Finding Description
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Example 7
The facility policy titled, Change in a Resident's Condition or Status, revised November 2015, states, in part: . 3. Prior to notifying the Physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the SBAR (Situation, Background, Assessment, and Recommendation) (Interact Version 4.0) Communication Form . 7. The Nurse Supervisor/Charge Nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status .
The facility policy, Falls Investigation Guideline, undated, states in part: .It is the practice of this facility to evaluate a resident following every fall . 2. Following a fall or when a resident is found on the ground without a witness to the fall, a nurse should note position, record vital signs, perform ROM (Range of Motion) on all extremities to evaluate for upper or lower extremity injuries, and evaluate the patient for possible injuries to the head, neck, spine, or hips . 4. If the fall was unwitnessed or involved a resident hit their head [sic], initiate neurological evaluation . document evaluation and PCC (Point Click Care, electronic health record) . 9. Document relevant post-fall clinical findings such as, but not limited to, vital signs, neurological checks, pain, swelling, bruising, alterations in skin integrity, range of motion, decreased mobility, and changes in level of consciousness in the patient's record. It is also desirable to note the absence of such significant findings to demonstrate that the patient is being monitored appropriately . 11. Monitor resident and observe for changes for a minimum of 72 hours.
R42 admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, type 2 diabetes, gout, chronic pain, congestive heart failure, osteoarthritis, and muscle weakness.
R42's Minimum Data Set (MDS) comprehensive assessment dated [DATE] indicates a Brief Interview for Mental Status (BIMS) score of 15. A score of 15 indicates R42 is cognitively intact.
On 10/28/24 at 8:30 AM, Surveyor was notified R42 was hospitalized over the weekend. Surveyor reviewed R42's medical record. R42's medical record revealed the last progress note made was on 10/23/24. R42's medical record did not include an evaluation on when R42 went to the hospital or the reason for the transfer. R42's medical record census line indicated R42 was transferred from the facility on 10/26/24.
On 10/28/24 at 9:56 AM, Surveyor interviewed MT K (Medication Technician). MT K indicated R42 went to the hospital on [DATE]. MT K, indicated on 10/26/24, R42 complained of nausea, constipation, and dehydration. MT K indicated she informed the nurse of R42's complaints.
On 10/28/24 at 12:39 PM, Surveyor interviewed LPN M (Licensed Practical Nurse). LPN M indicated MT K reported to LPN M that R42 wanted to go to the hospital. LPN M indicated R42 complained of nausea, constipation, and dehydration. LPN M indicated he offered R42 her PRN (As Needed) medications to resolve R42's complaints of nausea and constipation and offered fluids for R42's complaint of feeling dehydrated. LPN M indicated R42 did not want the PRN medications and wanted to go to the hospital. Surveyor asked LPN M if he assessed or collected data prior to sending R42 to the hospital. LPN M indicated he had reviewed her medical record to ascertain when R42 last had a bowel movement and to review R42s diagnoses. LPN M indicated R42's vital signs were stable, and he looked for signs of dehydration. LPN M indicated he did not listen for bowel sounds or palpate R42's abdomen. LPN M indicated he used the messaging system to notify the on-call medical provider and was given the order to send R42 to the hospital. Surveyor asked LPN M where he documented his observations. LPN M indicated he did not document the encounter with R42. Surveyor asked if the information should have been documented and LPN M indicated he should have documented his findings and the encounter that lead to R42 being sent out. Surveyor asked LPN M how anyone would know what happened to R42 and what interventions the facility did for R42 if there is no documentation. LPN M indicated since there is no documentation, there is not a way of knowing what happened or what was offered.
On 10/28/24 at 9:22 AM, Surveyor interviewed RN L (Registered Nurse) regarding change in conditions and transfers to the hospital. RN L indicated a progress note should be made in the resident's medical record to include an assessment of the change in condition including vital signs and where the resident was being transferred to.
On 10/28/24 at 3:24 PM, Surveyor interviewed DON B (Director of Nursing). DON B indicated she would expect nurses to document a change in condition. DON B indicated R42 should have had a documented assessment of the change in condition including vital signs, pain rating, bowel sounds and palpitation of the abdomen in her medical record. DON B was unable to provide any documentation that an assessment was completed.
