DEPARTMENT OF HEALTH AND HUMAN SERVICES OMB NO. 0938-0391 PRINTED: 08/11/2010

Transcription

PRINTED: 08/11/2010
FORM APPROVED
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
OMB NO. 0938-0391
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
C
B. WING _____________________________
345334
NAME OF PROVIDER OR SUPPLIER
07/27/2010
STREET ADDRESS, CITY, STATE, ZIP CODE
1716 LEGION ROAD
BRITTHAVEN OF CHAPEL HILL
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COMPLETED
CHAPEL HILL, NC 27517
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
F 000 INITIAL COMMENTS
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
ID
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DATE
F 000
The Division of Health Service Regulation
(DHSR), Nursing Home Licensure and
Certification Section began a complaint
investigation survey on 2/18/10. During the
complaint survey, the Medicaid Criminal
Investigation Unit began an investigation and the
survey was postponed until the criminal
investigation was completed. DHSR staff
conducted visits to the facility on 2/18/10, 6/15/10
through 6/17/10 and 6/29/10 through 7/1/10. It
was determined the facility had provided
substandard quality of care at the Immediate
Jeopardy level. A partial extended survey was
conducted on 7/26/10 and an exit conference was
held with the facility on 7/27/10. After the
completion of the complaint survey and partial
extended survey, no current deficient practice
was identified. The Immediate Jeopardy began on
2/13/10 and was removed on 2/15/10. Therefore,
the deficiencies cited are Past Non-Compliance.
F 223 483.13(b), 483.13(b)(1)(i) FREE FROM
SS=K ABUSE/INVOLUNTARY SECLUSION
Past noncompliance: no plan of
correction required.
F 223
The resident has the right to be free from verbal,
sexual, physical, and mental abuse, corporal
punishment, and involuntary seclusion.
The facility must not use verbal, mental, sexual,
or physical abuse, corporal punishment, or
involuntary seclusion.
This REQUIREMENT is not met as evidenced
by:
Based on observation, staff interviews and record
reviews, the facility failed to ensure residents
were free from abuse for 14 of 29 residents on
the Alzheimer's Unit (#1, #2, #3, #4, #5, #6, #7,
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
(X6) DATE
TITLE
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that
other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days
following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14
days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued
program participation.
FORM CMS-2567(02-99) Previous Versions Obsolete
Event ID: 18OL11
Facility ID: 923014
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#8, #9, #13, #14, #15, #16, #73) who received a
narcotic they were not prescribed. Toxicology
reports indicated 14 residents tested positive for
morphine. Seven residents were hospitalized (#1,
#4, #5, #6, #7, #8 and #9) and one resident died
(#1) from aspiration pneumonia and morphine
toxicity.
Findings:
The facility failed to ensure that a Registered
Nurse, an agent of the facility, adhered to
established policies and procedures regarding
medication administration and physician's orders
on the Alzheimer's Unit. On or about February
13, 2010, an agent of the facility administered
Morphine to residents on the Alzheimer's Unit
without a physician's order.
Nurse #1 was arrested on 6/7/10 for charges of
second-degree murder and patient abuse. She
was in jail at the time of the investigation.
A review of the facility's policies and procedures
for "Controlled Substances Quick Controlled
Substances," revised 7/29/09, indicated "A.
General Provisions 1. Controlled substances are
classified by the Controlled Substances Act of
1970 as follows: b. Schedule II contains drugs
with the greatest potential for abuse and include
primarily narcotics, amphetamines and rapid
acting barbiturates. 4. State and Federal
regulations prohibit dispensing of Schedule II
Controlled substances until a signed original
prescription or a faxed copy directly from the
physician is in the hands of the pharmacist. "
A review of Lexi-Comp's 2009 Geriatric Dosage
Handbook, 14th Edition, indicated morphine
sulfate is an opioid analgesic used in the relief of
Event ID: 18OL11
Facility ID: 923014
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moderate to severe acute pain; relief of
myocardial infarction; relief of dyspnea of acute
left ventricular failure and pulmonary edema. The
warnings and precautions indicated an
opioid-containing analgesic should be tailored to
each patient's needs and based upon the type of
pain being treated (acute versus chronic), the
route of administration, degree of tolerance for
opioids (naive versus chronic user), age, weight,
and medical condition. It further indicated
morphine sulfate "May cause respiratory
depression; use in caution in patients (particularly
elderly or debilitated) with impaired respiratory
function, morbid obesity, adrenal insufficiency,
prostatic hyperplasia, urinary stricture, renal
impairment, or severe hepatic dysfunction and in
patients with hypersensitivity reactions to other
phenanthrene derivative opioid agonists."
"Special Geriatric Considerations The elderly may
be particularly susceptible to the CNS depressant
and constipating effects of narcotics." Some
adverse reactions of morphine sulfate included
flushing, dizziness, nausea, vomiting, circulatory
depression, sedation, fever, confusion, headache,
oxygen saturation decreased, lethargy,
somnolence, respiratory depression, pulmonary
edema and hypoxia.
1. Resident #1 died from aspiration pneumonia
and morphine toxicity.
Resident #1 was admitted to the facility on
7/11/05 and had cumulative diagnoses that
included coronary artery disease, hypertension,
dementia, pernicious anemia, hyperlipidemia,
osteoarthritis and osteoporosis. Based on
information contained in the Minimum Data Set
(MDS) on 1/25/10, the resident had problems with
short term memory, long term memory and had
Event ID: 18OL11
Facility ID: 923014
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moderately impaired cognition. Resident #1 was
living in the facility's Alzheimer's Unit.
Resident #1's medications on 2/1/10 were:
Enteric coated Aspirin 81 mg (milligrams) daily,
Calcium 500 mg + Vitamin D (a calcium and
vitamin D supplement) daily, Toprol (a blood
pressure medication) XL (extended release) 25
mg daily, Fosamax (a medication for
osteoporosis) 70 mg weekly, Lotensin (a blood
pressure medication) 20 mg twice a day,
Risperdal (an antipsychotic medication) 0.25 mg
twice a day, Acetaminophen (a pain reliever)
1000 mg 3 times a day, Docusate Sodium (a
stool softener) 200 mg daily, Prazosin (a blood
pressure medication) 1 mg at bedtime, Milk of
Magnesia (a laxative) 30 ml (milliliters) every 12
hours as needed, Risperdal 0.25 mg twice a day
as needed for agitation and Desyrel (an
antidepressant medication used for insomnia) 50
mg at bedtime as needed for insomnia. Resident
#1 did not have an order for morphine sulfate or
any other opiate medication.
Review of the resident's nurse's notes showed:
"2/14/10 0700 (7 AM) O2 sat (saturation) 86% on
room air T (temperature) 98.6 pulse 98 - 20
(respirations) -117/64 (blood pressure). Mucus in
throat suction out mouth and throat; obtain yellow
thick mucus. No change in color. Reported to
oncoming nurse/charge nurse.
2/14/10 0800 (8 AM) 126/56 (blood pressure) 90 (pulse) - 20 (respirations) - 98.8 (temperature).
Resident noted to have uneven shallow
respiration this morning. This is a significant
change from her normal status. She is very
somnolent/lethargic this morning. She is not
following commands. (Physician ' s name) notified
& ordered that Pt (patient) be sent to (hospital
Event ID: 18OL11
Facility ID: 923014
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emergency room) via ambulance. Upper resp
(respiratory) wheeze noted with open mouth
breathing. HOB (head of bed) up 90%. Albuterol
(a bronchodilator medication) neb (nebulizer
treatment) given. O2 (oxygen) sat (saturation)
70% in RA (room air) & increased to 84% c (with)
2L (liters) NC (nasal cannula) & Albuterol neb tx
(treatment). Ambulance in route to center. Writer
telephoned (daughter's name) and informed her
of impending transfer to (hospital name)."
"2/14/10 1454 (2:54 PM) Lab: Urine Tox Screen
(urine drug screen) Opiate =/> (equal to or
greater than) 300 ng (nanogram)/ml (milliliter)."
"2/14/10 3 PM Writer rec'd (received) fax from
(daughter's name) stating Res.(resident) admitted
c (with) large R (right) sided pneumonia and
family @ (at) BS (bedside). Place in MD
(physician) book."
A review of the Emergency Department (ED)
notes, dated 2/14/10 at 9:12 a.m., indicated the
history of the resident's present illness as
"gurgling respirations, decreased mental status"
since 3 to 4 AM. Per the ED note, Resident #1
was reportedly "ambulatory at baseline,
conversive/oriented x 2 - 3 but with moderate
dementia." The ED note indicated it started that
day and it was still present at the time of the
evaluation. The severity was described as
"moderate." "Large" amounts of sputum were
suctioned from the resident's lungs. The resident
was admitted to the hospital for further evaluation
and treatment.
A review of a hospital Full Discharge Summary,
dated 2/17/10 at 12:03 p.m., indicated the
resident's admitting and discharge diagnosis was
Event ID: 18OL11
Facility ID: 923014
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altered mental status (AMS). Resident #1 had a
secondary diagnosis of pneumonia. The
discharge summary indicated:
"Hospital Course: Patient (pt) was admitted from
(nursing home name) with alerted mental status
and hypoxia - found to have large RLL (right lower
lobe of lung) infiltrate and was started on broad
spectrum antibiotics after blood and sputum
cultures taken in the ED (emergency
department). She remained stable on 100% NRB
(non rebreathing mask) overnight and the
following day her oxygenation improved and she
was able to be weaned down to nasal cannula.
Her mental status also improved from responsive
only to sternal rub to awake and talking (though
nonsensically). However, the following morning
(~36h (hours) into hospitalization) pt became
more hypoxic, placed back on NRB. Family's
original requests included trial of bipap (Bi-level
Positive Airway Pressure) which was called for
stat (immediately), however, pt's O2 sats dropped
and she became more bradycardic with eventual
PEA (pulseless electrical activity) prior to bipap
arriving.
Of note, the patient's Urine tox screen on
presentation was positive for opiates which were
not on the medication list from her SNF (skilled
nursing facility) and she did not receive any
opiates in the ED. This was sent for confirmation
and is still pending at the time of this summary.
Notified family (son and daughter) of presence of
this substance in the urine and the (sic) requested
no autopsy unless necessary for legal reasons.
Spoke with state medical examiner's office who
state unless overdose was thought to be cause of
death that no autopsy was necessary. Given that
hypoxia from aspiration pneumonia was etiology
of death, no autopsy was requested." The
discharge summary further indicated the resident
Event ID: 18OL11
Facility ID: 923014
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died on 2/16/10 at 7:36 a.m.
In an interview on 2/18/10 at 8:14 AM, Facility
Consultant #1 stated Resident #1 was sent to the
hospital on 2/14/10 and had altered mental status
with pneumonia. The resident had a drug screen
and tested positive for opiates. The resident was
on Levaquin (an antibiotic) in the hospital and was
treated for pneumonia. The resident died at the
hospital with the cause of death being
pneumonia.
On 2/18/10 a confirmation urine test done
completed by Laboratory (Lab) #2 showed a
morphine level of > (greater than) 50,000 ng/ml
(cutoff:100). The urine toxicology screens
completed on the residents were not all analyzed
at the same laboratory. The resident's urine
toxicology screens were completed by either the
hospital laboratory (Lab #3) or the facility's
contracted laboratory (Lab #1). The urine
toxicology confirmation tests were completed by
Lab #2.
A review of the Medical Examiner's Certificate of
Death, dated 3/19/10, indicated Resident # 1's
immediate cause of death as aspiration
pneumonia due to (or as a consequence of)
morphine toxicity.
On 4/29/10 the Report of Investigation by Medical
Examiner showed the probable cause of death
as: 1. Aspiration pneumonia 2. Morphine toxicity.
During an interview on 6/23/10 at 9:30 a.m.,
Nurse #12 stated she was off work on 2/12/10,
but came in to work on 2/13/10 and worked the
11 p.m. to 7 a.m. shift. Nurse #1 stated to Nurse
#12 that everything was fine with the residents on
Event ID: 18OL11
Facility ID: 923014
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her shift. Nurse #12 stated when she arrived, the
residents were sleeping. Nurse #12 stated a NA
informed her Resident #1 " had some stuff
coming out of her mouth." When she checked on
Resident #1, she had a yellow discolored mucus
coming out of her mouth and was having difficulty
breathing. She got the suction machine to try to
clear the resident's airway. The day shift nurse
had come in and tried to help her with the
resident. Nurse #12 stated the residents were still
in bed sleeping, "asleep as I thought." She
indicated it was "hard to assess for lethargic when
they are in bed sleeping." "I just did not even
suspect that was going on." While she was
working with Resident #1, she stated another NA
came in to see what the commotion was going
on. The NA stated another resident was doing the
same thing.
During an interview on 6/17/10 at 5:22 p.m.,
Nurse #11 stated he worked on 2/13/10 and
2/14/10 from 6:45 a.m. until 5 p.m. Nurse #11
indicated the residents were fine on Saturday,
2/13/10. On 2/14/10, the night shift nurse (Nurse
#12) informed him that two residents were having
some respiratory problems. Resident #1's
breathing was labored and shallow and the
resident's level of consciousness was not like it
was the day before. The nurses notified the
physician. After the night shift nurse left, he
worked with the residents a little more. He stated,
"It was too extensive." He called the physician
and the physician wanted to send Resident #1 out
to the hospital.
2.a. The residents in examples 2.a. through 2.f.
tested positive for morphine and required
hospitalization.
Event ID: 18OL11
Facility ID: 923014
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12/1/09 with diagnoses including dementia, atrial
fibrillation and osteoporosis. The resident was
readmitted to the facility on 2/24/10 with
diagnoses of delirium, medication intoxication,
altered mental status, aspiration pneumonia,
anemia and urinary retention. A Medicare 14 day
assessment, dated 3/9/10, indicated the
resident's cognitive skills for daily decision
making were moderately impaired with long and
short term memory problems. The resident had
mood/behaviors of being easily distracted,
disorganized speech, periods or restlessness,
repetitive verbalizations, unpleasant mood in the
morning, sad/pained expressions and repetitive
physical movements. She was physically abusive,
resistant to care and wandered. Resident #5
required extensive assistance with activities of
daily living and limited assistance with eating. She
did not have any devices or restraints. Resident
#5 resided on the locked Alzheimer's unit.
A review of the physician's orders, dated 2/1/10
through 2/28/10, indicated the resident was
receiving Lanoxin (heart medication), Norvasc
(blood pressure medication), Aspirin (blood
thinner) Trazodone (antidepressant), Vitamin D
(supplement), Caltrate (calcium supplement),
Zyprexa (antipsychotic) and Tylenol daily. She
also received Robitussin (cold and cough
medication), Naprosyn (anti-inflammatory),
Trazodone and Tylenol as needed (prn). A review
of the Medication Administration Record indicated
the resident had not received any of the prn
medications in February 2010. The resident did
not have physician's orders for morphine.
A review of the nurse's notes, dated 2/11/10 with
Event ID: 18OL11
Facility ID: 923014
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no time, indicated the resident was responsive to
verbal stimuli. Her skin was warm and dry. There
was no documentation that the resident was
lethargic.
A nurse's note written by Nurse #11, dated
2/14/10 at 2:30 p.m., indicated the resident had
been in bed throughout the day. The resident did
not want to get up. The head of the bed was
elevated and there was no distress noted. The
nurse indicated the resident tolerated intake by
mouth fairly well. The nurse spoke with the family
concerning the resident and indicated she would
continue to monitor the resident.
A nurse's note, dated 2/14/10 with no time,
indicated Nurse #1 informed the physician of the
resident's change in condition. The resident was
lethargic, but responsive by opening her eyes and
turning her head to the right. Her vital signs were:
blood pressure 156/76, pulse 90, respirations 16
and temperature 100.9 degrees Fahrenheit. The
nurse administered Tylenol in pudding without
difficulty. New orders were received for a chest
X-ray, complete blood count, basic metabolic
panel and a urinalysis and culture. At 6:15 p.m.,
the nurse informed the family of the resident's
new orders.
A review of a Transfer/Discharge Summary,
dated 2/14/10, and completed by Nurse #1,
indicated the resident was transferred to the
hospital on 2/14/10. The physician was notified at
8:10 p.m. and the family was notified at 8:15 p.m.
The transfer summary indicated the resident had
been lethargic since that morning and had been
unable to stand, eat or drink anything. Her eyes
were closed and her speech was slurred.
Event ID: 18OL11
Facility ID: 923014
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A review of a full hospital discharge summary,
dated 2/24/10, indicated the resident was
discharged from the hospital with diagnoses of
delirium secondary to drug intoxication. The
discharge summary indicated that the resident's
family member had visited the resident on 2/14/10
around 2 p.m. at the nursing home and found her
to be nonresponsive. The family indicated this
was unlike her as normally she was oriented to
name, able to walk and knew her name 90% of
the time. The family further reported that the
resident's nursing assistant informed him the
resident had been in the bed all day and did not
eat or drink and had a "glazed look" over her
eyes. The summary indicated the resident had
received 2 liters of normal saline (intravenous (IV)
fluids) and 0.4 milligrams (mg) of Narcan (an
opiate antagonist) IV. The hospital physician
indicated the resident received an IV dose of
Narcan and had immediate improvement in
mental status. A urine toxicology screen tested
positive for opiates. The resident urinalysis and
urine culture were negative. Radiology test of the
abdomen, head and chest were negative. The
physician indicated "Thus, suspect cause of
delirium was acute medication intoxication." The
summary further indicated the patient did likely
aspirate as a result of her drug intoxication. She
had intermittent fevers from February 15 through
February 17. A repeat chest X-ray on 2/17/10 and
2/19/10 were concerning for a right upper lobe
infiltrate. She was started on nebulizer treatments
and antibiotics on 2/16/10. The resident was
discharged from the hospital and returned to the
facility.
