Failure to Monitor Resident's Condition Leads to Immediate Jeopardy
Penalty
Summary
The facility failed to protect a resident's right to be free from neglect by not appropriately monitoring the resident's condition after the insertion of a catheter. The resident, who was admitted with diagnoses including prostatic hyperplasia, had a catheter inserted to drain urine. However, there was no documentation that the resident was monitored to ensure the catheter was properly inserted and draining. On a particular day, the resident had no urine output, and the catheter was removed, revealing copious amounts of blood and clots. Despite this acute change in condition, there was no documentation of the resident's status being monitored, including vital signs or output. The facility's records show that the resident was emergently transferred to an acute care hospital later that evening, unresponsive and with no urine output. Interviews with staff revealed that there was a lack of communication and documentation regarding the resident's condition throughout the day. The APRN had given orders to monitor the resident and send them to the hospital if there was no urine output or if clots continued, but these orders were not transcribed or followed in a timely manner. The resident's spouse had also reported concerns about the lack of urine output to the staff, but these concerns were not adequately addressed. The facility's investigation into the incident noted that the care provided was in adherence to physician orders, but the documentation and monitoring of the resident's condition were insufficient. The investigation revealed that staff failed to take necessary actions, such as obtaining vital signs and ensuring timely communication with the physician, which contributed to the neglect of the resident's care needs. The lack of proper monitoring and documentation led to a determination of Immediate Jeopardy, indicating a likelihood of serious harm to the resident.
Plan Of Correction
1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: • Resident #1 is no longer a resident. An AHCA Federal Immediate Report with a corresponding investigation was completed by the facility prior to this survey. 2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: • Facility residents with a score of 13 or greater were interviewed regarding the facility's provision of goods and services. • Facility residents with a score of 12 or less had skin evaluations completed. • Current residents had an RN assessment completed including a set of vital signs and observation for output and patency. Any changes identified were communicated to the provider and family notification completed. 3) What measures will be put into place or what systemic changes will you make to ensure that the deficient practice does not recur: Education: • The facility's Administrator and Director of Nursing were reeducated by Regional Nurse Consultant on: o The components of the regulation: F600 Free from and Neglect o Neglect, Misappropriation, Mistreatment, and Injury of Unknown Origin (ANEMMI) with indicators of neglect. o Facility standard and guideline P&P Neglect and Investigations to include: o Screening o Training o Prevention o Identification o Investigation o Protection o Reporting • The facility's Staff Development Coordinator/Designee completed education with facility staff on Neglect with an emphasis on the following F600 noncompliance: The facility failed to protect resident rights to be free from neglect by failing to appropriately monitor the resident's output and failure to monitor the resident when the was discontinued. On at approximately 4:30 p.m. resident's was discontinued. Resident experienced copious and was passing clots through his penis. The facility neglected to monitor resident's status including vital signs with a significant change in condition. • The facility's Staff Development Coordinator/Designee completed competencies with CNAs on emptying and measuring output for residents with . This competency was conducted using a mannequin with an to simulate the actual emptying of the . • The facility's Staff Development Coordinator/Designee completed education with CNAs to ensure that any notable changes in output for residents with and any residents experiencing a change in condition are reported immediately to the nurse. • The facility's Staff Development Coordinator/Designee completed competencies with CNAs and licensed nurses on the proper obtaining of resident vital signs including temperature, , and , and on a live member of staff. Vital signs obtained for an identified change in condition will be documented in the and vitals tab in PCC. This allows for these vitals to populate accurately in the SBAR/Change in Condition evaluation. • The facility's Staff Development Coordinator/Designee completed education with licensed nurses on the necessary completion of a change in condition evaluation when the following occur: o Accidents resulting in injury, or the potential to require physician intervention. o A significant change in the resident's physical, mental, or condition such as a deterioration in health, mental, or status. o This may include life-threatening conditions, or clinical complications and changes in output including color, consistency, and output. o Circumstances that may require a need to alter treatment. This may include new treatment and/or discontinue of current treatment due to an acute condition or a worsening of a condition. o A complete nursing evaluation must be conducted and documented in the medical record of systems including but not limited to functional status, evaluation, evaluation/evaluation, evaluation, skin evaluation, evaluation, and vital signs. o The physician/NP shall be made aware of pertinent evaluation findings. • The facility's Staff Development Coordinator/Designee completed education with licensed nurses on vital sign documentation, and on following timely transfer to a higher level of care upon directive from physician. • The facility's Staff Development Coordinator/Designee completed residents that returned to the hospital. o The review of all new admissions and existing residents with monitor output to ensure orders to include placement, patency/draining, irrigation, securement device, care Qshift, and to record the output Qshift. o The review of vital signs and the review of the nurse's change of condition evaluation for all residents that had a change in condition. o The review of vital signs for all residents per physician order. • Licensed Nurses and CNAs will complete competencies on care at the time of orientation and annually with the facility's Staff Development Coordinator. • The facility's Staff Development Coordinator/Designee completed education with licensed nurses on ensuring new orders for include placement, patency/draining, irrigation, securement device, care Qshift, and to record the output Qshift. 4) How will the corrective action(s) be monitored to ensure the deficient practice will not recur: • The facility initiated the completion of audits seven days a week including weekends and off hours on all residents to ensure vital sign orders and the proper documentation of these vital signs. These audits will be monitored by DON/designee and reviewed by the QAPI committee. These audits will be completed weekly x 4 weeks, biweekly x 2 months, then monthly thereafter until substantial compliance is determined by the QAPI committee. • The facility initiated the completion of audits seven days a week including weekends documentation of output for all residents with . These audits will be monitored by DON/designee and reviewed by the QAPI committee. These audits will be completed weekly x 4 weeks, biweekly x 2 months, then monthly thereafter until substantial compliance is determined by the QAPI committee.