Rosewood Rehabilitation and Nursing Center

Deficiency Details, Complaint Survey, November 30, 2012

PFI: 3920
Regional Office: Capital District Regional Office

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F514 483.75(l)(1): CLINICAL RECORDS MEET PROFESSIONAL STANDARDS

Scope: Isolated

Severity: Potential for more than Minimal Harm

Corrected Date: December 11, 2012

The facility must maintain clinical records on each resident in accordance with accepted professional standards and practices that are complete; accurately documented; readily accessible; and systematically organized. The clinical record must contain sufficient information to identify the resident; a record of the resident's assessments; the plan of care and services provided; the results of any preadmission screening conducted by the State; and progress notes.

Citation date: November 30, 2012

Based on medical record review, and staff interviews during a complaint investigation (Case #NY00122694), it was determined for one (Resident #1) of two residents reviewed, the facility did not maintain clinical records in accordance with accepted professional standards and practices that are complete, accurately documented, readily accessible and systematically organized. Specifically, there was no documentation on 09/03/2012 when the resident complained of not feeling well, experienced a blood pressure of 88/42 pulse oximetry 85% and required oxygen or vomiting on the 3:00 PM -11:00 PM shift . Additionally meal consumption was not thoroughly documented. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy. This is a repeat deficiency from the recertification survey in 4/2012. This was evidenced by the following:

Resident # 1
The resident was an 88 year old gentleman who was admitted to the facility on 08/31/2012 for a short term rehabilitation stay. His diagnosis was left total hip replacement, Myasthenia Gravis and spinal stenosis. Documentation reveals the resident was alert and oriented. There was no Minimum Data Set completed.

Nurse's notes reveal there is no nurse's note written for the morning of 09/03/2012.

Nurse's note written on 09/03/2012 at 2:00 PM by a Licensed Practical Nurse (LPN) she documented a blood pressure of 100/52, a pulse of 68, respirations of 18 and a temperature of 97.1 with an oxygen saturation of 91%. The note stated the resident was alert and complained of pain and received medication for pain with effectiveness. The resident needs assistance with his Activities of Daily Living (ADL) and transfers and that appetite was fair and fluids were encouraged.

Nurse's note written on 09/04/2012 at 4:30 AM by an LPN documented a blood pressure of 102/54, pulse 72, respirations 18 and temperature of 97. Oxygen saturation of 91% on room air. Complained of pain at 2:30 am and Norco was given for left hip pain with good effect, sleeping at 3:25 am.

Nurses notes on 09/04/2012 at 7:30 AM by the Registered Nurse Manager (RNM) she wrote that she entered the room and patient was with shallow respirations and light gurgle in back of his throat, skin cool and clammy at 6:43 AM. Cardiopulmonary resuscitation (CPR) initiated at 6:44 AM. The resident expired at 7:12 AM.

The resident's food and fluid intake showed there was no documentation for the evening meal on 09/02/2012. There is no documentation for the evening meal of 09/03/2012.

Physical Therapy documentation reveals there was a Physical Therapy evaluation dated 09/02/2012 and a Physical Therapy Discharge Summary dated 09/04/2012. There was no Physical Therapy documentation dated 09/03/2012.

Occupational Therapy documentation reveals there was an Occupational Therapy evaluation dated 09/01/2012 and an Occupational Therapy Discharge Summary dated 09/04/2012. There was no Occupational Therapy documentation dated 09/03/2012.

Nursing Service 24 hour report shows that on 09/03/2012 on the 7:00 PM to 3:00 PM shift the resident is documented for having a period of shortness of breath with oxygen saturation of 85% while in therapy. Blood pressure was 88/42, was put in bed with oxygen. Blood pressure was written a second time of 100/52.

Nursing Service 24 hour report shows that on 09/03/2012 on the 3:00 PM to 11:00 PM shift the resident is documented for having vomited a small amount, BRAT diet (term used to describe bland diet). Temperature was 97.2, pulse was 70, respirations were 18 with a blood pressure of 102/50.