A review of the completed urine toxicology (tox)
screen, dated 2/15/10, indicated Resident #5
tested positive for opiates with a result of =/>
Event ID: 18OL11
Facility ID: 923014
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(equal to or greater than) 300 ng/mL
(nanograms/milliliter). The urine toxicology
screens completed on the residents were not all
analyzed at the same laboratory. The resident's
urine toxicology screens were completed by either
the hospital laboratory (Lab #3) or the facility's
Lab #2. Resident #5's urine tox screen was
completed by Laboratory #3.
A review of a urine toxicology report (confirmation
test), dated 2/18/10, indicated the resident tested
positive for morphine and hydromorphone. The
morphine level was 23,220 nanograms/milliliter
(ng/mL). The hydromorphone level was 169
ng/mL. (The cutoff range was 100). The urine
confirmation test had been completed by Lab #2.
During an interview on 7/30/10 at 10:16 a.m., the
hospital laboratory assistant administrative
director indicated the cutoff range for morphine
had been developed and verified by clinical
testing by the hospital. She stated if the morphine
test result was greater than 100, then it was
clinically termed positive. She stated if the result
was less than 100 ng/mL, then it would be
considered negative or absent depending on the
result.
Nursing Assistant (NA) #3 indicated she worked
the 1st shift on 2/13/10 and 2/14/10. She stated
on the 1st shift on 2/13/10, the residents were
fine. She indicated nothing was unusual. On
2/14/10, NA #3 stated Resident #5 stayed in bed
all day and didn't eat. NA #3 indicated they sent
Resident #5 to the hospital on the second shift.
Event ID: 18OL11
Facility ID: 923014
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Director of Nursing (DON) #1 stated Resident #5
went out of the facility on 2/14/10 because she
was lethargic. She indicated Nurse #1 sent the
resident out that evening.
2.b. Resident #4 was admitted to the facility on
8/13/08, with diagnoses of senile dementia and
hypertension. The Minimum Data Set (MDS),
dated 12/7/09, indicated the resident had
moderately impaired cognitive skills for daily
decision making with long and short term memory
problems. She had persistent anger, sad or
pained expression, repetitive physical
movements, wandered and resisted care. She
daily living and required supervision with eating.
She did not have any devices or restraints.
Resident #4 resided on the locked Alzheimer's
unit.
receiving Boniva (osteoporosis medication),
Aspirin (blood thinner), multi-vitamin
(supplement), Fish Oil (supplement), Aricept
(dementia medication), Os-cal (calcium
supplement), Norvasc (blood pressure
medication), Celexa (antidepressant), Seroquel
(antipsychotic), Colace (stool softener), Feratab
(iron supplement) and Lipitor (cholesterol
medication). She received Proventil
(bronchodilator) nebulizer treatments and Tylenol
as needed (prn). The resident had been receiving
a 7-day course of Amoxicillin (antibiotic),
beginning on 2/9/10, for a urinary tract infection. A
review of the Medication Administration Record
for February 2010 indicated the resident had not
received any prn medications for pain. The
resident did not have physician's orders for
Event ID: 18OL11
Facility ID: 923014
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morphine.
A review of a nurse's notes, dated 2/13/10 at 4
a.m., indicated the resident continued on the
antibiotic and she had a quiet night. At 10 p.m.,
the nurse indicated the resident was voiding
without difficulty.
A nurse's notes, dated 2/14/10 at 5 a.m.,
indicated the resident rested well during the night.
She denied any pain.
A nurse's note, dated 2/15/10 at 3 a.m., indicated
the resident was resting well with no signs or
symptoms of distress. She did not have any
behavior problems.
A review of a physician's order, dated 2/15/10,
indicated an order to obtain a urine toxicology
screen.
A nurse's note on 2/16/10 at 5:05 p.m. indicated
the family was notified of the positive urine
toxicology screening. The resident did not have
any mental status changes.
A review of the urine toxicology screen,
completed 2/17/10, indicated the resident tested
positive for opiates with a result of =/> (equal to or
greater than) 300 ng/mL (nanograms/milliliter).
A review of a progress note by Nurse Practitioner
(NP) #1, dated 2/17/10, indicated the nurse
requested the resident be evaluated for abnormal
laboratory values. The resident was "very drowsy
but arousable" "respond to name and even talked
on the phone talking with family." NP #1 indicated
to monitor the resident's vital signs (VS) every 4
hours for 48 hours and monitor for any changes
Event ID: 18OL11
Facility ID: 923014
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in the resident's VS or level of consciousness.
A nurse's note, dated 2/17/10 at 4:15 p.m.,
indicated the resident had been in her room most
of the shift. The family came to visit the resident
and requested she be sent to the hospital.
A review of the hospital emergency department
(ED) Final Report, dated 2/17/10, indicated a
family member visited the resident that morning
and found her to be somnolent (sleepy, drowsy).
The emergency medical services were called and
the resident was given 2 milligrams (mg) of
Narcan (an opiate antagonist). The resident
became more awake and alert. In the ED, the
resident was more awake and close to baseline.
The resident was usually talkative, pleasant and
interactive. The resident was alert and oriented,
followed commands, and cooperative in the ED.
The resident had a positive urinalysis for a urinary
tract infection (UTI). She was started on
antibiotics. A review of the hospital History and
Physical, dated 2/17/10, indicated the resident
had altered mental status and lethargy. The
hospital physician indicated that given the positive
opiate screen and response to Narcan, it was
most likely due to the inappropriate opiate
administration, less likely from the urinary tract
infection. The Discharge Summary, dated
2/25/10, indicated the resident had "Delirium secondary to opiates." The resident was
discharged from the hospital to a different nursing
facility.
A review of a urine confirmation toxicology
laboratory report, completed 2/22/10, indicated
the resident tested positive for morphine with a
result of 1,376 ng/mL (cutoff: 100). This test was
performed by Lab #2.
Event ID: 18OL11
Facility ID: 923014
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on the 1st shift on 2/13/10, the residents were fine
and nothing was unusual. On 2/14/10, NA #3
stated Resident #4 would not eat and slept in her
wheelchair all the time.
2.c. Resident #8 was admitted to the facility on
included hypertension, heart murmur, Alzheimer's
dementia with psychotic features and depression.
Based on information contained in the MDS
(Minimum Date Set) on 11/24/09 the resident had
problems with short term memory, long term
memory and had moderately impaired cognition.
Resident #8 was living in the facility's Alzheimer's
Unit.
Resident #8's medications on 2/1/10 were
Trazodone (an antidepressant medication) 50 mg
(milligrams) at bedtime as needed, Zyprexa (an
antipsychotic medication) 2.5 mg at bedtime and
Acetaminophen (a medication for pain or fever)
650 mg every 6 hours as needed. Review of the
resident's MAR (Medication Administration
Record) showed that the resident had not taken
any Acetaminophen since 2/8/10 or Trazodone
since 2/10/10. The resident refused medications
on 2/6/10 at 8:00 AM and 2/11/10. The resident
did not have an order for morphine sulfate or any
opiate medication.
Review of Resident #8's nursing notes showed:
"2/12/10 2230 (10:30 PM) in bed all shift. still
holding hands up near face. no signs of distress
noted. seems confused but calm
2/13/10 340 (3:40 AM) quiet night no distress
Event ID: 18OL11
Facility ID: 923014
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2/14/10 500 (5 AM) no change in mental status,
still, very confused. no yelling screaming or trying
to get out of bed. rested well
2/15/10 800 (8 AM) no s/s (signs and symptoms
of ) illness. remains very confused to others and
her surroundings.
2/15/10 2300 (11 PM) remains in bed this shift.
still confused. no indications of pain."
"On 2/15/10 the resident's physician ordered a
"U/A (urinalysis) toxicology may do I+O (in and
out) Cath (catheterization)."
Further review of Resident #8's nurse's notes
showed:
"2/16/10 450 (4:50 AM) resident resting in bed u/a
cath in/out per order-tolerated well
2/16/10 1610 (4:10 PM) lying in bed, awake, son
visiting, Awake, muttering, speech incoherent,
does not follow commands. resistive to having
extremities manipulated. resistive to having pupils
checked. Unable to open eyes enough to check
with penlight. hand and arm strength strong. VS
(vital signs) WNL (within normal limits). earlier
today up in w/c (wheelchair) to dining room for
lunch.
2/16/10 4:27 PM RP (responsible party) notified
of positive U/A, MD (medical doctor) aware, RP
also aware of U/A test. inform to please call if he
had any questions. 440 P (4:40 PM) PA
(physician assistant) has see (sic) resident and
has decided to send to ER. RP aware."
A physician's note on 2/16/10 about the resident
showed:
"2/16/10-change in mental status
Alz (Alzheimer's) dementia, HTN (hypertension),
depression and falls, nurse request pt be
evaluated for being lethargic change in mental
Event ID: 18OL11
Facility ID: 923014
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status. Upon evaluation pt lying in bed with eyes
closed, refused to open eyes, when eyes opened
manually eyes pinpoint. Pt (patient) tested + for
opiates in urine drug screen test of unknown
etiology. Son at bedside and he attempted to
arouse pt with cold water on face with wash cloth.
Pt would not wake up just mumbled
incomprehensive words. Son request pt be sent
out for eval (evaluation) via EMS (emergency
medical services)."
A urine toxicology screen completed by
Laboratory (Lab) #3 on 2/16/10 showed "Opiate
Result =/>300 ng (nanograms)/ml, AB (abnormal
range)." A urine confirmation screening
completed by Lab #2 on 2/22/10 showed a
morphine level of 2,118 ng/ml and a
hydromorphone level of 212 ng/ml (cutoff: 100).
Notes from the hospital emergency room on
2/16/10 showed:
"2/16/10 6:58 PM Physical assessment-Alert.
Appears in no acute distress. The patient is
disoriented to place and to time. No facial
asymmetry noted. Pupillary exam: Right pupil
constricted. Left pupil constricted. Respirations
not labored. Skin intact. Skin is warm and dry
2/16/10 7:10 PM Pt sent to ED (emergency
department at the hospital) by EMS from (name
of nursing home) with report of lethargy and
pinpoint pupils. Per NP (nurse practitioner) at
(name of nursing home) pt was hard to arouse
and had a positive opiate test today (collected
yesterday). Per nurse, pt was given Narcan (a
narcotic antagonist medication) by EMS. No EMS
paperwork with patient.
Physical exam: no acute distress
Vital signs: have been reviewed
Eyes: pinpoint pupils
Event ID: 18OL11
Facility ID: 923014
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CVS (cardiovascular system): normal heart rate
and rhythm. Heart sounds normal. Pulses normal
Respiratory: No respiratory distress. Breath
sounds normal. Chest nontender.
Neuro: Oriented x 3
Clinical impression:
AMS (altered mental status) resolved
Abnormal tox screen."
The discharge summary from the hospital on
2/25/10 revealed the resident's admitting
diagnosis was lethargy and discharge diagnosis
was sedation secondary to medication
intoxication. A MRI (magnetic resonance imaging)
of the brain indicated there were no acute
findings. Further review of the discharge
summary indicated:
"Hospital course: General Notes- (resident's
name) was brought in due to increasing lethargy
and a positive urine opiate toxicology screen; she
is not routinely prescribed narcotics.
1. Delirium-given the positive urine tox delirium
was felt due to medication intoxication.
Nevertheless, urinalysis revealed + bacteria and
we sent off a culture. Her electrolytes, cardiac
enzymes were all WNL though she did have a
mild leukocytosis (13.2) without fever upon
admission. A chest film failed to reveal any acute
airspace distress. MRI of brain showed no acute
changes to infarct. EEG (electroencephalogram)
done and was normal.
2. Dementia-baseline fairly advanced per family
only intermittently oriented to person. Apparently
she does ambulate and will wander thus she is
usually a resident of a locked unit. During her
hospitalization she would go in and out of
alertness. She was entirely nonambulatory with
her upper extremities contracted.
3. HO (history of) htn (hypertension)- no
Event ID: 18OL11
Facility ID: 923014
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medication upon admission. During her short
hospital course her blood pressure ranged from
mid 120s to 150s systolic.
4. UTI (urinary tract infection) with proteus urine
culture started on amoxicillin PO (by mouth) for 5
days. She would occasionally refuse her PO dose
so she was started on Ampicillin for 24 hours
prior to discharge. She remained afebrile and had
a normal white count.
In an interview on 6/15/10 at 1:55 PM the
physician from the hospital stated: "during that
period of time we had a couple of people
(residents from the nursing home) coming in with
sudden onset of cognitive disorder. We did
screens and they had opiate levels but were not
on opiates on their MAR (medication
administration record). We had several more and
alerted (nursing home name) and the hospital
administrator as well. There was concern that she
may have received an opiate overdose. We
tested for opiates and she was + (positive) for the
screen. She had an elevated white count of 13.2,
but no fever. We could not find any reason for her
decline. We could not say after having her here
what was wrong with her. I never knew her at
baseline so I couldn't tell what was wrong. Even
before she was only intermittently oriented. I'm
not sure what was wrong. Nothing proved out. We
did an MRI of her brain and checked for
infection." The physician stated the resident's
worsening mental status was undetermined, and
it wasn't related to the morphine. He further
stated morphine was short acting and the
morphine levels were low. The resident's change
in mental status was a "red herring."
Resident #8 did not return to the facility.
Event ID: 18OL11
Facility ID: 923014
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2.d. Resident #9 was admitted to the nursing
home on 11/15/06 with cumulative diagnoses that
included included Alzheimer's dementia with
behavior disturbance, depression, hypertension,
hyperlipidemia and hypothyroidism. Based on
information contained in the MDS (Minimum Data
Set) on 12/29/09 the resident had problems with
The physician's order sheet for February 2010
showed Resident #9 was on the following
medications:
Synthroid (a medication for hypothyroidism) 75
mcg (micrograms) daily
Vasotec (a medication for high blood pressure)
10 mg (milligrams) daily
Norvasc (a medication for high blood pressure)
2.5 mg daily
Docusate Sodium (a stool softener) 200 mg every
morning
Effexor (a medication for depression and anxiety)
XR (extended-release) 150 mg daily
Acetaminophen (a pain medication) 500 mg 3
times a day.
Seroquel (an antipsychotic medication) 25 mg 3
times a day
Aricept (a dementia medication) 10 mg daily
Senokot S (a laxative/stool softener medication) 2
tablets at bedtime
Zocor (a hyperlipidemia medication) 20 mg daily
The resident did not have an order for morphine
sulfate or any opiate medication.
Resident #9 was last seen by psychiatry on 2/4/10
and the notes from that visit showed the resident
was "resistant to care, ADLs (activities of daily
living), decreased activity and attention consistent
Event ID: 18OL11
Facility ID: 923014
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with dementia progression."
Review of the nurses notes in Resident #9's
record showed:
"2/10/10 4:30 AM up all night going in and out of
resident room. Confused and agitated.
2/10/10 3:35 PM refused to let staff assist her to
room to be changed.
2/14/10 6:30 AM moderate amount of thick yellow
mucus coming from month. O2 (oxygen) Sat
(saturation) 78%
2/14/10 7:30 AM O2 at 2 L (liters) n/c (nasal
cannula) O2 90%.
2/14/10 12 noon resident found to be very
somnolent at time during rounds. O2 2L n/c
started. increased O2 sat from 79% to 95%. Pt
(patient) responds to touch and hearing. Denies
any pain. upper respiratory gurgling. no apparent
distress noted. will continue to monitor.
2/14/10 (no time) new orders rec'd (received)
BMP (basic metabolic panel) and CBC (complete
blood count) in AM (morning), clear liquid diet x
24 hours. give additional fluids 300 cc (cubic
centimeters) q (every) shift x 48 hours, In and out
cath (catheter) UA (urinalysis) C&S (culture and
sensitivity), Seroquel 25 mg. po (by mouth) now
refusing to have diaper and clothes changes. Call
placed to RP (responsible party). VSs (vital signs)
WNL (within normal limits). Res (resident)
received routine Tylenol. CXR (chest x-ray) for
cough and congestion.
2/15/10 3:00 AM OOB (out of bed) in chair no
respiratory distress. O2 95% on room air. States,
"I feel better."
2/15/10 9:00 PM in bed all shift refused changing
clothes x 3 . Refused meds."
Review of physician's notes in Resident #9's
record showed:
Event ID: 18OL11
Facility ID: 923014
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"2/15/10 AMS (Altered Mental State) over
weekend, (physician practice) notified and labs,
U/A (urinalysis), CXR (chest x-ray) checked, also
reported to have episode of dec (decreased) O2
(oxygen) sat (saturation) which responded to
oxygen. also reported to have yellowish mucus.
today pt reports episode of nausea but no
vomiting. AMS (altered mental status) now at
baseline. BMP (basic metabolic panel), CBC
(complete blood count) ordered, awaiting U/A will
also order tox (toxicology) screening."
