IDPH has cited and fined Heritage Health nursing home in Carlinville after a resident died from acute metabolic encephalopathy due to sepsis from a urinary tract infection.
One of the ways that nursing home care differs from a hospital is that there are not doctors on hand on a 24/7 basis. When there is not a doctor on hand, it is part of the function of the nursing staff to serve as the “eyes and ears” of the doctor and report changes in the resident’s condition. When things happen such as a resident having a nursing home fall, developing a bed sore, having abnormal labs, or a medication error, it is part of the job of the nursing staff to let the doctor know what happened.
Outside of clearly defined events such as that, it is also part of the nursing staff to notify the doctor of changes in condition, which can be a bit more subtle, but just as important. Examples of this would be increased lethargy, increased confusion, or other changes in mental status.
When the doctor receives a report from the nursing home staff, the doctor has four basic options: to decide to come in to see the resident himself, order the resident sent to the hospital, issue orders for the nursing staff to carry out, or to make no orders at all. Whatever choice is made, the fact of the communication with the doctor and the response of the doctor should be recorded in the resident chart.
Of course crucial to all of this is the substance of what was communicated to the doctor. If the pertinent information is not communicated to the doctor, then that can result in poor decision-making by the doctor with the net being loss of opportunity to help the resident when help is needed most. And this brings us to this citation issued by IDPH …
The resident was admitted to the nursing home after apparently breaking her right leg in a fall. At the time of her admission on through the first several days of her admission, she was assessed as being cognitively intact, alert and oriented x3. However, she began to complain of significant pain apparently from muscle spasms on the side with the broken leg. The nurse practitioner prescribed Ropinrole to address the pain complaints.
The second day after the Ropinrole was started she began to demonstrate changes in mental status. One nurse noted that she demonstrated forgetfulness. Her daughter arrived in the facility and her mother told her that she was seeing bugs and ants which were not there, was seeing Cheerios on the floor, and that the ceiling black. The nurse to whom the daughter reported this also noted that she was less responsive, more lethargic, and difficult to arouse. She claims that she passed this information on to the nurse at the change of shift.
The nurse who had the next shift does not remember being told about hallucinations or anything out of the ordinary. She told the surveyor that she would have called the physician had she been told. She was told by other family members the next day that they were concerned that the new medication was making the resident confused. The Director of Nursing saw the resident later that day and there was discussion about the effects of the new medication. She looked the medication up and saw that many of the symptoms that were being reported were listed as side effects for the medication.
The Director of Nursing called the doctor, and what was said is a crucial issue. The Director of Nursing claims to have told the doctor about the reports of hallucinations, but he denied that, and his office record only noted a request to change her dose of pain medication and concerns over the side effects of the Roprinole. The doctor told the state surveyor that had he been told of hallucinations earlier, he would have ordered her sent to the hospital sooner.
The day after this phone call, she had a set of routine labs drawn. The results of this showed critically high abnormal scores. This prompted another call to the doctor who ordered the resident transferred to the hospital. At the local hospital, she diagnosed as suffering from Acute Metabolic Toxic Encepholapathy, a disease of the brain caused by a viral infection or toxins from the blood. She was sent to a hospital in Springfield where she died five days later. Cause of death was bacteremia from a urinary tract infection.
The key issues here relate to the substance and timing of the communication with the doctor. The doctor made it clear that had he been told earlier that the resident was having hallucinations, he would have sent her to the hospital. This goes all the way back to the first report by the family members to the nurse that the resident was seeing bugs and so forth, approximately 48 hours before she was finally sent to the hospital, and also to the call that was placed by the Director of Nursing approximately 24 hours later.
The fact that this was due to a urinary tract infection also deserves some attention that was not addressed in the citation by IDPH. There are a number of other issues worth examination: was the resident using a catheter? What were the vital signs? Were there changes in the amount, color, or smell of the urine? Were the complaints of burning while urinating? These are questions that should be addressed in any competent investigation of the care that this resident received.
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