Nurses notes on 09/04/2012 at 7:30 AM by the Registered Nurse Manager (RNM) she wrote that she entered the room and patient was with shallow respirations and light gurgle in back of his throat, skin cool and clammy at 6:43 AM. Cardiopulmonary resuscitation (CPR) initiated at 6:44 AM. The resident expired at 7:12 AM.

During an interview on 11/26/2012 at 9:30 AM, the Occupational Therapist stated that on 09/03/2012 the resident was receiving his physical therapy treatment and he complained of feeling funny at approximately 10:00 AM and she assisted the physical therapist in putting the resident into bed. The physical therapist took the resident's blood pressure and it was 88/42. The Nursing Supervisor was summoned and took the blood pressure again and said it was OK, the resident was left in bed. She stated the family came in at that time and she told told them he was not feeling well.

During an interview on 11/26/2012 at 11:00 AM via telephone, the Nursing Supervisor stated that he remembered being called to the resident's room because he wasn't feeling well. He did not remember documenting this event and stated it should have been documented in the nurse's notes.

During an interview on 11/26/2012 at 12:00 PM the DON stated the Nursing Supervisor did not document the event in nurses notes but did place it on the twenty four hour report.

10 NYCRR 415 22 (a)(1-4)

F157 483.10(b)(11): INFORM OF ACCIDENTS/SIGNIFICANT CHANGES/TRANSFER/ETC.

Scope: Isolated

Severity: Potential for more than Minimal Harm

Corrected Date: December 11, 2012

A facility must immediately inform the resident; consult with the resident's physician; and if known, notify the resident's legal representative or an interested family member when there is an accident involving the resident which results in injury and has the potential for requiring physician intervention; a significant change in the resident's physical, mental, or psychosocial status (i.e., a deterioration in health, mental, or psychosocial status in either life threatening conditions or clinical complications); a need to alter treatment significantly (i.e., a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or a decision to transfer or discharge the resident from the facility as specified in 483.12(a). The facility must also promptly notify the resident and, if known, the resident's legal representative or interested family member when there is a change in room or roommate assignment as specified in 483.15(e)(2); or a change in resident rights under Federal or State law or regulations as specified in paragraph (b)(1) of this section. The facility must record and periodically update the address and phone number of the resident's legal representative or interested family member.

Citation date: November 30, 2012

Based on medical record review and interview during complaint investigation (NY00122694), the facility did not ensure that the resident's physician was notified of a change in the resident's condition for 1 (Resident #1) of 2 residents reviewed. Specifically, the facility did not notify the physician when a resident had a significant change of condition on 09/03/2012 . The resident complained of not feeling well, his blood pressure was 88/42, the resident had a pulse oxymetry of 85% ( normal above 90%), and oxygen was applied. The resident remained in bed the remainder of the day and he vomited on the 3:00 PM to 11:00 PM shift and expired the following morning. This is a repeat deficiency from the recertification survey in 4/2012. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy. This was evidenced by the following:

Resident #1
The resident was an 88 year old gentleman who was admitted to the facility on 08/31/2012 for a short term rehabilitation stay. His diagnosis was left total hip replacement, Myasthenia Gravis and spinal stenosis. Documentation revealed the resident was alert and oriented. There was no Minimum Data Set available.

There was no nurse's notes written written for the morning of 09/03/2012.

Nurse's note written on 09/03/2012 at 2:00 PM by a Licensed Practical Nurse (LPN) documented a blood pressure of 100/52, a pulse of 68, respirations of 18 and a temperature of 97.1 with an oxygen saturation of 91%. The note stated the resident was alert and complained of pain and received medication for pain with effectiveness.

Nurse's note written on 09/04/2012 at 4:30 am by an LPN documented a blood pressure of 102/54, pulse 72, respirations 18 and temperature of 97. Oxygen saturation of 91% on room air. Complained of pain at 2:30 am and Norco was given for left hip pain with good effect, sleeping at 3:25 am.