Further review of the nurses notes indicated:
"2/16/10 6:30 AM resident refused AM (morning)
care.
2/16/10 4:15 PM Alert and oriented to person.
stated 'I just feel sleepy.' Aroused to verbal
stimuli.
2/16/10 4:35 PM called to notify of pos (positive)
U/A - MD (physician) aware. MD to see resident
this afternoon."
A physician's note, dated 2/16/10, indicated:
"Pt (patient) seen of 15th (of February) for AMS
over the weekend-seen on Monday, pt back at
baseline. BMP, CBC, CXR and urine for tox
(toxicology screen). Chest X-ray neg (negative).
Nurse request pt be evaluated for increased
lethargy and confusion. Pt has positive screen for
opiates. Due to increased lethargy and +
(positive) opiate screen pt will be sent to hospital
for eval.
A nurses noted, dated 2/16/10 at 5:15 PM
indicated:
"(nurse practitioner name) saw resident and
decided to send resident to ER (emergency
room) for eval (evaluation). (name of responsible
party) called daughter asked to be called when
Event ID: 18OL11
Facility ID: 923014
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911 arrived."
Resident #9 was admitted to the hospital on
2/16/10 at 6:10 PM with admission diagnosis of
AMS (altered mental status). The initial physical
assessment at 6:36 PM showed: "Alert. Appears
in no acute distress. All VSs (vital signs) WNLs
(within normal limits). Resident was found eating
dinner at facility when EMS (emergency medical
service) arrived to transport. didn't receive any
Narcan (a narcotic antagonist medication). has dx
(diagnosis) Alz dementia. resident denies
requesting narcotics for pain. Has AMS. found
had UTI (urinary tract infection)-mild infection
asymptomatic bacteruria vs UTI though will treat
as latter-culture pending started on Cipro (an
antibiotic)."
A urine toxicology screen on 2/16/10 showed the
resident had an abnormal opiate level of =/> 300
ng (nanogram)/ml (milliliter).
A review of the Hospital Discharge Summary,
dated 2/17/10, indicated the resident's admitting
diagnosis was altered mental status (AMS). The
discharge diagnosis was altered mental status
due to narcotic side effect (intentional vs
unintentional). The resident had secondary
diagnosis of Alz (Alzheimer's) dementia, HTN
(hypertension), HLD (hyperlipidemia),
hypothyroid. Further review of the hospital
"History of present illness: 82F (82 year old
female) with h/o (history of) Alzheimer's
dementia, htn, hld, hypothyroid was in usual state
of health at (nursing home name) when pt was
found to be less arousable than normal today. By
report from ED (emergency department) to me, a
number of people (residents from the nursing
Event ID: 18OL11
Facility ID: 923014
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home) had similar status today and were found to
have opiates in their urine when tested. An
investigation is apparently underway as pt doesn't
have narcotics listed in her medications as a
standing order or prn (as needed). Pt apparently
had no complaints, didn't receive any Narcan (a
narcotic antagonist medication), but was sent for
close observation to ED.
Assessment and Recommendation:
1. AMS Unclear if due to UTI or opiate
consumption. Details are under investigation. She
does have a positive opiate screen and will be
monitored overnight. Her urine has a mild
infection, asymptomatic bacteruria vs UTI,
though will treat as latter due to unclear
contribution of opiates. Also due to unknown
nature of opiates, could be long acting and will
admit for observation. Pt is alert now, but will
place on tele (telemetry) overnight with 02
(oxygen). Will seek outside records in AM
(morning)
2. Opiate consumption, inadvertent. As above,
investigation is ongoing. Pt. denies requesting
narcotics for pain.
3. Full code
4. HTN, continue outpt (outpatient) meds
5. UTI, continue abx (antibiotics) x 3 days,
Ciprofloxacin (Cipro) 250 mg BID (twice a day)
culture pending.
dispo. (disposition) will observe overnight. Will
have clinical care management team assess in
AM, consider if placement satisfactory to family or
seek new place for her due to unusual
circumstances and current investigation regarding
possible medication error."
Resident #9 was discharged back to the nursing
home on 2/17/10 at 12:05 PM.
Event ID: 18OL11
Facility ID: 923014
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Review of the nursing home physician's notes in
Resident #9's record showed a note, dated
2/18/10, that indicated the resident had been
"admitted to (hospital name) secondary to AMS,
tested + opiates at time, admitted for further
observation; did not receive any narcs (narcotics).
Also has UTI, AMS also possibly secondary UTI,
given antibiotic; has been alert and back to
baseline; this AM she is up and about, eating
breakfast, is at her baseline mental status. AMS
possibly secondary UTI-on Cipro (an antibiotic),
continue and finish course of antibiotic;
encourage fluids. + drug screen-for confirmation
test; back to her baseline, supportive care, safety
measures."
On 2/19/10 a confirmation urine drug test done by
Laboratory #2 on Resident #9 showed an opiate
level of 13,140 ng/ml (cutoff: 100).
some respiratory problems. He stated they went
to see the residents. Resident #9 was sedated.
He indicated Resident #9's oxygen saturations
were low, at 80 - 90%.
Nurse #12 stated she was off work on 2/12/10.
She came in to work on 2/13/10. She worked the
her shift. When Nurse #12 arrived, she stated the
residents were still in bed sleeping, "asleep as I
thought." She indicated it was "hard to assess for
Event ID: 18OL11
Facility ID: 923014
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lethargic when they are in bed sleeping." "I just
did not even suspect that was going on." During
her shift, a nursing assistant reported to the nurse
that Resident #9 had a change of condition.
Nurse #12 went to check on Resident #9. She
had drainage coming from her mouth and was
having some difficulty breathing. They got
Resident #9 up and she was a little more alert.
"She was coughing and getting the stuff out of her
mouth." The nurses put oxygen on her and she
got better. Nurse #12 notified the physician. The
physician did not want to send Resident #9 out to
the hospital at that time because after they put
oxygen on her, her oxygen saturation improved.
2.e. Resident #7 was admitted to the facility on
included Alzheimer's dementia, atrial fibrillation,
hypertension, coronary artery disease and high
cholesterol. Information contained in the
resident's MDS (Minimum Data Set) on 2/8/10
showed the resident had problems with short
term memory, long term memory and had
Resident #7's medications as of 2/1/10 were:
Aspirin 81 mg (milligrams) daily, Lasix (a diuretic
medication) 20 mg daily, K-Dur (a potassium
supplement) 20 mEq (milliequivalents), Altace (a
blood pressure medication) 5 mg daily, Vitamin C
500 mg daily, Seroquel (an antipsychotic
medication) 25 mg at 8 AM, 50 mg. at 2 PM and 8
PM, Lopressor (a blood pressure medication) 50
mg twice a day, Welchol (a cholesterol lowering
medication) 625 mg 3 times a day, Namenda (an
Alzheimer's medication) 10 mg at bedtime,
Coumadin (a blood thinning medication) 7 mg
daily and Seroquel 25 mg 3 times a day as
Event ID: 18OL11
Facility ID: 923014
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needed for agitation. The resident did not have an
order for morphine sulfate or any opiate
medication.
Review of nurse's notes for Resident #7 showed:
"2/10/10 3 PM wandering in unit no aggressive
behavior noted.
2/15/10 11:10 AM sitting on floor in 800 hall
eating an apple. assisted to stand.
2/16/10 3:55 PM resident noted with altered
mental status, U/A tox (urine toxicology screen)
noted to be pos (positive). MD (medical doctor)
aware. RP (responsible party) noted that resident
will be going to ER (emergency room)."
A urine specimen was collected on 2/15/10. A
urine toxicology screen completed by Lab #3 on
2/16/10 indicated Resident #7 was positive for
opiates with a result of opiate =/> 300 ng/ml
(nanograms/milliliter).
Review of a physician note for Resident #7
showed:
"2/16/10- nurse request pt (resident) be evaluated
for change in mental status. Upon evaluation pt
very confused increased from baseline, unable to
ambulate and pupils dilated, glassy eyed. Resp
(respiration) even, nonlabored. VS (vital signs)
stable. Pt also tested + (positive) for opiates
unknown source. Talked with daughters and they
agree with sending pt to ER (emergency room)."
Notes from the hospital emergency room
concerning Resident #7 showed:
"Arrived 2/16/10 4:40 PM
4:45 PM-History: This started today. (coming from
[nursing home name]. ams (altered mental
status) had a urine screen this am (morning) and
found to be pos (positive) for opiates, per
Event ID: 18OL11
Facility ID: 923014
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daughter states others (sic) pts on unit was (sic)
found to have pos opiate daughter states has
slept all day, didn't recognize her.
2/16/10 5:11 PM History of Present Illness: Chief
Complaint: Decreased Mental Status. This started
last night and is now gone. It was gradual in
onset. It is gone now. Lethargic. Nursing home
resident. History of chronic dementia. No
weakness or numbness. Usually has normal
mobility. AAO X 0 (Alert and Oriented times zero).
Patient has not had similar symptoms previously.
Not recently seen or assessed.
Neuro (Neurological): Alert. Altered mental status
(at baseline). Speech normal. Cranial nerves
normal (as tested). No motor deficit. Reflexes
normal. Unable to test fully given patient's
dementia.
2/16/10 5:11 PM Physical Assessment:
AMS since Sunday. Reports tested positive for
opiates at (name of the nursing home). Is not
prescribed opiates. Per family, pt has been
sleeping more than normal but at this time
appears to be at baseline. Alert, Appears in no
acute distress. No facial asymmetry noted.
Respirations not labored. Breath sounds within
normal limits
Progress and Procedures:
2/16/10 5:11 PM 63 yo (year old) M (male) w/
(with) severe dementia brought in by daughters
because they were concerned that the patient
seemed altered and had a positive urine test for
opiates earlier today. Pt (resident) is a patient at
(name of nursing home), where several patients
have been found with opiates in their urine, but
are not supposed to be on narcotics. This is the
Event ID: 18OL11
Facility ID: 923014
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case with (Resident #7). At his baseline, he can
recognize his daughters and give them a hug,
feeds himself and walks around frequently. He
was not doing any of those things earlier today.
However, he seems to have returned to his
baseline mental status. Will proceed with head
CT (computed tomography), CXR (chest x-ray),
labs, UA (urinalysis) and Utox (urine drug screen)
to evaluate for possible causes of AMS. Will
touch (sic) base with Social Work to ensure that it
would be safe to go back to (name of the facility)
if workup is normal.
2/16/10 7 PM-only urine is back, which shows no
UTI (urinary tract infection), but opiate positive.
Serum labs CXR and Head CT still pending.
2/16/10 7:32 PM Waiting on results from CXR
and labwork. Head CT with no acute intracranial
events. Blood work + (positive) for opiates, not on
(facility name) MAR (Medication Administration
Record). Reported back to baseline since in ED
(emergency department).
2/16/10 8:51 PM Paged geriatric team for
admission. Per ED coordinator, all (facility name)
patient (sic) with AMS, + opiates should be
admitted for observation. Talked to patient and
family about plan and lab results. Patient has
elevated CK-MB (creatine kinase-MB fraction-a
cardiac marker), but fraction is low 2/2 increased
CK. This is likely due to immobility earlier today.
Altered mental status still appears to be related to
opioid use.
Clinical impression-change mental status with
lethargy (secondary to opioids)
2/16/10 11:19 PM condition at departure:
improved and stable."
On 2/22/10, a urine confirmation test done was
Event ID: 18OL11
Facility ID: 923014
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completed by Lab #2 and showed Resident #7's
morphine level was 5,320 ng/ml
(nanograms/milliliter) (cutoff: 100) and a
2.f. Resident #6 was admitted to the facility on
4/20/09 with the diagnoses of Alzheimer's
dementia, cerebrovascular disorder, depression,
diabetes mellitus and hypertension. The
Minimum Data Set (MDS, an assessment tool)
dated 5/20/10 indicated the resident had a
problem with long and short term memory and his
cognitive skills for daily decision making was
moderately impairment. He required extensive
assistance for mobility, transfers and personal
hygiene. Resident #6 resided in the facility on the
Alzheimer's Unit.
Review of the Physician's Orders for February
2010 revealed Resident #6 had an order for
Acetaminophen (Tylenol) 325 mg (milligram) 2
tablets by mouth every six hours as needed for
pain or fever. Resident #6 also had an order for
Hydrocodone/APAP 5/500 (Vicodin/Lortab-5) 1
tablet by mouth every 6 hours as needed for pain.
Further review of the Physician Orders for
February 2010 revealed Resident #6 did not have
an order for morphine.
Review of the Medication Administration Record
(MAR) for the month of February 2010 indicated
Resident #6 was not given any Tylenol for pain or
Vicodin/Lortab-5 for pain.
Record review of the nurse's notes indicated
Resident #6 was not having pain and had not
been given medication for any indications for
Event ID: 18OL11
Facility ID: 923014
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pain.
Record review of the nurse's notes written by
Nurse #1 indicated Resident #6 had a change in
condition on 2/14/10. The nurse's notes revealed
Resident #6 was lethargic and had not consumed
any meals or fluids that day. Resident #6 had an
elevated temperature of 101.0 degrees F
(Fahrenheit) and Tylenol 325 mg 2 tabs by mouth
were given without difficulty. The nurse's notes
stated the resident would not open his eyes or
follow commands. Nurse #1 revealed in the
nurse's notes that Resident #6 was transferred by
stretcher to the ED (Emergency Department) on
2/14/10 at 9:30 PM due to change in mental
status.
Record review of the full hospital discharge
summary revealed Resident #6 was admitted with
a diagnosis of delirium secondary to opioid
(Morphine) intoxication. A toxicology report for
Resident #6 collected on 2/15/10 at 12:22 AM,
and completed by Lab #3, revealed a positive
result for opiates (Morphine). A urine screen
confirmation, completed on 2/18/10 by Lab #2,
indicated the resident's level of Morphine was
28,740 ng/mL (nanograms/milliliter.) (The cutoff
was 100).
Record review of the Physician Orders for
February 2010 for Resident #6 revealed there
were no orders for Morphine.
Record review of the Physician's re-admission
History and Physical (H&P) to the facility dated
2/18/10 revealed Resident #6 had been admitted
to the hospital on 2/15/10 with diagnoses of
delirium secondary to opioid (Morphine)
intoxication.
Event ID: 18OL11
Facility ID: 923014
PRINTED: 08/11/2010
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Nurse #1 was not available for an interview
regarding the change of condition for Resident
#6.
3.a. The residents in examples 3.a. through 3.g.
tested positive for morphine, but did not require
hospitalization.
9/27/07 with diagnoses of mental disorder,
hypothyroidism, hypertension, senile dementia
and depressive disorder. The Minimum Data Set
(MDS), dated 3/22/10, indicated the resident's
cognitive skills for daily decision making were
moderately impaired with short and long term
memory loss. The resident was easily distracted,
had periods of altered perception, disorganized
speech, periods of restlessness, expressions of
what appears to be unrealistic, unpleasant mood
in the morning, sad/pained expressions, repetitive
physical movements and wandering behavior. He
required extensive assistance with bed mobility,
toilet use, personal hygiene and bathing. Resident
receiving Symbyax (antipsychotic/antidepressant
medication), Norvasc (blood pressure), Plavix
(platelet inhibitor), Senna S (laxative/stool
softener), Effexor XR (antidepressant), Risperdal
(antipsychotic), Zocor (cholesterol medication),
Synthroid (thyroid medication) and Tylenol as
needed. A review of the Medication
Administration Record for February 2010
indicated the resident had not received any
Tylenol for pain. The resident was not prescribed
morphine or any other opiates.
Event ID: 18OL11
Facility ID: 923014
PRINTED: 08/11/2010
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A review of a nurse's notes, dated 2/14/10 at 1:30
a.m., indicated the resident's blood pressure was
150/70, pulse 102, respirations 16 and oxygen
saturation was 91%. The nurse heard moaning
sounds from the resident's room. She found the
resident sitting up in bed with his eyes rolled
back. His face was red. He answered when his
name was called. The physician was notified. At
5:30 a.m., the resident's left eye was looking off
to the left and his right eye was looking straight
ahead. His face was red, with no other facial
symptoms. The resident was not moaning, but
was not as verbal as usual. He would answer his
name when he was called. The physician and
family were notified. The nurse administered
oxygen. At 2 p.m., the resident was out of bed in
the chair. He was ambulatory with assistance of
the walker.
A review of a nurse's note, dated 2/14/10 at 10
p.m., indicated new orders were obtained for the
resident's change in mental status. A basic
metabolic panel, complete blood count and
urinalysis and culture were ordered. The resident
was placed on a clear liquid diet for 24 hours and
additional fluids were ordered every shift. An
order was also received for Phenergan 25 mg by
mouth or suppository every 6 hours as needed for
24 hours for nausea and vomiting. The nurse
administered Phenergan at 6 p.m. and it was
effective.
On 2/15/10 at 10:50 a.m., the resident was up in
the dining room for breakfast, he was calm and
cooperative. A chest X-ray was done. At 11 p.m.,
he was more confused than usual that shift. He
refused vital signs and the nurse had difficulty
getting him to take his medications.
Event ID: 18OL11
Facility ID: 923014
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A review of a physician's progress note, dated
2/15/10, indicated the resident had an episode of
moaning, red face and episode of nausea and
vomiting. He was evaluated for his altered mental
status and lethargy. The physician indicated the
resident appeared to be at baseline that day and
ordered a urine toxicology and a urinalysis.