On 10/22/24, Surveyor interviewed R42. R42 indicated she was self-transferring into the bathroom over the weekend and had a fall on 10/19/24. R42 indicated she did not have pain initially when she fell. R42 indicated the next day on 10/20/24 she stated to have pain. R42 indicated she had x-rays post fall due to pain in her right wrist, right rib cage, and left knee. R42 indicated she had been given Tylenol (a pain-relieving medication) and Flexeril (a muscle relaxant to treat pain and stiffness). R42 indicated these medications were effective.
On 10/23/24, Surveyor reviewed R42's medical record. X-ray results for wrist, rib cage, and knee indicates no acute findings. There were only 2 progress notes made regarding R42's fall. Both progress notes were on 10/19/24.
First progress note dated 10/19/24 at 6:34 AM states: Resident was found sitting on the bathroom floor, and barefoot. Resident stated that she was rushing to use the bathroom, peed on the floor and the urine made her slide and land on her buttocks, denied hitting his [sic] head. Resident was assisted from the floor via mechanical lift with 2 staff members, was assessed for injuries, no injuries noted, and ROM (range of motion) and neuros (neurological checks) were WNL (Within Normal Limits). [NP Name], NP, and Nurse on Duty [Name] were updated, resident is her own person.
Second progress note dated 10/19/24 at 6:50 AM states: Post-Fall: Total Fall Risk Score is: 10 Fall risk scored above 5, resident is at a HIGH risk for falls.
BP (Blood Pressure) 140/77 - 10/16/2024 10:12 Position: Lying l/arm (Left Arm)
T (Temperature) 98.0 - 10/7/2024 21:25 Route: Forehead (non-contact)
P (Pulse) 70 - 10/16/2024 10:12 Pulse Type: Regular
R (Respirations) 18.0 - 10/7/2024 21:25
O2 (Oxygen Saturation) 97.0 % - 10/7/2024 21:25 Method: Oxygen via Mask
Pnl (Pain Level) 2 - 10/19/2024 06:46 Pain scale: Numerical
Resident is receiving anti-coagulant medication. The resident does not receive anti-diabetic medications. Resident is receiving psychotropic medication. Resident is receiving a laxative. There have not been any changes in the medication. There is no new pain, post fall. There is not a noted pattern to falls. The resident does not have any injury noted. New interventions for this fall that are being implemented: Use gripper socks, use call light for assistance Pain Eval: Pain Scale is at: 0. Location is: Pain does not radiate. Current pain pattern is intermittent. Pain is chronic and onset unknown. Discomfort has NOT changed in the past 7 days; Worst pain in the past 24 hours is 0. Pain Score is: Chronic Satisfactory pain management / Continue with current plan of care. Skin Observation: Resident does not have a new skin issue. Neuro Observation: Resident is alert. Resident is oriented x4 (person, place, time & situation). Pupils: PERRLA (Pupils are equal, round, and reactive to light and accommodation - an abbreviated to describe the normal response of the pupils during a neurological exam). PERRLA Eye evaluation is at resident baseline. Speech is clear. Responds to simple commands. Verbalizes appropriately. There are no noted changes in baseline speech clarity. Hand grasp equal bilaterally. There are no changes to the baseline hand grasp strength. Movement and sensation intact in all 4 extremities. Evaluation indicates no changes from baseline.
It is important to note the following:
-R42 was found on the bathroom floor, indicating R42's fall was unwitnessed. Neurological observations were not fully completed at the time of the fall nor continued for 72 hours.
-There is no other documented monitoring or observation for R42 regarding this fall in her medical records.
On 10/23/24 at 11:54 AM, Surveyor interviewed LPN N (Licensed Practical Nurse) regarding post fall monitoring and observations. LPN N indicated at the time of a fall, the nurse should assess the resident for injury, pain, range of motion, vital signs, and initiate neurological observations for an unwitnessed fall or if the resident hit their head. LPN N indicated the nurse will notify the appropriate personnel, the doctor, the activated power of attorney if a resident has one and the facility's on-call nurse manager. LPN N indicated the during shift report, the nurse will pass on to the next shift the sheet of paper containing the neurological observations so the observations will be continued for 72 hours. LPN N also indicated the nurse will do charting every shift for 72 hours in the resident's medical record. LPN N indicated the charting would include vital signs, any potential injury, pain, skin concerns or any noted changes in the resident.
