Compliance Perspective – Negligence:
The Compliance Officer will review the facility’s policies and procedures with the DON and the Administrator to ensure that policies and procedures address the compliance role in quality of care issues. Staff will receive training regarding the protocol for providing adequate supervision of residents who may pose a risk to themselves that is avoidable if adequately supervised, but if left unsupervised may result in severe injury or death. Staff will also be trained regarding what steps to take when a caregiver has serious concerns about a resident, alerts a nurse or supervisor multiple times and nothing happens. An audit will be conducted to review the care and supervision being given to residents at risk for dislodging or pulling out feeding tubes, dialysis and other catheters. Nursing aides will be interviewed to determine if there have been any instances where their concerns that a resident should be more closely supervised have been ignored. The Compliance Officer and the DON will analyze the compliance audit results and present any findings to QAPI for their review and recommendations.
Last September, for the second time in a two-year span a resident living in an already troubled Missouri nursing home’s death has been linked to negligence by federal investigators and resulted in a suspension of state and federal payments for new residents.
The resident, whose gender was not made known, pulled out the dialysis catheter located in the his/her groin area and subsequently bled to
death. The resident had been admitted to the facility with diagnoses that included heart failure, dementia, paralysis on one side and a seizure disorder. Beside having the dialysis catheter, the resident had a catheter in the arm to provide vein access and a feeding tube. The resident was also being given blood thinning medication. Nurses had reported shortly after the resident was admitted that the resident continually pulled at the tubing and needed constant watching.
It was noted in the resident’s medical records at 4:18 a.m. that the resident was continuing to pull at the tubing on the different areas where they were connected. The next entry on the medical record was at 6:50 a.m. indicating that the nurse was “called to the room and found a significant amount of blood on the floor and bed” that was caused by the resident’s pulling out the stitches and the catheter. At 6:55 a.m. the nurse’s notes indicate that the resident was unresponsive.
Investigators found that the patient’s electronic medical record was changed two days after the resident’s death to add notes that at 5:42 a.m. and 6:38 a.m. all of the resident’s tubing was intact.
An aide told investigators that the resident had pulled the feeding tube out earlier that same night and that she had informed two nurses multiple times what the resident was doing, but she was not instructed to stay with the resident.
An EMT called to the facility told the investigators that some of the blood that had pooled under the resident’s bed when he arrived was already coagulated and the resident was not conscious. The EMT also said that the staff had conflicting stories and they were not able to say when the incident had occurred and when the resident had last been seen
The nursing home’s director of nursing told investigators “she did not believe staff exhausted all efforts at possible interventions.”