On 2/16/10 at 12:30 p.m., the resident was
"somewhat more confused & resistive to care
today than usual" "refused oral care and shaving."
At 2:10 p.m., the nurses notes indicated the
resident was incoherent and delusional. He was
"very hyper." At 6:15 p.m., an order was received
to send the resident to the hospital. The resident's
family member was informed that the resident
had mental status changes and had been
confused. At 6:45 p.m., an order was received to
discontinue transport to hospital. Resident was
"better" at that time. At 11:30 p.m., the resident
was "doing better." He was "less confused" and
took his medications.
A review of a urine confirmation toxicology report
for Resident #13, collected on 2/15/10, indicated
a test result of 7,900 nanograms per milliliter
(ng/mL) (cutoff: 100) of morphine and
hydromorphone 180 ng/mL (cutoff: 100). The
urine toxicology screens completed on the
residents were not all analyzed at the same
laboratory. The resident's urine toxicology
screens were completed by either the hospital
laboratory (Lab #3) or the facility's contracted
laboratory (Lab #1). The urine toxicology
confirmation tests were completed by Lab #2.
Resident #13's confirmation test was completed
by Lab #2.
Event ID: 18OL11
Facility ID: 923014
PRINTED: 08/11/2010
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A review of a chest X-ray report, dated 2/15/10
indicated there was no acute cardiopulmonary
disease seen. A review of a urinalysis, dated
2/18/10, indicated there was no growth.
During an interview on 6/17/10 at 12:48 p.m., NA
(nursing assistant) #4 indicated she usually
worked the 1st shift, 7 a.m. to 3 p.m. She
indicated on 2/13/10, the residents were fine. On
2/14/10, Resident #13 was in the bed and the
nurse informed the nursing assistants to leave
him alone because they thought he was having a
stroke. She stated He was pretty much laying
there." She indicated it was hard to try to get him
to get up.
She came in to work on 2/13/10 and worked the
her shift. When Nurse #12 arrived, the residents
were sleeping. Nurse #12 stated around 2 to 2:30
a.m., Resident #13 was having some difficulty
breathing and his eyes were not focusing right.
She thought he was having symptoms of a
stroke. She put oxygen on the resident. She
called the doctor and notified the family.
2/14/10 from 6:45 a.m. until 5 p.m. He stated
Resident #13 had to be ambulated with
assistance on 2/14/10. He indicated normally the
resident was independent and was walking
around fine on 2/13/10. Resident #13 was
unstable on his feet on 2/14/10. "He was just a
little bit slower."
Event ID: 18OL11
Facility ID: 923014
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Resident #13 was not transferred to the hospital.
3.b. Resident #73 was admitted to the nursing
home on 5/1/08, with diagnoses of dementia,
deconditioning, chronic renal insufficiency,
depression and cerebrovascular accident. A
significant change Minimum Data Set (MDS),
dated 1/13/10, indicated the resident's cognitive
skills for daily decision making were moderately
impaired with short and long term memory loss.
She was easily distracted and had episodes of
disorganized speech. She had repetitive health
complaints, insomnia, sad facial expressions and
crying or tearfulness. She did not have any
behavior issues. She required extensive
assistance with bed mobility, transfers, dressing,
eating, toilet use and personal hygiene. She
required total assistance with locomotion on and
off the unit and with bathing. She had not
ambulated during the assessment period. The
MDS indicated the resident had moderate pain
less than daily. Resident #73 resided on the
locked Alzheimer's unit.
receiving multivitamin tablets (supplement),
Synthroid (thyroid medication), Lotrel (heart
medication), Lactulose (bowel medication),
Cymbalta (antidepressant), Prilosec (stomach
medication), Lidoderm (pain medication patch),
Senokot (laxative), Seroquel (antipsychotic),
artificial tears (eye lubricant), Aricept (dementia
medication) and Tylenol (pain/fever medication).
There were orders for Vicodin (pain medication),
milk of magnesia (laxative), fleets enema
(laxative), Dulcolax (laxative) and Tylenol as
needed. There were no orders for morphine.
Event ID: 18OL11
Facility ID: 923014
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A review of the Medication Administration
Records (MARs) for January 2010 and February
2010 indicated the resident last received Vicodin
on 1/26/10. She did not receive Vicodin in
February 2010.
A review of a nurse's notes, dated 2/12/10 at
2225 (10:25 p.m.) indicated the resident was in
bed all shift. There was no sign of pain or
distress.
A nurse's note, dated 2/14/10 at 0500 (5:00 a.m.)
indicated the resident was in bed resting with no
signs or symptoms of distress. She was not
having any behavioral problems.
indicated new orders were received by Nurse #1
for a basic metabolic panel, complete blood
count, clear liquid diet for 24 hours, 300 cc (cubic
centimeters) additional fluids for 48 hours, and a
urinalysis and culture. The resident's vital signs
were blood pressure 102/52, pulse 68,
respirations 18, temperature 96.2. The nurse
further indicated the responsible party was
notified of the change in mental status. There was
no description of what changes the resident was
having in her mental status.
2/15/10, indicated the chief complaint was
lethargy, altered mental status, nausea and
vomiting. The physician indicated the resident
"appears to be more confused than baseline
although appeared to be in no distress." The
physician indicated the resident did not have any
new medications that could have been
contributing to confusion. A urine toxicology
screen was ordered.
Event ID: 18OL11
Facility ID: 923014
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A review of an opiates blood screen, dated
2/19/10, indicated a negative result.
A review of laboratory report, collected 2/19/10,
indicated the resident's opiate screen was
positive for Morphine. The Morphine level was
1618 ng/mL (nanograms/milliliter). The cutoff limit
was 200. This laboratory test was completed by a
different laboratory (Lab #1) from the other
residents who tested positive for morphine.
An interview was conducted with Facility
Consultant (FC) #1 and Director of Nursing
(DON) #1 on 7/1/10 at 11 a.m. Director of Nursing
(DON) #1 stated initially Resident #73's family
refused the urine toxicology (tox) screen. Later
on, the responsible party requested that it be
done. The resident's blood tox screen was
negative, but the urine tox was positive for
morphine. DON #1 stated the morphine was "out
of her blood, but it was lingering in her urine due
to the way her body was filtering the morphine
out." DON #1 stated she did not remember the
resident having a change in mental status and
that was initially why the responsible party refused
to have the urine tox screen. FC #1 stated
Resident #73 was not on any opiates. The
resident did not receive any Vicodin in February
2010.
2/5/09 with cumulative diagnoses that included
Alzheimer's dementia with lethargy, hypertension,
osteoporosis and allergic rhinitis. Information
contained in the resident's MDS (Minimum Data
Set) on 1/5/10 showed the resident had problems
with short term memory, long term memory and
had moderately impaired cognition. Resident #16
Event ID: 18OL11
Facility ID: 923014
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was living in the facility's Alzheimer's Unit.
A review of the physician's orders indicated the
resident's medications on 2/1/10 were:
Aspirin 81 mg (milligrams) daily
Boniva (a medication for osteoporosis) 150 mg
monthly
Ritalin (a central nervous system stimulant) 5 mg
daily
Namenda (an Alzheimer's medication) 10 mg
twice a day
OsCal 500 + (Vitamin) D twice a day
Tylenol (a pain reliever) Arthritis Strength 1300
mg twice a day
Senokot S (a laxative/stool softener combination)
2 tabs twice a day
Remeron (an antidepressant) 15 mg at bedtime
Docusate Sodium (a stool softener) 200 mg at
bedtime
Lactulose (a laxative) 15 ml (milliliters) daily
Dulcolax (a laxative) 10 mg suppository daily as
needed.
Review of physician notes about Resident #16
showed:
"2/5/10-Alzheimer's dementia with lethargy: prev
(previously) responding to Methylphenidate (same
as Ritalin) cont (continue) current dose & follow;
continue supportive care."
Review of the nursing notes about Resident #16
showed:
"2/14/10 - 1030 (10:30 AM) Res. (resident) has
change (symbol) in mental status however, she
has improved. VS (vital signs) 174/82 (blood
pressure)-67 (pulse)-97.4 (temperature) & 16
(respirations). New ordered rec'd (received)
Event ID: 18OL11
Facility ID: 923014
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earlier. BMP (basic metabolic panel), CBC
(complete blood count) in am (morning). clear
liquid diet x 24 hrs give additional 300 cc (cubic
centimeters) fluid q (every) shift x 48 hrs. In and
out cath (catheter) UA (urinalysis) C&S (culture
and sensitivity)."
A nurse's note, dated 2/15/10 at 7:45 a.m.,
indicated an I/O (in and out) catheter was done
for a urine culture and sensitivity.
A physician's note, dated 2/15/10 indicated:
"reported to have inc (increased) lethargy, AMS
(altered mental status) which then improved.
(Physician) notified and recommended UA
(urinalysis), labs. Today pt (patient) appeared to
be at baseline, resting comfortably in bed.
Arousable, smiled. Agree with labs, check UTox
(urine drug screen) for other cause cont VS q
(every) shift x 3 days."
showed:
"2/16/10 - 1400 (2 PM) I/O cath done for urine tox
screen
2/16/10 - 2230 (10:30 PM) resident found on floor
in room. On assessment-favoring R (right) hip
and wincing in pain. VS (vital signs) 114/57 (blood
pressure)-46 (pulse)-18 (respirations)-97.7
(temperature). (Physician) called and new order
received for a R (right) hip x-ray and VS q (every)
shift x 48 hrs. Resident back in bed resting "
A urine drug test done on 2/16/10 was positive for
opiates with a result of =/> 300 ng
(nanograms)/ml (milliliter). A confirmation urine
test done 2/17/10 by Lab #2 showed a morphine
level of 778 ng/ml.
Event ID: 18OL11
Facility ID: 923014
PRINTED: 08/11/2010
FORM APPROVED
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B. WING _____________________________
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07/27/2010
1716 LEGION ROAD
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showed:
"2/17/10- reported to have inc (increased)
lethargy several days ago included labs +UA?UA
now + for UTI with E. Coli (a bacteria) sens
(sensitive) to Bactrim (an antibiotic), Ceftriaxone,
(an antibiotic), Resistant to Augmentin (an
antibiotic), Amp (ampicillin-an antibiotic), Cipro
(an antibiotic) , Levaquin (an antibiotic). Pt
(resident) also reported to have fallen-X-ray neg
(negative) for fx (fracture). UTI (urinary tract
infection)-tx (treatment) with Bactrim DS 1 tab po
(by mouth) qd (daily) x 10 days, encourage PO
(by mouth) fluids. Falls-in setting of UA,
Alzheimer's dementia, cont (continue) fall
precautions, close monitoring."
Resident #16 had physician orders that showed:
"2/17/10 VS q4hrs. Please have MD follow up in
am."
showed:
"2/17/10 - 2400 (midnight) no further falls or fall
related injuries. No change in mental status.
Resting quietly with even unlabored resp.
(respirations). Skin w/d (warm and dry). Afebrile.
(no fever)."
showed:
"2/22/10 recent increase in drowsiness in setting
of UTI Pt started tx (treatment) c (with) Bactrim
DS. Pt (patient) also r
F 281 483.20(k)(3)(i) SERVICES PROVIDED MEET
SS=K PROFESSIONAL STANDARDS
F 281
The services provided or arranged by the facility
must meet professional standards of quality.
Event ID: 18OL11
Facility ID: 923014
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by:
reviews, the facility failed to ensure residents did
not receive a narcotic without a physician's order
for 14 of 29 residents (#1, #2, #3, #4, #5, #6, #7,
#8, #9, #13, #14, #15, #16, #73). Toxicology
reports indicated 14 residents tested positive for
toxicity.
Findings:
Event ID: 18OL11
Facility ID: 923014
PRINTED: 08/11/2010
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edema and hypoxia.
1. Cross Refer to F329. Based on observation,
staff interviews and record reviews, the facility
failed to keep residents free from unnecessary
drugs when 14 of 29 residents (#1, #2, #3, #4, #5,
Event ID: 18OL11
Facility ID: 923014
PRINTED: 08/11/2010
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#6, #7, #8, #9, #13, #14, #15, #16, #73) received
a narcotic without an adequate indication for use.
Toxicology reports indicated 14 residents tested
positive for morphine. Seven residents were
hospitalized (#1, #4, #5, #6, #7, #8 and #9) and
one resident died (#1) from aspiration pneumonia
The facility provided their correction action plan
on 7/26/10.
In an interview with Facility Consultant #1 on
2/18/10 at 8:14 AM, she indicated the facility
began conducting an investigation on 2/15/10
concerning the positive opiate test on residents
who were not prescribed opiates. The only
medication the residents who tested positive had
in common was Tylenol (a pain reliever). The
facility took all of the Tylenol out of the facility and
had it tested by Lab #1 and there were no issues
with the Tylenol. The facility also tested all the
liquid morphine in the facility; even though none
of the residents were on it that tested positive for
opiates. The facility drug tested all the residents
in the facility and based on these tests, the facility
realized that all the residents who tested positive
for opiates were not on any opiates. The facility
increased their monitoring by assigning a second
nurse to accompany the nurse already
administering medications to the residents. The
facility called in a pharmacist on Monday 2/15/10
and Tuesday 2/16/10. The facility put a
pharmacist with the nurses that were
administering medications so that a pharmacist
was monitoring each medication pass and each
medication given. The pharmacist checked all the
narcotic sheets for the entire building, checked
the drugs and the documentation and there were
no discrepancies at all. On 2/16/10 the facility
Event ID: 18OL11
Facility ID: 923014
PRINTED: 08/11/2010
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drug tested and suspended every staff member
on the Alzheimer's unit. None of the employee
drug tests were positive. On 2/16/10, the facility
took all the water pitchers out of residents' rooms
and bought disposable water bottles to use. They
used these disposable water bottles for all
medication passes and for resident drinking. On
2/16/10, the facility made an appointment with
local police and met with them on 2/17/10. The
facility furnished the police department with their
investigation. The police told the facility they could
not open an investigation because they had no
proof that a crime was committed. On 2/17/10,
the facility suspended all of the dietary staff. All
the food in the facility that had been opened was
discarded and new food was brought in. Dietary
staff from other facilities were brought in to work
in the kitchen. All the dietary staff were drug
tested and there were no positives at that time.
The facility placed a staff member in the
Alzheimer ' s unit to monitor 24 hours to observe
for anything suspicious. All of the medications
from the Alzheimer ' s unit were sent back to the
pharmacy and replaced. On 2/17/10, the facility
closed down all the ice machines in the building.
The only ice used for the residents came from the
kitchen and was supervised from opening to
closing of the kitchen by corporate dieticians. The
facility did a 100% audit of all rooms, resident
belongings, nurses stations, medication carts and
treatment carts.
Address how corrective action will be
accomplished for those residents found to have
been affected by the deficient practice
The facility started an investigation on 2/15/10.
Staff members identified as having potential
involvement were interviewed on 2/15/10. Upon
Event ID: 18OL11
Facility ID: 923014
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interview during second shift on 2/15/10, the
alleged perpetrator was immediately suspended
and never reinstated. On 2/16/10 the remaining
staff that worked the Alzheimer's unit to include
RNs, LPNs, CNAs, housekeepers, dietary, and
activities assistant were suspended and drug
tested per facility policy pending outcome of the
investigation. Local law enforcement was notified
on 2/16/10 by the VP of Operations and a
meeting was held with the Captain of the police
department on 2/17/10. Subsequently the State
Bureau of Investigation was notified. Notification
to Division of Health Care Services Regulations
by the VP of Operations on 2/16/10. A 24 hour
report was submitted to the health care personnel
registry on 2/16/10.
accomplished for those residents having the
potential to be affected by the same deficient
practice
Urine toxicology began for all residents on
2/15/10. A 100% audit of the Alzheimer's
resident's rooms and nurse's station were
completed for hazardous materials and chemicals
by the Facility Consultant on 2/15/10. A visitor
sign in log and receptionist was placed at the
front door of the Alzheimer's unit on 2/16/10. All
residents were observed for signs and symptoms
of abuse and change in condition on 2/15/10 by
the Facility Consultants and the DON. Q 2 hour
safety checks for monitoring of all residents for
abuse and change in condition were completed
by the Facility Consultants and licensed nurses
from 2/16/10-3/11/10. Department heads began
monitoring the Alzheimer's unit on 2/16/10 for the
monitoring of abnormal behavior, changes in
condition of residents and suspicious behaviors of
Event ID: 18OL11
Facility ID: 923014
PRINTED: 08/11/2010
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visitor and employees. All ice machines were
emptied on 2/16/10 and closed for use. On
2/16/10 until 3/11/10 all opened containers of
food were replaced with a new shipment of food
in a locked compartment refrigerator. 2/16/10 until
2/28/10 all beverages were replaced with
prepackaged beverages and med passes were
administered with bottled water. Bottled water
continues to be utilized in the Alzheimer's unit. All
apple sauce containers from all med carts were
replaced with individual packages of applesauce
on 2/16/10 and continue to be utilized on the
Alzheimer's unit. On 2/16/10 all staff were
inserviced by the staff development coordinator
on not using pitchers of water but using bottled
water only. All staff were inserviced by the Staff
development Coordinator on the abuse policy on
3/12/10 through 3/27/10 and on going to include
upon hire, monthly, and with any event related to
abuse. This abuse inservice emphasizes it is the
responsibility of any staff member to immediately
report any incident of suspected abuse to their
supervisor. The supervisor and or the employee
must then report immediately to the
Administrator.