On 10/24/24 at 9:49 AM, Surveyor interviewed DON B (Director of Nursing). DON B indicated any resident who has a fall should be monitored for 72 hours. DON B indicated observations and monitoring should be documented in the resident's medical record. DON B indicated R42 should have been monitored and there should have been documentation in her medical record for at least 72 hours. DON B did not provide any additional medical record documentation regarding R42's fall.
Example 3
The facility's policy titled, Change in a Resident's Condition or Status, dated 11/2015, states in part: Policy Statement: Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status . 1. The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been: . c. a reaction to medication; . 2. A significant change of condition is a decline or improvement in the resident's status that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting); b. Impacts more than one area of the resident's health status; c. Requires interdisciplinary review and/or revision to the care plan; .
The American Medical Directors Association standard of practice for Acute Change of Condition in Long-term Care Setting states in part; immediately notify the physician of a urine culture greater than 100,000 CFU/ML (colony forming units.)
According to the American Cancer Society, one of the time periods oncologists will monitor for is the [NAME]. The [NAME] occurs when the number of white blood cells in your body goes down to its lowest levels due to cancer treatments. The [NAME] usually occurs about seven to ten days after receiving chemotherapy treatment and indicates when the person is most at risk for infection. Source: (https://www.cancer.org/cancer/managing-cancer/side-effects/low-blood-counts/neutropenia.html)
According to the National Comprehensive Cancer Network, one of the side effects of DLBCL is infections. Infections occur more frequently and are more severe in those with a weakened immune system. During treatment for DLBCL (Diffuse Large B-cell lymphoma (DLBCL) is a fast-growing cancer of the lymphatic system, a major part of the body's immune system) can weaken the body's natural defense against infections. If not treated early, infections can be fatal. Neutropenia, a low number of white blood cells, can lead to frequent or severe infections. When someone with neutropenia also develops a fever, it is called febrile neutropenia. With febrile neutropenia, your risk of infection may be higher than normal. This is because a low number of white blood cells leads to a reduced ability to fight infections. Source: (www.nccn.org/patients/guidelines/content/PDF/nhl-diffuse-patient.pdf)
According to the Center for Disease Control and Prevention, patients can help to prevent infections during cancer treatment by monitoring temperature and taking their temperature any time they do not feel well, washing hands often, healthcare workers washing hands often, prompt identification of symptoms of infection including fever, cough, and diarrhea. Source: www.cdc.gov/cancer/features/preventing-infections.html
R66 was admitted to the facility on [DATE] with diagnoses that includes in part: diffuse large B-cell lymphoma (Diffuse Large B-cell lymphoma (DLBCL) is a fast-growing cancer of the lymphatic system, a major part of the body's immune system) enterocolitis due to clostridium difficile, type 2 diabetes, urinary tract infection, neutropenia, other pancytopenia, and calculus of ureter.
R66 's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/4/24 indicates R66 has a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicates R66 is cognitively intact.
R66's Comprehensive Care Plan states in part:
Focus: The resident has a h/o (history of) recurrent UTIs (urinary tract infections) and recurrent C Diff (clostridium difficile). Goal: Resident will be free from s/sx (signs and symptoms) of UTI through review date. Date Initiated: 8/27/24. Target Date: 11/25/2024. Interventions: encourage adequate fluid intake. Date Initiated: 8/27/24. Give antibiotic therapy as ordered. Monitor/document for side effects and effectiveness. Date Initiated: 8/27/24.
Focus: The resident requires contact barrier precautions. Date Initiated: 9/5/24. Goal: The resident will have appropriate isolation precautions and procedures followed during the period that isolation is necessary per facility policy. Date Initiated: 8/27/24. Target Date: 11/25/24. Interventions: Ensure that proper enhanced barrier precautions are in place. If resident has a shared room offer appropriate barriers to roommate. Date Initiated: 9/5/24.