Nurses notes on 09/04/2012 at 7:30 am by the Registered Nurse Manager (RNM) documented that she entered the room and patient was with shallow respirations and light gurgle in back of his throat, skin cool and clammy at 6:43 am. Cardiopulmonary resuscitation (CPR) initiated at 6:44 am the resident expired at 7:12 am.

Nursing Service 24 hour report shows that on 09/03/2012 on the 7:00 am to 3:00 PM shift the resident is documented for having a period of shortness of breath with oxygen saturation of 85% while in therapy. Blood pressure was 88/42, he was put in bed with oxygen. The next blood pressure was written a second time of 100/52. There was no evidence documented that the physician was notified.

Nursing Service 24 hour report shows that on 09/03/2012 on the 3:00 PM to 11:00 PM shift the resident is documented for having vomited a small amount, received a BRAT diet (term used to describe bland diet). Temperature was 97.2, pulse was 70, respirations were 18 with a blood pressure of 102/50. There was no evidence the physician was notified.

Nursing Service 24 hour report shows that on 09/04/2012 on the 11:00 PM to 7:00 am shift blood pressure was 102/54, pulse was 72, and respirations were 18. Oxygen saturation was 91% on room air, and temperature of 97.1. It is further written the resident expired at 7:12 am.
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The resident's food and fluid intake showed there was no documentation for the evening meal on 09/02/2012. The breakfast meal on 09/03/2012 had documentation that the resident had refused breakfast food and fluid. For the lunch meal on 09/03/2012 he ate 25% to 49% food and drank 25% to 49% fluids. There is no documentation for the evening meal of 09/03/2012.

The Physical Therapy documentation reveals there was a Physical Therapy evaluation dated 09/02/2012 and a Physical Therapy Discharge Summary dated 09/04/2012. There was no Physical Therapy documentation dated 09/03/2012.

The Occupational Therapy documentation reveals there was an Occupational Therapy evaluation dated 09/01/2012 and an Occupational Therapy Discharge Summary dated 09/04/2012. There was no Occupational Therapy documentation dated 09/03/2012.

During an interview on 11/26/2012 at 9:30 am, the Occupational Therapist stated that on 09/03/2012 the resident was receiving his physical therapy treatment and he complained of feeling funny at approximately 10:00 am and she assisted the physical therapist in putting the resident into bed. The physical therapist took the resident's blood pressure and it was 88/42. The Nursing Supervisor was summoned and took the blood pressure again and said it was OK, the resident was left in bed. She stated the family came in at that time and she told told them he was not feeling well.

During an interview on 11/26/2012 at 10:45 am, the RNM stated she did not work on 09/03/2012 (Labor Day). She stated she was not made aware of the event with the resident on 09/04/2012, and she did not find out about the event until after the resident had expired and the Director of Nursing (DON) told her the daughter was asking about the chart.

During an interview on 11/26/2012 at 11:00 am via telephone, the Nursing Supervisor stated that he remembered being called to the resident's room because he wasn't feeling well. He did not remember any other details and did not remember calling the physician. He did not remember documenting this event and stated it should have been documented in the nurse's notes.

During an interview on 11/26/2012 at 11:15 am via telephone, the Licensed Practical Nurse stated she did not remember the incident but she does remember the resident. She further stated that she does not remember the Nursing Supervisor calling the physician.

During an interview on 11/26/2012 at 11:20 am via telephone, the resident's physician stated that he remembered the resident and that he had Myasthenia Gravis. He did not remember being notified of the medical event on 09/03/2012. He stated that he did complete a chart review of this resident at the request of DON and did not remember seeing a note. He further stated that if he was notified there should be a note in the chart by the nurse and/or himself.

During an interview on 11/26/2012 at 12:00 PM the DON stated the Nursing Supervisor did not document but did place it on the twenty four hour report. She further stated the physician should have been notified of the event.

10NYCRR 415.3(e)(2)(ii)(b)