Address what measures will be put into place or
systemic changes made to ensure that the
deficient practice will not occur
Staff members will be interviewed by the Facility
Consultants and Administrative nurses to assure
continued understanding of the facility abuse
policy utilizing a Quality improvement tool. These
audit tools will be done 3 days per week for 4
weeks then 2 times per week for the next 20
weeks. These audit tools will occur on all three
shifts and weekends.
Event ID: 18OL11
Facility ID: 923014
PRINTED: 08/11/2010
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Indicate how the facility plans to monitor the
measures to make sure solutions are sustained
The results of the QI audit tools will be compiled
by the Administrator and reviewed noting trends
and actions taken by the facility for the quality
improvement executive committee monthly for the
next 2 months.
F 329 483.25(l) DRUG REGIMEN IS FREE FROM
SS=K UNNECESSARY DRUGS
F 329
Each resident's drug regimen must be free from
unnecessary drugs. An unnecessary drug is any
drug when used in excessive dose (including
duplicate therapy); or for excessive duration; or
without adequate monitoring; or without adequate
indications for its use; or in the presence of
adverse consequences which indicate the dose
should be reduced or discontinued; or any
combinations of the reasons above.
Based on a comprehensive assessment of a
resident, the facility must ensure that residents
who have not used antipsychotic drugs are not
given these drugs unless antipsychotic drug
therapy is necessary to treat a specific condition
as diagnosed and documented in the clinical
record; and residents who use antipsychotic
drugs receive gradual dose reductions, and
behavioral interventions, unless clinically
contraindicated, in an effort to discontinue these
drugs.
by:
Event ID: 18OL11
Facility ID: 923014
PRINTED: 08/11/2010
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F 329
reviews, the facility failed to keep residents free
from unnecessary drugs when 14 of 29 residents
(#1, #2, #3, #4, #5, #6, #7, #8, #9, #13, #14, #15,
#16, #73) received a narcotic without an
adequate indication for use. Toxicology reports
indicated 14 residents tested positive for
toxicity.
Findings:
Event ID: 18OL11
Facility ID: 923014
PRINTED: 08/11/2010
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edema and hypoxia.
1. Resident #1 died from aspiration pneumonia
included coronary artery disease, hypertension,
dementia, pernicious anemia, hyperlipidemia,
Event ID: 18OL11
Facility ID: 923014
PRINTED: 08/11/2010
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F 329
osteoarthritis and osteoporosis. Based on
information contained in the Minimum Data Set
(MDS) on 1/25/10, the resident had problems with
Resident #1's medications on 2/1/10 were:
Enteric coated Aspirin 81 mg (milligrams) daily,
Calcium 500 mg + Vitamin D (a calcium and
vitamin D supplement) daily, Toprol (a blood
pressure medication) XL (extended release) 25
mg daily, Fosamax (a medication for
osteoporosis) 70 mg weekly, Lotensin (a blood
pressure medication) 20 mg twice a day,
Risperdal (an antipsychotic medication) 0.25 mg
twice a day, Acetaminophen (a pain reliever)
1000 mg 3 times a day, Docusate Sodium (a
stool softener) 200 mg daily, Prazosin (a blood
pressure medication) 1 mg at bedtime, Milk of
Magnesia (a laxative) 30 ml (milliliters) every 12
hours as needed, Risperdal 0.25 mg twice a day
as needed for agitation and Desyrel (an
antidepressant medication used for insomnia) 50
mg at bedtime as needed for insomnia. Resident
#1 did not have an order for morphine sulfate or
any other opiate medication.
Review of the resident's nurse's notes showed:
"2/14/10 0700 (7 AM) O2 sat (saturation) 86% on
room air T (temperature) 98.6 pulse 98 - 20
(respirations) -117/64 (blood pressure). Mucus in
throat suction out mouth and throat; obtain yellow
thick mucus. No change in color. Reported to
oncoming nurse/charge nurse.
2/14/10 0800 (8 AM) 126/56 (blood pressure) 90 (pulse) - 20 (respirations) - 98.8 (temperature).
Resident noted to have uneven shallow
respiration this morning. This is a significant
Event ID: 18OL11
Facility ID: 923014
PRINTED: 08/11/2010
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change from her normal status. She is very
somnolent/lethargic this morning. She is not
following commands. (Physician ' s name) notified
& ordered that Pt (patient) be sent to (hospital
emergency room) via ambulance. Upper resp
(respiratory) wheeze noted with open mouth
breathing. HOB (head of bed) up 90%. Albuterol
(a bronchodilator medication) neb (nebulizer
treatment) given. O2 (oxygen) sat (saturation)
70% in RA (room air) & increased to 84% c (with)
2L (liters) NC (nasal cannula) & Albuterol neb tx
(treatment). Ambulance in route to center. Writer
telephoned (daughter's name) and informed her
of impending transfer to (hospital name)."
"2/14/10 1454 (2:54 PM) Lab: Urine Tox Screen
(urine drug screen) Opiate =/> (equal to or
greater than) 300 ng (nanogram)/ml (milliliter)."
"2/14/10 3 PM Writer rec'd (received) fax from
(daughter's name) stating Res.(resident) admitted
c (with) large R (right) sided pneumonia and
family @ (at) BS (bedside). Place in MD
(physician) book."
A review of the Emergency Department (ED)
notes, dated 2/14/10 at 9:12 a.m., indicated the
history of the resident's present illness as
"gurgling respirations, decreased mental status"
since 3 to 4 AM. Per the ED note, Resident #1
was reportedly "ambulatory at baseline,
conversive/oriented x 2 - 3 but with moderate
dementia." The ED note indicated it started that
day and it was still present at the time of the
evaluation. The severity was described as
"moderate." "Large" amounts of sputum were
suctioned from the resident's lungs. The resident
was admitted to the hospital for further evaluation
and treatment.
Event ID: 18OL11
Facility ID: 923014
PRINTED: 08/11/2010
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A review of a hospital Full Discharge Summary,
dated 2/17/10 at 12:03 p.m., indicated the
resident's admitting and discharge diagnosis was
altered mental status (AMS). Resident #1 had a
secondary diagnosis of pneumonia. The
"Hospital Course: Patient (pt) was admitted from
(nursing home name) with alerted mental status
and hypoxia - found to have large RLL (right lower
lobe of lung) infiltrate and was started on broad
spectrum antibiotics after blood and sputum
cultures taken in the ED (emergency
department). She remained stable on 100% NRB
(non rebreathing mask) overnight and the
following day her oxygenation improved and she
was able to be weaned down to nasal cannula.
Her mental status also improved from responsive
only to sternal rub to awake and talking (though
nonsensically). However, the following morning
(~36h (hours) into hospitalization) pt became
more hypoxic, placed back on NRB. Family's
original requests included trial of bipap (Bi-level
Positive Airway Pressure) which was called for
stat (immediately), however, pt's O2 sats dropped
and she became more bradycardic with eventual
PEA (pulseless electrical activity) prior to bipap
arriving.
Of note, the patient's Urine tox screen on
presentation was positive for opiates which were
not on the medication list from her SNF (skilled
nursing facility) and she did not receive any
opiates in the ED. This was sent for confirmation
and is still pending at the time of this summary.
Notified family (son and daughter) of presence of
this substance in the urine and the (sic) requested
no autopsy unless necessary for legal reasons.
Spoke with state medical examiner's office who
state unless overdose was thought to be cause of
Event ID: 18OL11
Facility ID: 923014
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death that no autopsy was necessary. Given that
hypoxia from aspiration pneumonia was etiology
of death, no autopsy was requested." The
discharge summary further indicated the resident
died on 2/16/10 at 7:36 a.m.
In an interview on 2/18/10 at 8:14 AM, Facility
Consultant #1 stated Resident #1 was sent to the
hospital on 2/14/10 and had altered mental status
with pneumonia. The resident had a drug screen
and tested positive for opiates. The resident was
on Levaquin (an antibiotic) in the hospital and was
treated for pneumonia. The resident died at the
hospital with the cause of death being
pneumonia.
On 2/18/10 a confirmation urine test done
completed by Laboratory (Lab) #2 showed a
morphine level of > (greater than) 50,000 ng/ml
(cutoff:100). The urine toxicology screens
completed on the residents were not all analyzed
at the same laboratory. The resident's urine
toxicology screens were completed by either the
hospital laboratory (Lab #3) or the facility's
Lab #2.
A review of the Medical Examiner's Certificate of
Death, dated 3/19/10, indicated Resident # 1's
immediate cause of death as aspiration
pneumonia due to (or as a consequence of)
morphine toxicity.
On 4/29/10 the Report of Investigation by Medical
Examiner showed the probable cause of death
as: 1. Aspiration pneumonia 2. Morphine toxicity.
Event ID: 18OL11
Facility ID: 923014
PRINTED: 08/11/2010
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Nurse #12 stated she was off work on 2/12/10,
but came in to work on 2/13/10 and worked the
her shift. Nurse #12 stated when she arrived, the
residents were sleeping. Nurse #12 stated a NA
informed her Resident #1 " had some stuff
coming out of her mouth." When she checked on
Resident #1, she had a yellow discolored mucus
coming out of her mouth and was having difficulty
breathing. She got the suction machine to try to
clear the resident's airway. The day shift nurse
had come in and tried to help her with the
resident. Nurse #12 stated the residents were still
in bed sleeping, "asleep as I thought." She
indicated it was "hard to assess for lethargic when
they are in bed sleeping." "I just did not even
suspect that was going on." While she was
working with Resident #1, she stated another NA
came in to see what the commotion was going
on. The NA stated another resident was doing the
same thing.
some respiratory problems. Resident #1's
breathing was labored and shallow and the
resident's level of consciousness was not like it
was the day before. The nurses notified the
physician. After the night shift nurse left, he
worked with the residents a little more. He stated,
"It was too extensive." He called the physician
and the physician wanted to send Resident #1 out
to the hospital.
Event ID: 18OL11
Facility ID: 923014
PRINTED: 08/11/2010
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2.a. The residents in examples 2.a. through 2.f.
tested positive for morphine and required
hospitalization.
12/1/09 with diagnoses including dementia, atrial
fibrillation and osteoporosis. The resident was
readmitted to the facility on 2/24/10 with
diagnoses of delirium, medication intoxication,
altered mental status, aspiration pneumonia,
anemia and urinary retention. A Medicare 14 day
assessment, dated 3/9/10, indicated the
resident's cognitive skills for daily decision
making were moderately impaired with long and
short term memory problems. The resident had
mood/behaviors of being easily distracted,
disorganized speech, periods or restlessness,
repetitive verbalizations, unpleasant mood in the
morning, sad/pained expressions and repetitive
physical movements. She was physically abusive,
resistant to care and wandered. Resident #5
daily living and limited assistance with eating. She
did not have any devices or restraints. Resident
receiving Lanoxin (heart medication), Norvasc
(blood pressure medication), Aspirin (blood
thinner) Trazodone (antidepressant), Vitamin D
(supplement), Caltrate (calcium supplement),
Zyprexa (antipsychotic) and Tylenol daily. She
also received Robitussin (cold and cough
medication), Naprosyn (anti-inflammatory),
Trazodone and Tylenol as needed (prn). A review
of the Medication Administration Record indicated
the resident had not received any of the prn
Event ID: 18OL11
Facility ID: 923014
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medications in February 2010. The resident did
not have physician's orders for morphine.
A review of the nurse's notes, dated 2/11/10 with
no time, indicated the resident was responsive to
verbal stimuli. Her skin was warm and dry. There
was no documentation that the resident was
lethargic.
A nurse's note written by Nurse #11, dated
2/14/10 at 2:30 p.m., indicated the resident had
been in bed throughout the day. The resident did
not want to get up. The head of the bed was
elevated and there was no distress noted. The
nurse indicated the resident tolerated intake by
mouth fairly well. The nurse spoke with the family
concerning the resident and indicated she would
continue to monitor the resident.
indicated Nurse #1 informed the physician of the
resident's change in condition. The resident was
lethargic, but responsive by opening her eyes and
turning her head to the right. Her vital signs were:
blood pressure 156/76, pulse 90, respirations 16
and temperature 100.9 degrees Fahrenheit. The
nurse administered Tylenol in pudding without
difficulty. New orders were received for a chest
X-ray, complete blood count, basic metabolic
panel and a urinalysis and culture. At 6:15 p.m.,
the nurse informed the family of the resident's
new orders.
A review of a Transfer/Discharge Summary,
dated 2/14/10, and completed by Nurse #1,
indicated the resident was transferred to the
hospital on 2/14/10. The physician was notified at
8:10 p.m. and the family was notified at 8:15 p.m.
The transfer summary indicated the resident had
Event ID: 18OL11
Facility ID: 923014
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been lethargic since that morning and had been
unable to stand, eat or drink anything. Her eyes
were closed and her speech was slurred.
A review of a full hospital discharge summary,
dated 2/24/10, indicated the resident was
discharged from the hospital with diagnoses of
delirium secondary to drug intoxication. The
discharge summary indicated that the resident's
family member had visited the resident on 2/14/10
around 2 p.m. at the nursing home and found her
to be nonresponsive. The family indicated this
was unlike her as normally she was oriented to
name, able to walk and knew her name 90% of
the time. The family further reported that the
resident's nursing assistant informed him the
resident had been in the bed all day and did not
eat or drink and had a "glazed look" over her
eyes. The summary indicated the resident had
received 2 liters of normal saline (intravenous (IV)
fluids) and 0.4 milligrams (mg) of Narcan (an
opiate antagonist) IV. The hospital physician
indicated the resident received an IV dose of
Narcan and had immediate improvement in
mental status. A urine toxicology screen tested
positive for opiates. The resident urinalysis and
urine culture were negative. Radiology test of the
abdomen, head and chest were negative. The
physician indicated "Thus, suspect cause of
delirium was acute medication intoxication." The
summary further indicated the patient did likely
aspirate as a result of her drug intoxication. She
had intermittent fevers from February 15 through
February 17. A repeat chest X-ray on 2/17/10 and
2/19/10 were concerning for a right upper lobe
infiltrate. She was started on nebulizer treatments
and antibiotics on 2/16/10. The resident was
discharged from the hospital and returned to the
facility.
Event ID: 18OL11
Facility ID: 923014
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A review of the completed urine toxicology (tox)
screen, dated 2/15/10, indicated Resident #5
tested positive for opiates with a result of =/>
(equal to or greater than) 300 ng/mL
(nanograms/milliliter). The urine toxicology
screens completed on the residents were not all
analyzed at the same laboratory. The resident's
urine toxicology screens were completed by either
the hospital laboratory (Lab #3) or the facility's
Lab #2. Resident #5's urine tox screen was
completed by Laboratory #3.
A review of a urine toxicology report (confirmation
test), dated 2/18/10, indicated the resident tested
positive for morphine and hydromorphone. The
morphine level was 23,220 nanograms/milliliter
(ng/mL). The hydromorphone level was 169
ng/mL. (The cutoff range was 100). The urine
confirmation test had been completed by Lab #2.
During an interview on 7/30/10 at 10:16 a.m., the
hospital laboratory assistant administrative
director indicated the cutoff range for morphine
had been developed and verified by clinical
testing by the hospital. She stated if the morphine
test result was greater than 100, then it was
clinically termed positive. She stated if the result
was less than 100 ng/mL, then it would be
considered negative or absent depending on the
result.
on the 1st shift on 2/13/10, the residents were
fine. She indicated nothing was unusual. On
2/14/10, NA #3 stated Resident #5 stayed in bed
Event ID: 18OL11
Facility ID: 923014
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all day and didn't eat. NA #3 indicated they sent
Resident #5 to the hospital on the second shift.
Director of Nursing (DON) #1 stated Resident #5
went out of the facility on 2/14/10 because she
was lethargic. She indicated Nurse #1 sent the
resident out that evening.
2.b. Resident #4 was admitted to the facility on
8/13/08, with diagnoses of senile dementia and
hypertension. The Minimum Data Set (MDS),
dated 12/7/09, indicated the resident had
moderately impaired cognitive skills for daily
decision making with long and short term memory
problems. She had persistent anger, sad or
pained expression, repetitive physical
movements, wandered and resisted care. She
daily living and required supervision with eating.
She did not have any devices or restraints.
Resident #4 resided on the locked Alzheimer's
unit.
receiving Boniva (osteoporosis medication),
Aspirin (blood thinner), multi-vitamin
(supplement), Fish Oil (supplement), Aricept
(dementia medication), Os-cal (calcium
supplement), Norvasc (blood pressure
medication), Celexa (antidepressant), Seroquel
(antipsychotic), Colace (stool softener), Feratab
(iron supplement) and Lipitor (cholesterol
medication). She received Proventil
(bronchodilator) nebulizer treatments and Tylenol
as needed (prn). The resident had been receiving
a 7-day course of Amoxicillin (antibiotic),
beginning on 2/9/10, for a urinary tract infection. A
Event ID: 18OL11
Facility ID: 923014
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review of the Medication Administration Record
for February 2010 indicated the resident had not
received any prn medications for pain. The
resident did not have physician's orders for
morphine.
A review of a nurse's notes, dated 2/13/10 at 4
a.m., indicated the resident continued on the
antibiotic and she had a quiet night. At 10 p.m.,
the nurse indicated the resident was voiding
without difficulty.