Focus: The resident has a h/o (history of) diarrhea. Date Initiated: 10/1/24. Goal: The resident will be free from s/sx (signs and symptoms) of dehydration through the review date. Date Initiated: 8/27/24. Target Date: 11/25/24. Interventions: Encourage fluid intake as tolerated. Date Initiated: 8/27/24.
Focus: The resident is on antibiotic therapy per orders. Date Initiated: 8/27/24. Goal: The resident will be free of any discomfort or adverse side effects of antibiotic therapy through the review date. Date Initiated: 8/27/24. Target Date: 11/25/24. Interventions: Administer ANTIBIOTIC medications as ordered by physician. Monitor/document side effects and effective Q-SHIFT (every shift). Date Initiated: 8/27/24.
Focus: The resident has altered respiratory status/difficulty breathing r/t (related to) morbid obesity with alveolar hypoventilation cough and dyspnea. Date Initiated: 8/27/24. Goal: The resident will have no complications related to SOB (shortness of breath) through the review date. Date Initiated: 8/27/24. Target Date: 11/25/24. Interventions: Elevate HOB (Head of Bed) to alleviate Shortness of Breath. Administer medication/puffers as ordered. Date Initiated: 8/27/24. Monitor for effectiveness and side effects. Date Initiated: 8/27/24. OXYGEN SETTINGS: O2 per orders. Date Initiated: 10/7/24.
(Of note: Surveyor could find no evidence in R66's Comprehensive Care Plan relating to her chemotherapy treatment, neutropenia, being immunocompromised, or required monitoring related to these care areas. Additionally, none of these care areas were added following R66's hospitalization even though she had an additional cycle of chemotherapy to receive following her readmission to the facility.)
Physician Orders state in part:
Sulfamethoxazole-Trimethoprim Oral Tablet 800-160 MG (Sulfamethoxazole-Trimethoprim) Give 1 tablet by mouth in the morning every Mon, Wed, Fri for infection.
Azithromycin Tablet 250 MG. Give 250 mg (milligram) by mouth in the afternoon for infection for 4 days. Order date: 9/6/24.
Azithromycin Tablet 500 MG. Give 500 mg by mouth in the afternoon for infection for 1 day. Order date: 9/6/24.
Vancomycin HCl Oral Suspension (Vancomycin HCl) Give 125 mg by mouth in the morning for C-DIF INFECTION
Order date: 8/23/24. End Date: 9/24/2024
Vancomycin Oral Capsule 125 MG (Vancomycin HCl) Give 1 capsule by mouth in the morning for c-diff no stop date given.
Order date: 9/30/2024.
Macrobid Oral Capsule 100 MG (Nitrofurantoin Monohyd Macro) Give 1 capsule by mouth every morning and at bedtime for UTI for 5 Days. Order date: 9/13/24.
Acyclovir Oral Tablet 400 MG (Acyclovir) Give 1 tablet by mouth two times a day for viral infection. Order date: 9/30/24.
On 8/1/24, prior to facility admission, R66 received cycle 3 of 6 of her chemotherapy R-[NAME]-CHP. The package insert for this chemotherapy indicates that it is administered in six, 21-day cycles, followed by two additional cycles of rituximab (non-chemotherapy medication used to treat certain types of cancer). The most common adverse reactions to this treatment were peripheral neuropathy, nausea, fatigue, diarrhea, constipation, alopecia (hair loss), and mucositis (inflammation of mucus membranes that line the mouth and digestive tract). Laboratory abnormalities that occur with this treatment include neutropenia, among others. The package insert also notes serious adverse reactions occurred in 34% of patients receiving this treatment, which includes febrile neutropenia and pneumonia. Additionally, neutropenia is listed as a Grade 3-4 adverse reaction. According to the National Cancer Institute, Cancer Therapy Evaluation Program, Grade 3-4 adverse reactions indicate a severe to life-threatening or disabling adverse reaction. Sources:
(https://www.accessdata.fda.gov/drugsatfda_docs/label/2023/761121s008lbl.pdf)
(https://ctep.cancer.gov/protocoldevelopment/electronic_applications/docs/ctcaev3.pdf)
On 8/1/24, labs were also drawn and indicate: white blood cell count (white blood cells fight infection) of 6.2, which is normal, hemoglobin (protein that attaches to red blood cells and carries oxygen and carbon dioxide) of 10.7 which lower than a normal reference range, hematocrit (percentage of red blood cells in blood) of 33.5 which is lower than a normal reference range, a platelet count (cell fragments that help blood clot and heal wounds) of 25.1 which is normal, and an absolute neutrophil count (type of white blood cell, measures the body's capacity to fight infections) of 4.60 which is normal.
