data Set (MDS) documented the resident's cognitive status as modified independence and that extensive assistance with activities of daily living (ADL) was needed.

The April 3, 2010 nursing note timed 2:30 PM documented Resident #1 was treated with Macrobid (antibiotic) 100 mg twice a day for 7 days for a UTI (urinary tract infection). The April 6, 2010 nursing note timed 3:30 PM documented the facility physician discontinued the Macrobid with no further orders. The April 7, 2010 nursing note at 3:30 PM documented NP (nurse practitioner) #1 ordered Augmentin (antibiotic) 500/125 mg twice a day for five days. The April 12, 2010 nursing note at 6:30 AM to 6:30 PM shift documented the resident had the last dose of Augmentin. There was no evidence that a re-assessment of the resident's urine occurred.

The April 23, 2010 nursing note at 8:50 AM documented the RN (registered nurse) was called by the LPN (licensed practical nurse) to the resident's room secondary to lethargy. The note specified the resident's vital signs were stable, heart rate was regular with spontaneous breathing, and the resident was non-responsive to stimuli. This nursing note documented that instructions were given to call the physician and that the resident's glucose level was 78.

The medication administration record (MAR) for April 23, 2010 at 7:00 AM, revealed no oral medications were given since 6:00 AM that morning. This MAR documented four units of regular insulin were administered due to the resident's glucose level of 78. The injection site was documented and the LPN signed her initials. The April 23, 2010 7:00 AM MAR documented that the morning insulin was held. There was no documentation describing why the MAR contained conflicting information about the morning insulin.

During interview, CNA (certified nurses aide) #1 (interviewed via telephone on August 20, 2010 at 2:00 PM) stated the resident was not herself on the morning of April 23, 2010. Rounds were done at 7:00 AM, the resident would not open her eyes and was snoring. It was not unusual for the resident to snore. The CNA stated the resident was not breathing hard and at 8:30 AM, when breakfast trays were passed, the resident was still snoring and remained in bed for breakfast.

LPN #1 (interviewed via telephone on August 10, 2010 at 4:05 PM) stated she worked the day shift on April 23, 2010 and remembered the resident was "out of it" and was making unusual noises that morning. LPN #1 stated she got the RN who did an assessment. The resident's blood sugars were up and down. LPN #1 stated she was unable to answer any further questions until she looked at the chart. LPN #1 was interviewed again via phone on August 12, 2010 at 6:30 PM. LPN #1 stated she did not give the resident all of her medications. When she saw the resident at 7:00 AM, she was lethargic, appeared to be sleeping, could not wake up and later was making loud noises. LPN #1 stated she got the supervisor and the nurse manager. A finger stick was obtained and resident's blood sugar was 103.

RN #1 was interviewed via telephone on August 12, 2010 at 12:30 PM and stated he went with the LPN to see the resident, checked her vital signs and heart/lungs. The resident was breathing, had a normal heart rate and was unresponsive. RN
#1 stated the nurse manager called the physician because the resident was normally alert.

The April 23, 2010 nursing note at 9:20 AM documented the physician was updated that the resident would not " wake up and was snoring." The resident's vital signs included blood pressure 150/72, pulse 64, respirations 20, BS (blood sugar) was 103, and oxygen saturation level was 94% on room air. Ultram (pain relieving medication) was discontinued and it was noted the physician would assess at the next visit.

The April 23, 2010 nursing note at 9:45 AM documented that the resident's son was called and was updated. The resident's son requested transfer to a hospital. Instructions were received from the RN to proceed with transfer.

The nurse manager (LPN #2) was interviewed via phone on August 12, 2010 at 6:50 PM. LPN #2 stated the CNA reported the resident was awake at 6 AM. The resident was given her medication at 6:30 AM, but did not receive her insulin at 7:00 AM. The resident was not awake and was difficult to arouse, so RN #1 was called. The physician was informed and stated he would see the resident that day. The resident's son requested the resident be transport to the hospital.

The April 23, 2010 nursing note at 9:45 AM documented that the EMS (emergency medical services) crew arrived at 10:20 AM.

The EMS crew documented on the April 23, 2010 pre-hospital care report their primary impression was hypoglycemia and secondary impression was unconscious state. The EMT (emergency medical technician) documented the facility staff heard "gurgling breathing." The April 23, 2010 EMT note documented the resident was completely unresponsive with a 91% oxygen saturation and a "low" reading on the glucometer. Rales (crackles) and rhonchi (course rattling which sounds like snoring) were heard from the door of the resident's room. After 25 g of dextrose (glucose) was administered, the glucose level rose to 202 mg/dl. The resident remained unresponsive throughout transport.

On August 10, 2010 the EMT supervisor sent the Department of Health documentation that the "low" glucometer reading means the glucose level was below 20 mg/dl.

On April 23, 2010, the facility's physician documented he received a call that morning because the resident was lethargic and minimally responsive. The resident had stable vital signs. The physician documented he told the nurse he would be in to evaluate the resident, however, prior to his arrival the family demanded the resident be sent to the emergency department.

On April 23, 2010 at 1:15 PM, the hospital physician assistant (PA) documented in dictated note that EMS got a blood sugar of "low" on their glucometer, gave D50 (glucose) and got a reading of 202. The PA documented that "by the time the resident arrived at the hospital her blood sugar was back down to 90 or so."

On April 23, 2010 at 2:15 PM, the hospital physician documented in the history and physical that the patient will be admitted to the intensive care unit.

The April 25, 2010 hospital progress note documented that the patient expired on April 25, 2010.

In summary, the facility did not ensure that immediate medical attention was provided to a resident with a marked change in her level of responsiveness, rhonchi and rales, and inconsistent blood sugars.
10 NY CRR 415.12