A nurse's notes, dated 2/14/10 at 5 a.m.,
indicated the resident rested well during the night.
She denied any pain.
A nurse's note, dated 2/15/10 at 3 a.m., indicated
the resident was resting well with no signs or
symptoms of distress. She did not have any
behavior problems.
A review of a physician's order, dated 2/15/10,
indicated an order to obtain a urine toxicology
screen.
A nurse's note on 2/16/10 at 5:05 p.m. indicated
the family was notified of the positive urine
toxicology screening. The resident did not have
any mental status changes.
A review of the urine toxicology screen,
completed 2/17/10, indicated the resident tested
positive for opiates with a result of =/> (equal to or
greater than) 300 ng/mL (nanograms/milliliter).
A review of a progress note by Nurse Practitioner
(NP) #1, dated 2/17/10, indicated the nurse
requested the resident be evaluated for abnormal
laboratory values. The resident was "very drowsy
Event ID: 18OL11
Facility ID: 923014
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but arousable" "respond to name and even talked
on the phone talking with family." NP #1 indicated
to monitor the resident's vital signs (VS) every 4
hours for 48 hours and monitor for any changes
in the resident's VS or level of consciousness.
A nurse's note, dated 2/17/10 at 4:15 p.m.,
indicated the resident had been in her room most
of the shift. The family came to visit the resident
and requested she be sent to the hospital.
A review of the hospital emergency department
(ED) Final Report, dated 2/17/10, indicated a
family member visited the resident that morning
and found her to be somnolent (sleepy, drowsy).
The emergency medical services were called and
the resident was given 2 milligrams (mg) of
Narcan (an opiate antagonist). The resident
became more awake and alert. In the ED, the
resident was more awake and close to baseline.
The resident was usually talkative, pleasant and
interactive. The resident was alert and oriented,
followed commands, and cooperative in the ED.
The resident had a positive urinalysis for a urinary
tract infection (UTI). She was started on
antibiotics. A review of the hospital History and
Physical, dated 2/17/10, indicated the resident
had altered mental status and lethargy. The
hospital physician indicated that given the positive
opiate screen and response to Narcan, it was
most likely due to the inappropriate opiate
administration, less likely from the urinary tract
infection. The Discharge Summary, dated
2/25/10, indicated the resident had "Delirium secondary to opiates." The resident was
discharged from the hospital to a different nursing
facility.
A review of a urine confirmation toxicology
Event ID: 18OL11
Facility ID: 923014
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laboratory report, completed 2/22/10, indicated
the resident tested positive for morphine with a
result of 1,376 ng/mL (cutoff: 100). This test was
performed by Lab #2.
on the 1st shift on 2/13/10, the residents were fine
and nothing was unusual. On 2/14/10, NA #3
stated Resident #4 would not eat and slept in her
wheelchair all the time.
included hypertension, heart murmur, Alzheimer's
dementia with psychotic features and depression.
Based on information contained in the MDS
(Minimum Date Set) on 11/24/09 the resident had
problems with short term memory, long term
memory and had moderately impaired cognition.
Resident #8 was living in the facility's Alzheimer's
Unit.
Resident #8's medications on 2/1/10 were
Trazodone (an antidepressant medication) 50 mg
(milligrams) at bedtime as needed, Zyprexa (an
antipsychotic medication) 2.5 mg at bedtime and
Acetaminophen (a medication for pain or fever)
650 mg every 6 hours as needed. Review of the
resident's MAR (Medication Administration
Record) showed that the resident had not taken
any Acetaminophen since 2/8/10 or Trazodone
since 2/10/10. The resident refused medications
on 2/6/10 at 8:00 AM and 2/11/10. The resident
did not have an order for morphine sulfate or any
opiate medication.
Review of Resident #8's nursing notes showed:
Event ID: 18OL11
Facility ID: 923014
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"2/12/10 2230 (10:30 PM) in bed all shift. still
holding hands up near face. no signs of distress
noted. seems confused but calm
2/13/10 340 (3:40 AM) quiet night no distress
2/14/10 500 (5 AM) no change in mental status,
still, very confused. no yelling screaming or trying
to get out of bed. rested well
2/15/10 800 (8 AM) no s/s (signs and symptoms
of ) illness. remains very confused to others and
her surroundings.
2/15/10 2300 (11 PM) remains in bed this shift.
still confused. no indications of pain."
"On 2/15/10 the resident's physician ordered a
"U/A (urinalysis) toxicology may do I+O (in and
out) Cath (catheterization)."
Further review of Resident #8's nurse's notes
showed:
"2/16/10 450 (4:50 AM) resident resting in bed u/a
cath in/out per order-tolerated well
2/16/10 1610 (4:10 PM) lying in bed, awake, son
visiting, Awake, muttering, speech incoherent,
does not follow commands. resistive to having
extremities manipulated. resistive to having pupils
checked. Unable to open eyes enough to check
with penlight. hand and arm strength strong. VS
(vital signs) WNL (within normal limits). earlier
today up in w/c (wheelchair) to dining room for
lunch.
2/16/10 4:27 PM RP (responsible party) notified
of positive U/A, MD (medical doctor) aware, RP
also aware of U/A test. inform to please call if he
had any questions. 440 P (4:40 PM) PA
(physician assistant) has see (sic) resident and
has decided to send to ER. RP aware."
A physician's note on 2/16/10 about the resident
showed:
Event ID: 18OL11
Facility ID: 923014
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"2/16/10-change in mental status
Alz (Alzheimer's) dementia, HTN (hypertension),
depression and falls, nurse request pt be
evaluated for being lethargic change in mental
status. Upon evaluation pt lying in bed with eyes
closed, refused to open eyes, when eyes opened
manually eyes pinpoint. Pt (patient) tested + for
opiates in urine drug screen test of unknown
etiology. Son at bedside and he attempted to
arouse pt with cold water on face with wash cloth.
Pt would not wake up just mumbled
incomprehensive words. Son request pt be sent
out for eval (evaluation) via EMS (emergency
medical services)."
A urine toxicology screen completed by
Laboratory (Lab) #3 on 2/16/10 showed "Opiate
Result =/>300 ng (nanograms)/ml, AB (abnormal
range)." A urine confirmation screening
completed by Lab #2 on 2/22/10 showed a
morphine level of 2,118 ng/ml and a
Notes from the hospital emergency room on
2/16/10 showed:
"2/16/10 6:58 PM Physical assessment-Alert.
Appears in no acute distress. The patient is
disoriented to place and to time. No facial
asymmetry noted. Pupillary exam: Right pupil
constricted. Left pupil constricted. Respirations
not labored. Skin intact. Skin is warm and dry
2/16/10 7:10 PM Pt sent to ED (emergency
department at the hospital) by EMS from (name
of nursing home) with report of lethargy and
pinpoint pupils. Per NP (nurse practitioner) at
(name of nursing home) pt was hard to arouse
and had a positive opiate test today (collected
yesterday). Per nurse, pt was given Narcan (a
narcotic antagonist medication) by EMS. No EMS
Event ID: 18OL11
Facility ID: 923014
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paperwork with patient.
Physical exam: no acute distress
Vital signs: have been reviewed
Eyes: pinpoint pupils
CVS (cardiovascular system): normal heart rate
and rhythm. Heart sounds normal. Pulses normal
Respiratory: No respiratory distress. Breath
sounds normal. Chest nontender.
Neuro: Oriented x 3
Clinical impression:
AMS (altered mental status) resolved
Abnormal tox screen."
The discharge summary from the hospital on
2/25/10 revealed the resident's admitting
diagnosis was lethargy and discharge diagnosis
was sedation secondary to medication
intoxication. A MRI (magnetic resonance imaging)
of the brain indicated there were no acute
findings. Further review of the discharge
summary indicated:
"Hospital course: General Notes- (resident's
name) was brought in due to increasing lethargy
and a positive urine opiate toxicology screen; she
is not routinely prescribed narcotics.
1. Delirium-given the positive urine tox delirium
was felt due to medication intoxication.
Nevertheless, urinalysis revealed + bacteria and
we sent off a culture. Her electrolytes, cardiac
enzymes were all WNL though she did have a
mild leukocytosis (13.2) without fever upon
admission. A chest film failed to reveal any acute
airspace distress. MRI of brain showed no acute
changes to infarct. EEG (electroencephalogram)
done and was normal.
2. Dementia-baseline fairly advanced per family
only intermittently oriented to person. Apparently
she does ambulate and will wander thus she is
usually a resident of a locked unit. During her
Event ID: 18OL11
Facility ID: 923014
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hospitalization she would go in and out of
alertness. She was entirely nonambulatory with
her upper extremities contracted.
3. HO (history of) htn (hypertension)- no
medication upon admission. During her short
hospital course her blood pressure ranged from
mid 120s to 150s systolic.
4. UTI (urinary tract infection) with proteus urine
culture started on amoxicillin PO (by mouth) for 5
days. She would occasionally refuse her PO dose
so she was started on Ampicillin for 24 hours
prior to discharge. She remained afebrile and had
a normal white count.
In an interview on 6/15/10 at 1:55 PM the
physician from the hospital stated: "during that
period of time we had a couple of people
(residents from the nursing home) coming in with
sudden onset of cognitive disorder. We did
screens and they had opiate levels but were not
on opiates on their MAR (medication
administration record). We had several more and
alerted (nursing home name) and the hospital
administrator as well. There was concern that she
may have received an opiate overdose. We
tested for opiates and she was + (positive) for the
screen. She had an elevated white count of 13.2,
but no fever. We could not find any reason for her
decline. We could not say after having her here
what was wrong with her. I never knew her at
baseline so I couldn't tell what was wrong. Even
before she was only intermittently oriented. I'm
not sure what was wrong. Nothing proved out. We
did an MRI of her brain and checked for
infection." The physician stated the resident's
worsening mental status was undetermined, and
it wasn't related to the morphine. He further
stated morphine was short acting and the
morphine levels were low. The resident's change
Event ID: 18OL11
Facility ID: 923014
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in mental status was a "red herring."
2.d. Resident #9 was admitted to the nursing
home on 11/15/06 with cumulative diagnoses that
included included Alzheimer's dementia with
behavior disturbance, depression, hypertension,
hyperlipidemia and hypothyroidism. Based on
information contained in the MDS (Minimum Data
Set) on 12/29/09 the resident had problems with
The physician's order sheet for February 2010
showed Resident #9 was on the following
medications:
Synthroid (a medication for hypothyroidism) 75
mcg (micrograms) daily
Vasotec (a medication for high blood pressure)
10 mg (milligrams) daily
Norvasc (a medication for high blood pressure)
2.5 mg daily
Docusate Sodium (a stool softener) 200 mg every
morning
Effexor (a medication for depression and anxiety)
XR (extended-release) 150 mg daily
Acetaminophen (a pain medication) 500 mg 3
times a day.
Seroquel (an antipsychotic medication) 25 mg 3
times a day
Aricept (a dementia medication) 10 mg daily
Senokot S (a laxative/stool softener medication) 2
tablets at bedtime
Zocor (a hyperlipidemia medication) 20 mg daily
Event ID: 18OL11
Facility ID: 923014
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Resident #9 was last seen by psychiatry on 2/4/10
and the notes from that visit showed the resident
was "resistant to care, ADLs (activities of daily
living), decreased activity and attention consistent
with dementia progression."
Review of the nurses notes in Resident #9's
record showed:
"2/10/10 4:30 AM up all night going in and out of
resident room. Confused and agitated.
2/10/10 3:35 PM refused to let staff assist her to
room to be changed.
2/14/10 6:30 AM moderate amount of thick yellow
mucus coming from month. O2 (oxygen) Sat
(saturation) 78%
2/14/10 7:30 AM O2 at 2 L (liters) n/c (nasal
cannula) O2 90%.
2/14/10 12 noon resident found to be very
somnolent at time during rounds. O2 2L n/c
started. increased O2 sat from 79% to 95%. Pt
(patient) responds to touch and hearing. Denies
any pain. upper respiratory gurgling. no apparent
distress noted. will continue to monitor.
2/14/10 (no time) new orders rec'd (received)
BMP (basic metabolic panel) and CBC (complete
blood count) in AM (morning), clear liquid diet x
24 hours. give additional fluids 300 cc (cubic
centimeters) q (every) shift x 48 hours, In and out
cath (catheter) UA (urinalysis) C&S (culture and
sensitivity), Seroquel 25 mg. po (by mouth) now
refusing to have diaper and clothes changes. Call
placed to RP (responsible party). VSs (vital signs)
WNL (within normal limits). Res (resident)
received routine Tylenol. CXR (chest x-ray) for
cough and congestion.
2/15/10 3:00 AM OOB (out of bed) in chair no
respiratory distress. O2 95% on room air. States,
"I feel better."
2/15/10 9:00 PM in bed all shift refused changing
Event ID: 18OL11
Facility ID: 923014
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clothes x 3 . Refused meds."
Review of physician's notes in Resident #9's
record showed:
"2/15/10 AMS (Altered Mental State) over
weekend, (physician practice) notified and labs,
U/A (urinalysis), CXR (chest x-ray) checked, also
reported to have episode of dec (decreased) O2
(oxygen) sat (saturation) which responded to
oxygen. also reported to have yellowish mucus.
today pt reports episode of nausea but no
vomiting. AMS (altered mental status) now at
baseline. BMP (basic metabolic panel), CBC
(complete blood count) ordered, awaiting U/A will
also order tox (toxicology) screening."
Further review of the nurses notes indicated:
"2/16/10 6:30 AM resident refused AM (morning)
care.
2/16/10 4:15 PM Alert and oriented to person.
stated 'I just feel sleepy.' Aroused to verbal
stimuli.
2/16/10 4:35 PM called to notify of pos (positive)
U/A - MD (physician) aware. MD to see resident
this afternoon."
A physician's note, dated 2/16/10, indicated:
"Pt (patient) seen of 15th (of February) for AMS
over the weekend-seen on Monday, pt back at
baseline. BMP, CBC, CXR and urine for tox
(toxicology screen). Chest X-ray neg (negative).
Nurse request pt be evaluated for increased
lethargy and confusion. Pt has positive screen for
opiates. Due to increased lethargy and +
(positive) opiate screen pt will be sent to hospital
for eval.
A nurses noted, dated 2/16/10 at 5:15 PM
indicated:
Event ID: 18OL11
Facility ID: 923014
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"(nurse practitioner name) saw resident and
decided to send resident to ER (emergency
room) for eval (evaluation). (name of responsible
party) called daughter asked to be called when
911 arrived."
Resident #9 was admitted to the hospital on
2/16/10 at 6:10 PM with admission diagnosis of
AMS (altered mental status). The initial physical
assessment at 6:36 PM showed: "Alert. Appears
in no acute distress. All VSs (vital signs) WNLs
(within normal limits). Resident was found eating
dinner at facility when EMS (emergency medical
service) arrived to transport. didn't receive any
Narcan (a narcotic antagonist medication). has dx
(diagnosis) Alz dementia. resident denies
requesting narcotics for pain. Has AMS. found
had UTI (urinary tract infection)-mild infection
asymptomatic bacteruria vs UTI though will treat
as latter-culture pending started on Cipro (an
antibiotic)."
A urine toxicology screen on 2/16/10 showed the
resident had an abnormal opiate level of =/> 300
ng (nanogram)/ml (milliliter).
A review of the Hospital Discharge Summary,
dated 2/17/10, indicated the resident's admitting
diagnosis was altered mental status (AMS). The
discharge diagnosis was altered mental status
due to narcotic side effect (intentional vs
unintentional). The resident had secondary
diagnosis of Alz (Alzheimer's) dementia, HTN
(hypertension), HLD (hyperlipidemia),
hypothyroid. Further review of the hospital
"History of present illness: 82F (82 year old
female) with h/o (history of) Alzheimer's
dementia, htn, hld, hypothyroid was in usual state
Event ID: 18OL11
Facility ID: 923014
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of health at (nursing home name) when pt was
found to be less arousable than normal today. By
report from ED (emergency department) to me, a
number of people (residents from the nursing
home) had similar status today and were found to
have opiates in their urine when tested. An
investigation is apparently underway as pt doesn't
have narcotics listed in her medications as a
standing order or prn (as needed). Pt apparently
had no complaints, didn't receive any Narcan (a
narcotic antagonist medication), but was sent for
close observation to ED.
Assessment and Recommendation:
1. AMS Unclear if due to UTI or opiate
consumption. Details are under investigation. She
does have a positive opiate screen and will be
monitored overnight. Her urine has a mild
infection, asymptomatic bacteruria vs UTI,
though will treat as latter due to unclear
contribution of opiates. Also due to unknown
nature of opiates, could be long acting and will
admit for observation. Pt is alert now, but will
place on tele (telemetry) overnight with 02
(oxygen). Will seek outside records in AM
(morning)
2. Opiate consumption, inadvertent. As above,
investigation is ongoing. Pt. denies requesting
narcotics for pain.
3. Full code
4. HTN, continue outpt (outpatient) meds
5. UTI, continue abx (antibiotics) x 3 days,
Ciprofloxacin (Cipro) 250 mg BID (twice a day)
culture pending.
dispo. (disposition) will observe overnight. Will
have clinical care management team assess in
AM, consider if placement satisfactory to family or
seek new place for her due to unusual
circumstances and current investigation regarding
possible medication error."