On 8/5/24, prior to facility admission, R66 was admitted to a hospital with symptoms of abdominal pain and worsening diarrhea.
On 8/9/24, prior to facility admission, R66 had labs drawn that indicate white blood cell count: 0.5, which is critically low, hemoglobin of 8.4, which is lower than a normal reference range and decreased from her previous lab results, hematocrit of 25.7 which is lower than a normal reference range and decreased from her previous lab results, and a platelet count of 41 which is critically low.
(Of note: These results coincide with the American Cancer Society's reporting of the [NAME] with neutropenia occurring 7 to 10 days following treatment and indicates when the person is most at risk for infection. This demonstrates that the resident has experienced at least one known adverse reaction to the chemotherapy treatment prior to facility admission.)
On 8/9/24, a urine culture and sensitivity resulted, which grew two different morphologies of Escherichia coli that was resistant to antibiotics: ampicillin, ampicillin sulbactam, cefazolin, ciprofloxacin, trimethoprim-sulfamethoxazole. The bacteria tested sensitive to antibiotics: ceftriaxone, nitrofurantoin, piperacillin-tazobactam.
On 8/22/24, R66 received cycle 4 of 6 of chemotherapy prior to discharge from the hospital.
On 8/23/24, R66 was admitted to the facility with a hospital discharge diagnosis of Clostridium difficile colitis. Discharge orders from the hospital state in part: O2 (oxygen) saturation daily. Additionally, the hospitalist documents cough and dyspnea on their assessment and plan, with the plan listed as monitor.
Of note, R66's O2 was not monitored daily.
On 9/6/24 at 5:45 PM, a Progress Note was written by NP Z (Nurse Practitioner). This note reports that R66 has a chief complaint of a cough, and states in part: .She overall reports that she continues to have her cough, but does find that Mucinex and Tessalon [NAME] are helpful at times. But she does report that overall she is not feeling well. At this time we will also order an azithromycin for coverage of [sic] the lingering URI (upper respiratory infection) versus rhinovirus. UA (urinalysis) collected, results are pending . The physical exam for respiratory status states, clear, no wheeze, no accessory muscle use, fair aeration, symmetric expansion.
On 9/8/24, Laboratory paperwork indicates urinalysis results are faxed to the facility at 00:55:03 (12:55 AM) and indicate that a urinary tract infection is present.
On 9/9/24 at 11:15 AM, a nursing progress note indicates that NP Z was notified of the results.
On 9/10/24 at 12:51 PM, Laboratory paperwork indicates the culture and sensitivity results are sent to the facility. Culture results indicate presence of 20,000 CFU/ML (colony forming units) of Escherichia coli, Greater than 100,000 CFU/ML of Enterococcus faecalis not VRE (vancomycin-resistant enterococcus), and 11,000 CFU/ML of Candida tropicalis. Sensitivity results indicate that the bacteria found in the culture are resistant to ampicillin, ampicillin sulbactam, levofloxacin, and trimethoprim-sulfamethoxazole. The bacteria tested sensitive to cefazolin, cefepime, ceftriaxone, gentamicin, meropenem, nitrofurantoin (Macrobid), and tobramycin.
Of note, there is no evidence NP Z was immediately notified of the urine culture results until 9/11/24. It should be noted R66's UA (Urinalysis) is resistant to the prophylactic Bactrim.
On 9/10/24 at 2:28 PM vital signs are assessed: BP (Blood Pressure) 118/60, HR (Heart Rate) 63, RR (Respiratory Rate) 18, temperature 97.7F (Fahrenheit), and 93% SpO2 (Saturation of Peripheral Oxygen).
