Neglect in Monitoring Resident's Condition Post-Catheterization
Penalty
Summary
The facility failed to protect a resident's right to be free from neglect, as evidenced by inadequate monitoring and care following the insertion of a catheter. The resident, who was admitted with diagnoses including prostatic hyperplasia, had a catheter inserted to drain urine. However, after the catheter was changed, there was no documentation to confirm that the catheter was properly inserted and draining. The resident subsequently experienced no urine output, and the catheter was removed, revealing a copious amount of blood and clots. Despite the acute change in the resident's condition, there was no documentation of monitoring the resident's status, including vital signs or urine output. The resident was eventually found unresponsive and was emergently transferred to an acute care hospital. The facility's failure to provide necessary care and services to prevent neglect created a likelihood of serious harm, as the resident was found to be unresponsive and required life support upon hospital admission. Interviews with staff and review of the clinical record revealed that the facility did not adequately monitor the resident's condition or follow up on the lack of urine output. The APRN's orders to monitor the resident and send him to the hospital if the condition did not improve were not transcribed in a timely manner. Additionally, there was a lack of communication among staff regarding the resident's condition, contributing to the delay in addressing the resident's acute change in condition.
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: - Screening - Training - Prevention - Identification - Investigation - Protection - 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 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, 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 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, 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 education with licensed nurses on care to include insertion, monitoring output, and proper documentation of output, including documenting this output on the resident's MAR. The licensed nurse must perform a visual observation of the color and clarity of output each shift. • The facility's Staff Development Coordinator/Designee completed education with licensed nurses on the nurses' requirement to notify the provider of any notable changes in resident condition. • The facility's Staff Development Coordinator completed competencies on the proper insertion of with return demonstrations for staff A, B, C, & D. • The facility's Staff Development Coordinator/Designee completed education on the identification of a change in condition with staff A, B, C, & D. System Change: • The facility reviewed all orders. Output was added to the MAR to ensure nursing documentation. • CNAs will be responsible for emptying output for residents with and will report this number to the licensed nurse, who then will be responsible for recording the output value on the MAR three times a day. • The daily clinical meeting form was edited to include: o Review of 24-hour report for change in condition. o The review of vital signs and the timely transfer of all residents that returned to the hospital. o The review of all new admissions and existing residents with to ensure orders to monitor output are in place. 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. F 600
Removal Plan
- The facility completed education for almost all of the nursing staff, with remaining staff to be educated before their next scheduled shift.
- Re-education of Certified Nursing Assistants (CNAs), Registered Nurses (RNs), and Licensed Practical Nurses (LPNs) was conducted.
- The facility Administrator and Director of Nursing were re-educated on the components of the regulation F600 Free from and Neglect.
- Staff education on neglect with emphasis on failure to protect resident rights to be free of neglect by failing to monitor output and to monitor the resident when the catheter was discontinued.
- A facility-wide audit of 155 residents was completed to ensure that all residents have physician's orders to take vital signs and that these were transcribed to the medication administration record (MAR).
- Review of all catheter orders and addition of output monitoring to the MAR to ensure nursing documentation.
- CNA education was initiated to ensure any changes in output for residents with catheters and any residents experiencing a change in condition must be reported immediately to the nurse.
- Vital sign assessment competencies including temperature, pulse, and respiration were initiated for staff members.
- The facility initiated audits of residents to ensure the nursing staff completed proper documentation of vital signs.
- An audit for residents with catheters was completed to ensure measuring and documenting of the output was completed on each shift.
- An ad hoc QAPI (Quality Assurance and Performance Improvement) meeting was held, and a root cause analysis of the incident was done.
- Re-education of nurses was completed, with the remaining nurses to be educated prior to working their next shift.
- Review of random resident records was completed to ensure accurate assessment and interventions were in place to prevent neglect related to the care of residents with catheters and for those who experience a change in condition.