Event ID: 18OL11
Facility ID: 923014
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Resident #9 was discharged back to the nursing
home on 2/17/10 at 12:05 PM.
Review of the nursing home physician's notes in
Resident #9's record showed a note, dated
2/18/10, that indicated the resident had been
"admitted to (hospital name) secondary to AMS,
tested + opiates at time, admitted for further
observation; did not receive any narcs (narcotics).
Also has UTI, AMS also possibly secondary UTI,
given antibiotic; has been alert and back to
baseline; this AM she is up and about, eating
breakfast, is at her baseline mental status. AMS
possibly secondary UTI-on Cipro (an antibiotic),
continue and finish course of antibiotic;
encourage fluids. + drug screen-for confirmation
test; back to her baseline, supportive care, safety
measures."
On 2/19/10 a confirmation urine drug test done by
Laboratory #2 on Resident #9 showed an opiate
level of 13,140 ng/ml (cutoff: 100).
some respiratory problems. He stated they went
to see the residents. Resident #9 was sedated.
He indicated Resident #9's oxygen saturations
were low, at 80 - 90%.
She came in to work on 2/13/10. She worked the
Event ID: 18OL11
Facility ID: 923014
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her shift. When Nurse #12 arrived, she stated the
residents were still in bed sleeping, "asleep as I
thought." She indicated it was "hard to assess for
lethargic when they are in bed sleeping." "I just
did not even suspect that was going on." During
her shift, a nursing assistant reported to the nurse
that Resident #9 had a change of condition.
Nurse #12 went to check on Resident #9. She
had drainage coming from her mouth and was
having some difficulty breathing. They got
Resident #9 up and she was a little more alert.
"She was coughing and getting the stuff out of her
mouth." The nurses put oxygen on her and she
got better. Nurse #12 notified the physician. The
physician did not want to send Resident #9 out to
the hospital at that time because after they put
oxygen on her, her oxygen saturation improved.
2.e. Resident #7 was admitted to the facility on
included Alzheimer's dementia, atrial fibrillation,
hypertension, coronary artery disease and high
cholesterol. Information contained in the
resident's MDS (Minimum Data Set) on 2/8/10
showed the resident had problems with short
term memory, long term memory and had
Resident #7's medications as of 2/1/10 were:
Aspirin 81 mg (milligrams) daily, Lasix (a diuretic
medication) 20 mg daily, K-Dur (a potassium
supplement) 20 mEq (milliequivalents), Altace (a
blood pressure medication) 5 mg daily, Vitamin C
500 mg daily, Seroquel (an antipsychotic
medication) 25 mg at 8 AM, 50 mg. at 2 PM and 8
PM, Lopressor (a blood pressure medication) 50
mg twice a day, Welchol (a cholesterol lowering
Event ID: 18OL11
Facility ID: 923014
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medication) 625 mg 3 times a day, Namenda (an
Alzheimer's medication) 10 mg at bedtime,
Coumadin (a blood thinning medication) 7 mg
daily and Seroquel 25 mg 3 times a day as
needed for agitation. The resident did not have an
order for morphine sulfate or any opiate
medication.
Review of nurse's notes for Resident #7 showed:
"2/10/10 3 PM wandering in unit no aggressive
behavior noted.
2/15/10 11:10 AM sitting on floor in 800 hall
eating an apple. assisted to stand.
2/16/10 3:55 PM resident noted with altered
mental status, U/A tox (urine toxicology screen)
noted to be pos (positive). MD (medical doctor)
aware. RP (responsible party) noted that resident
will be going to ER (emergency room)."
A urine specimen was collected on 2/15/10. A
urine toxicology screen completed by Lab #3 on
2/16/10 indicated Resident #7 was positive for
opiates with a result of opiate =/> 300 ng/ml
(nanograms/milliliter).
Review of a physician note for Resident #7
showed:
"2/16/10- nurse request pt (resident) be evaluated
for change in mental status. Upon evaluation pt
very confused increased from baseline, unable to
ambulate and pupils dilated, glassy eyed. Resp
(respiration) even, nonlabored. VS (vital signs)
stable. Pt also tested + (positive) for opiates
unknown source. Talked with daughters and they
agree with sending pt to ER (emergency room)."
Notes from the hospital emergency room
concerning Resident #7 showed:
"Arrived 2/16/10 4:40 PM
Event ID: 18OL11
Facility ID: 923014
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4:45 PM-History: This started today. (coming from
[nursing home name]. ams (altered mental
status) had a urine screen this am (morning) and
found to be pos (positive) for opiates, per
daughter states others (sic) pts on unit was (sic)
found to have pos opiate daughter states has
slept all day, didn't recognize her.
2/16/10 5:11 PM History of Present Illness: Chief
Complaint: Decreased Mental Status. This started
last night and is now gone. It was gradual in
onset. It is gone now. Lethargic. Nursing home
resident. History of chronic dementia. No
weakness or numbness. Usually has normal
mobility. AAO X 0 (Alert and Oriented times zero).
Patient has not had similar symptoms previously.
Not recently seen or assessed.
Neuro (Neurological): Alert. Altered mental status
(at baseline). Speech normal. Cranial nerves
normal (as tested). No motor deficit. Reflexes
normal. Unable to test fully given patient's
dementia.
2/16/10 5:11 PM Physical Assessment:
AMS since Sunday. Reports tested positive for
opiates at (name of the nursing home). Is not
prescribed opiates. Per family, pt has been
sleeping more than normal but at this time
appears to be at baseline. Alert, Appears in no
acute distress. No facial asymmetry noted.
Respirations not labored. Breath sounds within
normal limits
Progress and Procedures:
2/16/10 5:11 PM 63 yo (year old) M (male) w/
(with) severe dementia brought in by daughters
because they were concerned that the patient
seemed altered and had a positive urine test for
Event ID: 18OL11
Facility ID: 923014
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opiates earlier today. Pt (resident) is a patient at
(name of nursing home), where several patients
have been found with opiates in their urine, but
are not supposed to be on narcotics. This is the
case with (Resident #7). At his baseline, he can
recognize his daughters and give them a hug,
feeds himself and walks around frequently. He
was not doing any of those things earlier today.
However, he seems to have returned to his
baseline mental status. Will proceed with head
CT (computed tomography), CXR (chest x-ray),
labs, UA (urinalysis) and Utox (urine drug screen)
to evaluate for possible causes of AMS. Will
touch (sic) base with Social Work to ensure that it
would be safe to go back to (name of the facility)
if workup is normal.
2/16/10 7 PM-only urine is back, which shows no
UTI (urinary tract infection), but opiate positive.
Serum labs CXR and Head CT still pending.
2/16/10 7:32 PM Waiting on results from CXR
and labwork. Head CT with no acute intracranial
events. Blood work + (positive) for opiates, not on
(facility name) MAR (Medication Administration
Record). Reported back to baseline since in ED
(emergency department).
2/16/10 8:51 PM Paged geriatric team for
admission. Per ED coordinator, all (facility name)
patient (sic) with AMS, + opiates should be
admitted for observation. Talked to patient and
family about plan and lab results. Patient has
elevated CK-MB (creatine kinase-MB fraction-a
cardiac marker), but fraction is low 2/2 increased
CK. This is likely due to immobility earlier today.
Altered mental status still appears to be related to
opioid use.
Clinical impression-change mental status with
lethargy (secondary to opioids)
Event ID: 18OL11
Facility ID: 923014
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2/16/10 11:19 PM condition at departure:
improved and stable."
On 2/22/10, a urine confirmation test done was
completed by Lab #2 and showed Resident #7's
morphine level was 5,320 ng/ml
(nanograms/milliliter) (cutoff: 100) and a
2.f. Resident #6 was admitted to the facility on
4/20/09 with the diagnoses of Alzheimer's
dementia, cerebrovascular disorder, depression,
diabetes mellitus and hypertension. The
Minimum Data Set (MDS, an assessment tool)
dated 5/20/10 indicated the resident had a
problem with long and short term memory and his
cognitive skills for daily decision making was
moderately impairment. He required extensive
assistance for mobility, transfers and personal
hygiene. Resident #6 resided in the facility on the
Alzheimer's Unit.
Review of the Physician's Orders for February
2010 revealed Resident #6 had an order for
Acetaminophen (Tylenol) 325 mg (milligram) 2
tablets by mouth every six hours as needed for
pain or fever. Resident #6 also had an order for
Hydrocodone/APAP 5/500 (Vicodin/Lortab-5) 1
tablet by mouth every 6 hours as needed for pain.
Further review of the Physician Orders for
February 2010 revealed Resident #6 did not have
an order for morphine.
Review of the Medication Administration Record
(MAR) for the month of February 2010 indicated
Resident #6 was not given any Tylenol for pain or
Vicodin/Lortab-5 for pain.
Event ID: 18OL11
Facility ID: 923014
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Record review of the nurse's notes indicated
Resident #6 was not having pain and had not
been given medication for any indications for
pain.
Record review of the nurse's notes written by
Nurse #1 indicated Resident #6 had a change in
condition on 2/14/10. The nurse's notes revealed
Resident #6 was lethargic and had not consumed
any meals or fluids that day. Resident #6 had an
elevated temperature of 101.0 degrees F
(Fahrenheit) and Tylenol 325 mg 2 tabs by mouth
were given without difficulty. The nurse's notes
stated the resident would not open his eyes or
follow commands. Nurse #1 revealed in the
nurse's notes that Resident #6 was transferred by
stretcher to the ED (Emergency Department) on
2/14/10 at 9:30 PM due to change in mental
status.
Record review of the full hospital discharge
summary revealed Resident #6 was admitted with
a diagnosis of delirium secondary to opioid
(Morphine) intoxication. A toxicology report for
Resident #6 collected on 2/15/10 at 12:22 AM,
and completed by Lab #3, revealed a positive
result for opiates (Morphine). A urine screen
confirmation, completed on 2/18/10 by Lab #2,
indicated the resident's level of Morphine was
28,740 ng/mL (nanograms/milliliter.) (The cutoff
was 100).
Record review of the Physician Orders for
February 2010 for Resident #6 revealed there
were no orders for Morphine.
Record review of the Physician's re-admission
History and Physical (H&P) to the facility dated
Event ID: 18OL11
Facility ID: 923014
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2/18/10 revealed Resident #6 had been admitted
to the hospital on 2/15/10 with diagnoses of
delirium secondary to opioid (Morphine)
intoxication.
Nurse #1 was not available for an interview
regarding the change of condition for Resident
#6.
3.a. The residents in examples 3.a. through 3.g.
tested positive for morphine, but did not require
hospitalization.
9/27/07 with diagnoses of mental disorder,
hypothyroidism, hypertension, senile dementia
and depressive disorder. The Minimum Data Set
(MDS), dated 3/22/10, indicated the resident's
cognitive skills for daily decision making were
moderately impaired with short and long term
memory loss. The resident was easily distracted,
had periods of altered perception, disorganized
speech, periods of restlessness, expressions of
what appears to be unrealistic, unpleasant mood
in the morning, sad/pained expressions, repetitive
physical movements and wandering behavior. He
required extensive assistance with bed mobility,
toilet use, personal hygiene and bathing. Resident
receiving Symbyax (antipsychotic/antidepressant
medication), Norvasc (blood pressure), Plavix
(platelet inhibitor), Senna S (laxative/stool
softener), Effexor XR (antidepressant), Risperdal
(antipsychotic), Zocor (cholesterol medication),
Synthroid (thyroid medication) and Tylenol as
needed. A review of the Medication
Event ID: 18OL11
Facility ID: 923014
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Administration Record for February 2010
indicated the resident had not received any
Tylenol for pain. The resident was not prescribed
morphine or any other opiates.
A review of a nurse's notes, dated 2/14/10 at 1:30
a.m., indicated the resident's blood pressure was
150/70, pulse 102, respirations 16 and oxygen
saturation was 91%. The nurse heard moaning
sounds from the resident's room. She found the
resident sitting up in bed with his eyes rolled
back. His face was red. He answered when his
name was called. The physician was notified. At
5:30 a.m., the resident's left eye was looking off
to the left and his right eye was looking straight
ahead. His face was red, with no other facial
symptoms. The resident was not moaning, but
was not as verbal as usual. He would answer his
name when he was called. The physician and
family were notified. The nurse administered
oxygen. At 2 p.m., the resident was out of bed in
the chair. He was ambulatory with assistance of
the walker.
A review of a nurse's note, dated 2/14/10 at 10
p.m., indicated new orders were obtained for the
resident's change in mental status. A basic
metabolic panel, complete blood count and
urinalysis and culture were ordered. The resident
was placed on a clear liquid diet for 24 hours and
additional fluids were ordered every shift. An
order was also received for Phenergan 25 mg by
mouth or suppository every 6 hours as needed for
24 hours for nausea and vomiting. The nurse
administered Phenergan at 6 p.m. and it was
effective.
On 2/15/10 at 10:50 a.m., the resident was up in
the dining room for breakfast, he was calm and
Event ID: 18OL11
Facility ID: 923014
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cooperative. A chest X-ray was done. At 11 p.m.,
he was more confused than usual that shift. He
refused vital signs and the nurse had difficulty
getting him to take his medications.
2/15/10, indicated the resident had an episode of
moaning, red face and episode of nausea and
vomiting. He was evaluated for his altered mental
status and lethargy. The physician indicated the
resident appeared to be at baseline that day and
ordered a urine toxicology and a urinalysis.
On 2/16/10 at 12:30 p.m., the resident was
"somewhat more confused & resistive to care
today than usual" "refused oral care and shaving."
At 2:10 p.m., the nurses notes indicated the
resident was incoherent and delusional. He was
"very hyper." At 6:15 p.m., an order was received
to send the resident to the hospital. The resident's
family member was informed that the resident
had mental status changes and had been
confused. At 6:45 p.m., an order was received to
discontinue transport to hospital. Resident was
"better" at that time. At 11:30 p.m., the resident
was "doing better." He was "less confused" and
took his medications.
A review of a urine confirmation toxicology report
for Resident #13, collected on 2/15/10, indicated
a test result of 7,900 nanograms per milliliter
(ng/mL) (cutoff: 100) of morphine and
hydromorphone 180 ng/mL (cutoff: 100). The
urine toxicology screens completed on the
residents were not all analyzed at the same
laboratory. The resident's urine toxicology
screens were completed by either the hospital
laboratory (Lab #3) or the facility's contracted
laboratory (Lab #1). The urine toxicology
Event ID: 18OL11
Facility ID: 923014
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confirmation tests were completed by Lab #2.
Resident #13's confirmation test was completed
by Lab #2.
A review of a chest X-ray report, dated 2/15/10
indicated there was no acute cardiopulmonary
disease seen. A review of a urinalysis, dated
2/18/10, indicated there was no growth.
During an interview on 6/17/10 at 12:48 p.m., NA
(nursing assistant) #4 indicated she usually
worked the 1st shift, 7 a.m. to 3 p.m. She
indicated on 2/13/10, the residents were fine. On
2/14/10, Resident #13 was in the bed and the
nurse informed the nursing assistants to leave
him alone because they thought he was having a
stroke. She stated He was pretty much laying
there." She indicated it was hard to try to get him
to get up.
She came in to work on 2/13/10 and worked the
her shift. When Nurse #12 arrived, the residents
were sleeping. Nurse #12 stated around 2 to 2:30
a.m., Resident #13 was having some difficulty
breathing and his eyes were not focusing right.
She thought he was having symptoms of a
stroke. She put oxygen on the resident. She
called the doctor and notified the family.
2/14/10 from 6:45 a.m. until 5 p.m. He stated
Resident #13 had to be ambulated with
assistance on 2/14/10. He indicated normally the
resident was independent and was walking
Event ID: 18OL11
Facility ID: 923014
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around fine on 2/13/10. Resident #13 was
unstable on his feet on 2/14/10. "He was just a
little bit slower."
Resident #13 was not transferred to the hospital.
3.b. Resident #73 was admitted to the nursing
home on 5/1/08, with diagnoses of dementia,
deconditioning, chronic renal insufficiency,
depression and cerebrovascular accident. A
significant change Minimum Data Set (MDS),
dated 1/13/10, indicated the resident's cognitive
skills for daily decision making were moderately
impaired with short and long term memory loss.
She was easily distracted and had episodes of
disorganized speech. She had repetitive health
complaints, insomnia, sad facial expressions and
crying or tearfulness. She did not have any
behavior issues. She required extensive
assistance with bed mobility, transfers, dressing,
eating, toilet use and personal hygiene. She
required total assistance with locomotion on and
off the unit and with bathing. She had not
ambulated during the assessment period. The
MDS indicated the resident had moderate pain
less than daily. Resident #73 resided on the
locked Alzheimer's unit.
receiving multivitamin tablets (supplement),
Synthroid (thyroid medication), Lotrel (heart
medication), Lactulose (bowel medication),
Cymbalta (antidepressant), Prilosec (stomach
medication), Lidoderm (pain medication patch),
Senokot (laxative), Seroquel (antipsychotic),
artificial tears (eye lubricant), Aricept (dementia
medication) and Tylenol (pain/fever medication).
There were orders for Vicodin (pain medication),
Event ID: 18OL11
Facility ID: 923014
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milk of magnesia (laxative), fleets enema
(laxative), Dulcolax (laxative) and Tylenol as
needed. There were no orders for morphine.