On 9/11/24 at 3:45 PM, a Progress Note was written by NP Z. This note reports that R66 has a chief complaint of a cough and UTI (urinary tract infection). The note states in part: . She reports that her cough is not getting better. Mucinex does help slightly. She has rhonchi heard in the bases of her lungs. At this time we will order a chest x-ray. In addition, UA (Urinalysis) suggestive of UTI, reaching out to urology for further recommendations due to upcoming stent removal. She will be out all day tomorrow for treatment . Respiratory assessment indicates: RHONCHI, no accessory muscle use, fair aeration, symmetric expansion.
Of note, this is a change from NP Z's previous assessment now noting rhonci. Of note, despite the indication of continued cough, now rhonchi present and R66's extreme risk of infection the facility staff did not complete comprehensive nursing assessments of R66's respiratory system. Additionally, R66 has a renal calculi (Kidney Stone) with a stent placement there is no indication the facility staff are assessing R66's gentiourinary status despite a UTI (Urinary Tract Infection.)
It should be noted per phone transcripts with urology clinic facility staff notified urology on 9/11/24, R66 has UTI which was positive for bacteria and yeast. Facility told urology R66 was receiving prophylactic Bactrim however there is no evidence the facility informed urology the urine culture was resistant to Bactrim.
Hospital paperwork dated 9/12/24 indicates that R66 receives cycle 5 of 6 at this time. A chest x-ray is conducted at the clinic as ordered and labs are drawn. Labs indicate a white blood cell count of 4.3 (normal), hemoglobin of 10.0 (low), hematocrit of 31.6 (low), platelet count of 212 (normal), and absolute neutrophil of 3.39 (normal). The chest x-ray impression is probable pulmonary vascular congestion. PVC is a condition where the blood vessels in the lungs become enlarged due to an obstruction in the normal flow of blood. This can lead to the alveoli filling with blood. PVC is often associated with heart failure. Some causes of PVC include: high blood pressure, infections, cardiac insufficiencies, malnutrition, and rheumatic mitral valve disease.
It should be noted per phone transcripts with urology clinic facility staff notified urology clinic on 9/12/24 at 4:17 PM, labs from 9/9 positive urine culture with bacteria and yeast. Treat with Bactrim and Diflucan (antibiotic and antifungal)? On 9/12/24 at 4:49 PM the physician repliced sounds like need final urine culture results prior to treating.
On 9/13/24 at 6:15 PM, a Progress Note was written by NP Z. The note reports that R66 has a chief complaint of a UTI and a ureteral stent. The note states in part: . She reports that oncology [sic] obtained a chest x-ray yesterday. Nursing staff reaching out to urology for further recommendations in regards to her urinalysis results. For further discussion was sent over to PCP (Primary Care Provider) office for further management which he PCP has never met or seen her. Writer agreed to continue with managing. Then further follow-up urology is recommending that she follow-up with infectious disease due to specific bacteria in her urine. At this time writer started on Macrobid (antibiotic) for further coverage until infectious disease can make further recommendations . Respiratory assessment indicates: RHONCHI, no accessory muscle use, fair aeration, symmetric expansion.
On 9/13/24 at 4:10 PM, an order was placed for Macrobid Oral Capsule 100 MG (Nitrofurantoin Monohyd Macro) Give 1 capsule by mouth every morning and at bedtime for UTI for 5 Days. According to the Medication Administration Record, this medication was administered as ordered through 9/18/24.
It should be noted per phone transcripts with urology clinic facility staff notified urology clinic on 9/13/24 at 1:08 PM urine culture came back positive asking if physician wants to proceed with prescription for UTI. 2:13 PM can you confirm if (R66) should be on Bactrim and Diflucan. Response at 3:13 PM stated she needs to go to infectious disease bactrim is resistant and Macrobid is not a great antibiotic. She also has Candida tropiclis (fungal infection.)
On 9/16/24, the facility received a referral for R66 to see infectious disease. Appointment was scheduled the same day for 10/7/24.
