ATKINS NURSING AND REHABILITATION CENTER
Located 605 NORTHWEST 7TH STREET ATKINS, AR 72823 was cited by the DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES in 2013 for the following:
Please Note: The following are only highlighted portions of the report. The full report can be viewed here.
WARNING: The following can cause extreme anger.
Clinical Impression: Severe Dehydration, Respiratory Distress, Nursing Home Neglect, Pneumonia.
Give each resident enough fluids to keep them healthy and prevent dehydration.
Complaint # was substantiated, all or in part, with these findings: Based on record review and interview, the facility failed to provide sufficient fluid intake to maintain proper hydration and health for Resident #1. The facility failed to conduct and document ongoing monitoring of the resident’s hydration status and assess for increased fluid needs when the resident was diagnosed with [REDACTED].#1) of 2 (Residents #1 and #2) case mix residents who were at risk for dehydration. The failed practice resulted in actual harm for Resident #1, who was subsequently hospitalized with Severe Dehydration and Acute Kidney Injury, and had the potential to affect . 10 residents who were at risk for dehydration according to the Director of Nursing on 2/6/13 at 5:00 p.m.
The Plan of Care dated 1/18/13 documented, Nutrition/Hydration via PEG tube due to severe oropharyngeal dysphagia.
Administer tube feeding and water flushes as ordered, monitor for tolerance. monitor for fluid and skin turgor.
The hospital History and Physical dated 1/20/13 documented, .He was brought to the emergency room for worsening shortness of breath. Apparently patient was diagnosed with [REDACTED]. Today he was found to be severely dyspneic with a worsening cough and was unresponsive.There is also reported history of fever. Physical Examination. mucous membranes are dry. Assessment/Plan: .nursing home resident who came with severe dehydration. At this point we will perform aggressive IV (intravenous) hydration with consideration of patient’s [MEDICAL CONDITION] status. l. The hospital Discharge Summary dated
1/25/13 documented, The patient came with acute hypoxemic [MEDICAL CONDITION] and diagnosed with [REDACTED]. The patient was treated with IV antibiotics, IV fluid, free water. The patient had mild improvement of his chemistries. However, his kidney status overall did not improve despite maximum medical treatment. The patient’s condition deteriorated. On 1/25/13, the patient became unresponsive and the patient is pronounced dead at 3:15 p.m.
On 2/6/13 at 1:51 p.m., the hospital Social Worker was asked about the [DIAGNOSES REDACTED].She stated, I was told by QA (Quality Assurance) that it was because the patient was a tube feeder and that he never should have gotten to that point. that they should have been monitoring him. The lab work showed severe dehydration. n. On 2/6/13 at 2:41 p.m., Licensed Practical Nurse (LPN) #1, who provided care to Resident #1 on 1/17/13, 1/19/13 and 1/20/13, was
asked why Resident #1 would be diagnosed with [REDACTED]. He stated, He was running a fever and that caused him to sweat. And he sweated a lot even before the fever. He was asked if, based on that, a resident’s fluid needs would increase if they were sick and have a fever. He stated, Yes. He was asked who would be responsible for assessing the resident for the additional hydration needs. He stated, I guess, me. He was asked where that information would be documented if it was done. He stated, In the Nurse’s Notes.
The physician felt that there was no need in having a really high sodium and being dehydrated when the patient had a PEG tube. p. On 2/6/13 at 3:56 p.m., LPN # 2, who provided care to Resident #1 on 1/17/13 and 1/20/13, was asked during a telephone interview if she felt Resident #1’s fluid needs would increase since he was sick and running a fever. She stated, Yes. She was asked who would be responsible for assessing the resident for the hydration needs. She stated, I would say the nurses, but honestly I didn’t even think about that until you said it. I have taken care of tube feeders and I can’t remember even one time checking with the doctor for extra fluid needs because they get their fluid from the tube feeding and flushes. But it’s so obvious. I will think of it from now on. LPN #2 was asked where hydration assessments such as skin turgor and mucous membranes would be documented.
She stated, The Nurse’s Notes. But he didn’t appear to be dehydrated. She was asked why a resident who receives all of their hydration through a PEG tube would be severely dehydrated. She stated, I don’t know. That should never happen. q. On 2/6/13 at 4:25 p.m., the Director of Nursing (DON) was asked during an interview if she felt a resident’s fluid needs would increase if they were sick and running a fever. She stated, Yes. She was asked who would be responsible for assessing the resident for the hydration needs. She stated, The nurses on the floor should be assessing that and contacting the doctor for an order. She was asked where hydration assessments, such as skin turgor and mucous membranes, would be documented. She stated, In the Nurse’s Notes.
As of 2/6/13 at 4:30 p.m., there was no documentation in the Nurse Notes to indicate hydration assessments had been conducted on the resident from 1/17/13-1/20/13 when he was sent to the hospital.
Personal Note from NHAA Advocates: NHAA shares with all the families of loved ones who are confined to nursing homes the pain and anguish of putting them in the care of someone else. We expect our loved ones to be treated with dignity and honor in the homes we place them. We cannot emphasize enough to family members of nursing home residents; frequent visits are essential to our loved ones’ well being and safety. This nursing home and many others across the country are cited for abuse and neglect.
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