A review of the Medication Administration
Records (MARs) for January 2010 and February
2010 indicated the resident last received Vicodin
on 1/26/10. She did not receive Vicodin in
February 2010.
A review of a nurse's notes, dated 2/12/10 at
2225 (10:25 p.m.) indicated the resident was in
bed all shift. There was no sign of pain or
distress.
A nurse's note, dated 2/14/10 at 0500 (5:00 a.m.)
indicated the resident was in bed resting with no
signs or symptoms of distress. She was not
having any behavioral problems.
indicated new orders were received by Nurse #1
for a basic metabolic panel, complete blood
count, clear liquid diet for 24 hours, 300 cc (cubic
centimeters) additional fluids for 48 hours, and a
urinalysis and culture. The resident's vital signs
were blood pressure 102/52, pulse 68,
respirations 18, temperature 96.2. The nurse
further indicated the responsible party was
notified of the change in mental status. There was
no description of what changes the resident was
having in her mental status.
2/15/10, indicated the chief complaint was
lethargy, altered mental status, nausea and
vomiting. The physician indicated the resident
"appears to be more confused than baseline
although appeared to be in no distress." The
Event ID: 18OL11
Facility ID: 923014
PRINTED: 08/11/2010
FORM APPROVED
OMB NO. 0938-0391
A. BUILDING
C
B. WING _____________________________
345334
07/27/2010
1716 LEGION ROAD
(X4) ID
PREFIX
TAG
______________________
(X3) DATE SURVEY
COMPLETED
DEFICIENCY)
ID
PREFIX
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(X5)
COMPLETION
DATE
F 329
physician indicated the resident did not have any
new medications that could have been
contributing to confusion. A urine toxicology
screen was ordered.
A review of an opiates blood screen, dated
2/19/10, indicated a negative result.
A review of laboratory report, collected 2/19/10,
indicated the resident's opiate screen was
positive for Morphine. The Morphine level was
1618 ng/mL (nanograms/milliliter). The cutoff limit
was 200. This laboratory test was completed by a
different laboratory (Lab #1) from the other
residents who tested positive for morphine.
An interview was conducted with Facility
Consultant (FC) #1 and Director of Nursing
(DON) #1 on 7/1/10 at 11 a.m. Director of Nursing
(DON) #1 stated initially Resident #73's family
refused the urine toxicology (tox) screen. Later
on, the responsible party requested that it be
done. The resident's blood tox screen was
negative, but the urine tox was positive for
morphine. DON #1 stated the morphine was "out
of her blood, but it was lingering in her urine due
to the way her body was filtering the morphine
out." DON #1 stated she did not remember the
resident having a change in mental status and
that was initially why the responsible party refused
to have the urine tox screen. FC #1 stated
Resident #73 was not on any opiates. The
resident did not receive any Vicodin in February
2010.
2/5/09 with cumulative diagnoses that included
Alzheimer's dementia with lethargy, hypertension,
osteoporosis and allergic rhinitis. Information
Event ID: 18OL11
Facility ID: 923014
PRINTED: 08/11/2010
FORM APPROVED
OMB NO. 0938-0391
A. BUILDING
C
B. WING _____________________________
345334
07/27/2010
1716 LEGION ROAD
(X4) ID
PREFIX
TAG
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F 329
contained in the resident's MDS (Minimum Data
Set) on 1/5/10 showed the resident had problems
with short term memory, long term memory and
had moderately impaired cognition. Resident #16
was living in the facility's Alzheimer's Unit.
A review of the physician's orders indicated the
resident's medications on 2/1/10 were:
Aspirin 81 mg (milligrams) daily
Boniva (a medication for osteoporosis) 150 mg
monthly
Ritalin (a central nervous system stimulant) 5 mg
daily
Namenda (an Alzheimer's medication) 10 mg
twice a day
OsCal 500 + (Vitamin) D twice a day
Tylenol (a pain reliever) Arthritis Strength 1300
mg twice a day
Senokot S (a laxative/stool softener combination)
2 tabs twice a day
Remeron (an antidepressant) 15 mg at bedtime
Docusate Sodium (a stool softener) 200 mg at
bedtime
Lactulose (a laxative) 15 ml (milliliters) daily
Dulcolax (a laxative) 10 mg suppository daily as
needed.
showed:
"2/5/10-Alzheimer's dementia with lethargy: prev
(previously) responding to Methylphenidate (same
as Ritalin) cont (continue) current dose & follow;
continue supportive care."
showed:
"2/14/10 - 1030 (10:30 AM) Res. (resident) has
Event ID: 18OL11
Facility ID: 923014
PRINTED: 08/11/2010
FORM APPROVED
OMB NO. 0938-0391
A. BUILDING
C
B. WING _____________________________
345334
07/27/2010
1716 LEGION ROAD
(X4) ID
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F 329
change (symbol) in mental status however, she
has improved. VS (vital signs) 174/82 (blood
pressure)-67 (pulse)-97.4 (temperature) & 16
(respirations). New ordered rec'd (received)
earlier. BMP (basic metabolic panel), CBC
(complete blood count) in am (morning). clear
liquid diet x 24 hrs give additional 300 cc (cubic
centimeters) fluid q (every) shift x 48 hrs. In and
out cath (catheter) UA (urinalysis) C&S (culture
and sensitivity)."
A nurse's note, dated 2/15/10 at 7:45 a.m.,
indicated an I/O (in and out) catheter was done
for a urine culture and sensitivity.
A physician's note, dated 2/15/10 indicated:
"reported to have inc (increased) lethargy, AMS
(altered mental status) which then improved.
(Physician) notified and recommended UA
(urinalysis), labs. Today pt (patient) appeared to
be at baseline, resting comfortably in bed.
Arousable, smiled. Agree with labs, check UTox
(urine drug screen) for other cause cont VS q
(every) shift x 3 days."
showed:
"2/16/10 - 1400 (2 PM) I/O cath done for urine tox
screen
2/16/10 - 2230 (10:30 PM) resident found on floor
in room. On assessment-favoring R (right) hip
and wincing in pain. VS (vital signs) 114/57 (blood
pressure)-46 (pulse)-18 (respirations)-97.7
(temperature). (Physician) called and new order
received for a R (right) hip x-ray and VS q (every)
shift x 48 hrs. Resident back in bed resting "
A urine drug test done on 2/16/10 was positive for
opiates with a result of =/> 300 ng
Event ID: 18OL11
Facility ID: 923014
PRINTED: 08/11/2010
FORM APPROVED
OMB NO. 0938-0391
A. BUILDING
C
B. WING _____________________________
345334
07/27/2010
1716 LEGION ROAD
(X4) ID
PREFIX
TAG
______________________
(X3) DATE SURVEY
COMPLETED
DEFICIENCY)
ID
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DATE
F 329
(nanograms)/ml (milliliter). A confirmation urine
test done 2/17/10 by Lab #2 showed a morphine
level of 778 ng/ml.
showed:
"2/17/10- reported to have inc (increased)
lethargy several days ago included labs +UA?UA
now + for UTI with E. Coli (a bacteria) sens
(sensitive) to Bactrim (an antibiotic), Ceftriaxone,
(an antibiotic), Resistant to Augmentin (an
antibiotic), Amp (ampicillin-an antibiotic), Cipro
(an antibiotic) , Levaquin (an antibiotic). Pt
(resident) also reported to have fallen-X-ray neg
(negative) for fx (fracture). UTI (urinary tract
infection)-tx (treatment) with Bactrim DS 1 tab po
(by mouth) qd (daily) x 10 days, encourage PO
(by mouth) fluids. Falls-in setting of UA,
Alzheimer's dementia, cont (continue) fall
precautions, close monitoring."
Resident #16 had physician orders that showed:
"2/17/10 VS q4hrs. Please have MD follow up in
am."
showed:
"2/17/10 - 2400 (midnight) no further falls or fall
related injuries. No change in mental status.
Resting quietly with even unlabored resp.
(respirations). Skin w/d (warm and dry). Afebrile.
(no fever)."
showed:
"2/22/10 recent increase in drowsiness in setting
of UTI Pt started tx (treatment) c (with) Bactrim
DS. Pt (patient) also reported
F 333 483.25(m)(2) RESIDENTS FREE OF
Event ID: 18OL11
F 333
Facility ID: 923014
PRINTED: 08/11/2010
FORM APPROVED
OMB NO. 0938-0391
A. BUILDING
______________________
C
B. WING _____________________________
345334
07/27/2010
1716 LEGION ROAD
(X4) ID
PREFIX
TAG
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COMPLETED
DEFICIENCY)
ID
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DATE
F 333
SS=K SIGNIFICANT MED ERRORS
The facility must ensure that residents are free of
any significant medication errors.
by:
reviews, the facility failed to ensure residents
were free from significant medication errors for 14
of 29 residents (#1, #2, #3, #4, #5, #6, #7, #8, #9,
#13, #14, #15, #16, #73) who received a narcotic
they were not prescribed. Toxicology reports
indicated 14 residents tested positive for
toxicity.
Findings:
Event ID: 18OL11
Facility ID: 923014
PRINTED: 08/11/2010
FORM APPROVED
OMB NO. 0938-0391
A. BUILDING
C
B. WING _____________________________
345334
07/27/2010
1716 LEGION ROAD
(X4) ID
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physician is in the hands of the pharmacist."
edema and hypoxia.
Event ID: 18OL11
Facility ID: 923014
PRINTED: 08/11/2010
FORM APPROVED
OMB NO. 0938-0391
A. BUILDING
C
B. WING _____________________________
345334
07/27/2010
1716 LEGION ROAD
(X4) ID
PREFIX
TAG
______________________
(X3) DATE SURVEY
COMPLETED
DEFICIENCY)
ID
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DATE
F 333
1. Cross Refer to F329: Based on observation,
staff interviews and record reviews, the facility
failed to keep residents free from unnecessary
drugs when 14 of 29 residents (#1, #2, #3, #4, #5,
#6, #7, #8, #9, #13, #14, #15, #16, #73) received
a narcotic without an adequate indication for use.
Toxicology reports indicated 14 residents tested
positive for morphine. Seven residents were
hospitalized (#1, #4, #5, #6, #7, #8 and #9) and
one resident died (#1) from aspiration pneumonia
The facility provided their correction action plan
on 7/26/10.
In an interview with Facility Consultant #1 on
2/18/10 at 8:14 AM, she indicated the facility
began conducting an investigation on 2/15/10
concerning the positive opiate test on residents
who were not prescribed opiates. The only
medication the residents who tested positive had
in common was Tylenol (a pain reliever). The
facility took all of the Tylenol out of the facility and
had it tested by Lab #1 and there were no issues
with the Tylenol. The facility also tested all the
liquid morphine in the facility; even though none
of the residents were on it that tested positive for
opiates. The facility drug tested all the residents
in the facility and based on these tests, the facility
realized that all the residents who tested positive
for opiates were not on any opiates. The facility
increased their monitoring by assigning a second
nurse to accompany the nurse already
administering medications to the residents. The
facility called in a pharmacist on Monday 2/15/10
and Tuesday 2/16/10. The facility put a
pharmacist with the nurses that were
administering medications so that a pharmacist
Event ID: 18OL11
Facility ID: 923014
PRINTED: 08/11/2010
FORM APPROVED
OMB NO. 0938-0391
A. BUILDING
C
B. WING _____________________________
345334
07/27/2010
1716 LEGION ROAD
(X4) ID
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COMPLETION
DATE
F 333
was monitoring each medication pass and each
medication given. The pharmacist checked all the
narcotic sheets for the entire building, checked
the drugs and the documentation and there were
no discrepancies at all. On 2/16/10 the facility
drug tested and suspended every staff member
on the Alzheimer's unit. None of the employee
drug tests were positive. On 2/16/10, the facility
took all the water pitchers out of residents' rooms
and bought disposable water bottles to use. They
used these disposable water bottles for all
medication passes and for resident drinking. On
2/16/10, the facility made an appointment with
local police and met with them on 2/17/10. The
facility furnished the police department with their
investigation. The police told the facility they could
not open an investigation because they had no
proof that a crime was committed. On 2/17/10,
the facility suspended all of the dietary staff. All
the food in the facility that had been opened was
discarded and new food was brought in. Dietary
staff from other facilities were brought in to work
in the kitchen. All the dietary staff were drug
tested and there were no positives at that time.
The facility placed a staff member in the
Alzheimer ' s unit to monitor 24 hours to observe
for anything suspicious. All of the medications
from the Alzheimer ' s unit were sent back to the
pharmacy and replaced. On 2/17/10, the facility
closed down all the ice machines in the building.
The only ice used for the residents came from the
kitchen and was supervised from opening to
closing of the kitchen by corporate dieticians. The
facility did a 100% audit of all rooms, resident
belongings, nurses stations, medication carts and
treatment carts.
accomplished for those residents found to have
Event ID: 18OL11
Facility ID: 923014
PRINTED: 08/11/2010
FORM APPROVED
OMB NO. 0938-0391
A. BUILDING
C
B. WING _____________________________
345334
07/27/2010
1716 LEGION ROAD
(X4) ID
PREFIX
TAG
______________________
(X3) DATE SURVEY
COMPLETED
DEFICIENCY)
ID
PREFIX
TAG
(X5)
COMPLETION
DATE
F 333
been affected by the deficient practice
The facility started an investigation on 2/15/10.
Staff members identified as having potential
involvement were interviewed on 2/15/10. Upon
interview during second shift on 2/15/10, the
alleged perpetrator was immediately suspended
and never reinstated. On 2/16/10 the remaining
staff that worked the Alzheimer's unit to include
RNs, LPNs, CNAs, housekeepers, dietary, and
activities assistant were suspended and drug
tested per facility policy pending outcome of the
investigation. Local law enforcement was notified
on 2/16/10 by the VP of Operations and a
meeting was held with the Captain of the police
department on 2/17/10. Subsequently the State
Bureau of Investigation was notified. Notification
to Division of Health Care Services Regulations
by the VP of Operations on 2/16/10. A 24 hour
report was submitted to the health care personnel
registry on 2/16/10.
accomplished for those residents having the
potential to be affected by the same deficient
practice
Urine toxicology began for all residents on
2/15/10. A 100% audit of the Alzheimer's
resident's rooms and nurse's station were
completed for hazardous materials and chemicals
by the Facility Consultant on 2/15/10. A visitor
sign in log and receptionist was placed at the
front door of the Alzheimer's unit on 2/16/10. All
residents were observed for signs and symptoms
of abuse and change in condition on 2/15/10 by
the Facility Consultants and the DON. Q 2 hour
safety checks for monitoring of all residents for
abuse and change in condition were completed
Event ID: 18OL11
Facility ID: 923014
PRINTED: 08/11/2010
FORM APPROVED
OMB NO. 0938-0391
A. BUILDING
C
B. WING _____________________________
345334
07/27/2010
1716 LEGION ROAD
(X4) ID
PREFIX
TAG
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COMPLETED
DEFICIENCY)
ID
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F 333
by the Facility Consultants and licensed nurses
from 2/16/10-3/11/10. Department heads began
monitoring the Alzheimer's unit on 2/16/10 for the
monitoring of abnormal behavior, changes in
condition of residents and suspicious behaviors of
visitor and employees. All ice machines were
emptied on 2/16/10 and closed for use. On
2/16/10 until 3/11/10 all opened containers of
food were replaced with a new shipment of food
in a locked compartment refrigerator. 2/16/10 until
2/28/10 all beverages were replaced with
prepackaged beverages and med passes were
administered with bottled water. Bottled water
continues to be utilized in the Alzheimer's unit. All
apple sauce containers from all med carts were
replaced with individual packages of applesauce
on 2/16/10 and continue to be utilized on the
Alzheimer's unit. On 2/16/10 all staff were
inserviced by the staff development coordinator
on not using pitchers of water but using bottled
water only. All staff were inserviced by the Staff
development Coordinator on the abuse policy on
3/12/10 through 3/27/10 and on going to include
upon hire, monthly, and with any event related to
abuse. This abuse inservice emphasizes it is the
responsibility of any staff member to immediately
report any incident of suspected abuse to their
supervisor. The supervisor and or the employee
must then report immediately to the
Administrator.
Address what measures will be put into place or
systemic changes made to ensure that the
deficient practice will not occur
Staff members will be interviewed by the Facility
Consultants and Administrative nurses to assure
continued understanding of the facility abuse
policy utilizing a Quality improvement tool. These
Event ID: 18OL11
Facility ID: 923014
PRINTED: 08/11/2010
FORM APPROVED
OMB NO. 0938-0391
A. BUILDING
C
B. WING _____________________________
345334
07/27/2010
1716 LEGION ROAD
(X4) ID
PREFIX
TAG
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(X3) DATE SURVEY
COMPLETED
DEFICIENCY)
ID
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F 333
audit tools will be done 3 days per week for 4
weeks then 2 times per week for the next 20
weeks. These audit tools will occur on all three
shifts and weekends.
Indicate how the facility plans to monitor the
measures to make sure solutions are sustained
The results of the QI audit tools will be compiled
by the Administrator and reviewed noting trends
and actions taken by the facility for the quality
improvement executive committee monthly for the
next 2 months.
Event ID: 18OL11
Facility ID: 923014

DEPARTMENT OF HEALTH AND HUMAN SERVICES OMB NO. 0938-0391 PRINTED: 08/11/2010

Transcription

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