On 9/18/24 at 6:45 PM, a Progress Note was written by NP Z. The note reports that R66 has a chief complaint of stent and UTI and cough. The note states in part: .Further discussion with urology, her procedure for her stent will be postponed until she has a follow-up with infections disease for her bacteria in her urine. In addition she continues to report that she is have continuous cough congestion and is not feeling well . Respiratory assessment indicates: RHONCHI, no accessory muscle use, fair aeration, symmetric expansion.
(Of note: 9/19/24 is the start of the [NAME] with neutropenia occurring 7 to 10 days following treatment and indicates when the person is most at risk for infection. No care plan is in place and no facility nursing assessments are completed to monitor for infection. R66 is being treated for a UTI with no evidence of assessment and monitoring of R66's urinary output and no respiratory assessment including physician ordered daily oxygen saturations.)
On 9/19/24 at 12:37 PM vital signs are assessed: BP (Blood Pressure) 142/73, HR (Heart Rate) 63, RR (Respiratory Rate) 18, temperature 97.9F (Fahrenheit), and 94% SpO2 (Saturation of Peripheral Oxygen).
On 9/20/24 at 2:45 AM, a Progress Note was written by NP Z. The note reports that R66 has a chief complaint of UTI. The note states in part: Patient continues [sic] to have a cough, waiting to hear back from ID (infectious disease) for further recommendations for her UTI. Currently on Macrobid . Respiratory assessment indicates: no accessory muscle use, fair aeration, symmetric expansion.
(Of note: No RN assessments could be found since 9/1/24 regarding the resident's respiratory and genitourinary status. R66's temperature was also only taken twice since 9/1/24, on 9/10/24 and 9/19/24.)
On 9/20/24 at 4:23 PM, a nursing progress note is written by RN AA. The note states that CNA (CNA Name) approached the writer and reported a change of condition with R66. RN AA went to the room and assessed R66 to be experiencing tremors, she was drowsy, and she was only responding to self. Vital signs listed at this time were BP 108/55, HR 103, Temperature 98.6 F, and blood sugar 95. The physician was called and R66 was ordered to be sent to the hospital. Family was also notified.
On 9/20/24 at 4:31 PM, a nursing progress note is written by RN AA. The note states that R66 was sent to the hospital for further evaluation.
On 9/20/24, Hospital documentation indicates that R66 presented to the ER (Emergency Room) by EMS (Emergency Medical Services) with altered mental status, lethargy, fevers, cough, and hypoxemia (Low blood oxygen) requiring 4L (liters) of oxygen. In the ER, R66 reports that her nonproductive cough and fatigue have been going on for several weeks and the fever started that day. Initial vital signs in the ER were BP 102/58, HR 97, and Temperature 103.1 F.
On 9/20/24 at 8:32 PM, a note was written by a critical care physician upon admission. The note states that R66 was found to be febrile (fever) and hypotensive (low blood pressure) upon arrival to the ER. Initial treatment consisted of a 30 mL/kg (milliliters per kilogram) sepsis fluid bolus and blood cultures were taken. The resident was also treated with antibiotics: vancomycin, cefepime, and azithromycin. The physician lists notable labs of a white blood cell count of 0.1 (critically low), platelets of 18 (critically low), and hemoglobin of 7.9 (low). Chest x-ray shows hazy bilateral opacities that was concerning for pneumonia per the ER physician. Urinalysis also suggests urinary tract infection. Ultimately, R66 required norepinephrine (similar to adrenaline and used to treat life-threatening low blood pressure) for persistent hypotension despite fluid resuscitation. She also required 2 packs of platelets for thrombocytopenia (low platelet count) and admission to the intensive care unit for further care. On arrival to the intensive care unit, R66 reported several weeks of nonproductive cough and fatigue and that her fever started today. The physician also notes that R66 reported dysuria. The reason for admission is listed as neutropenic fever, septic shock. The physician's pulmonary assessment and plan states, Cough. New oxygen requirement. CXR (chest x-ray) with hazy opacities. Possible pneumonia vs pulmonary edema. -supplemental oxygen. The physician's cardiovascular assessment and plan states: Septic shock. Lactate normal. Got seps[TRUNCATED]