The Minnesota Department of Health (DOH) has determined that a resident at an assisted living facility in Brooklyn Park died due to neglect. A state report revealed that the resident did not receive sufficient care in the weeks leading up to her death. She was not given enough water, correct medications, timely transfers, or incontinence care. The resident had suffered a stroke and stayed at the facility for about ten weeks. She was on a feeding tube for hydration and nutrients. The report states that she was not given the amount of water that the doctor ordered and missed several doses of her medications.
The resident’s admission and provider orders indicated the resident was to receive 180 milliliters (ml) water flushes every 4 hours and tube feedings at 55 ml per hour for 20 hours a day through the gastrostomy tube. The facility tube feeding instructions directed staff to flush the resident’s gastrostomy tube every four hours with 30 ml of water (not 180 ml every four hours according to the provider’s order). This change in instructions deprived the resident of a significant amount of water during her stay at the facility.
A certified nursing assistant (CNA) stated that she did receive training on tube feeding administration. She said management assumed she was trained because she was a CNA. She also said staff members were flushing the gastrostomy tube when feedings started and stopped, and after medication administration. She said no other water was administered to the resident.
The report also highlighted that miscommunication among staff led to the gaps in care. A nurse, who was interviewed for the report, claimed that another nurse failed to order water, and the subsequent two nurses did not notice the mistake. The nurse also stated that some caregivers did not recognize the generic names of the woman’s prescribed medication and did not administer them. Staff did not report the missed doses until the nurse completed a monthly audit of the medication administration record.
The resident’s death certificate indicated the resident’s primary cause of death included Escherichia coli (E. coli) bacteria pneumonia, E. coli urinary tract infection, and E. coli sepsis.
Compliance Perspective
Issue
According to F692 in the State Operations Manual Appendix PP, facilities must ensure that residents are ordered sufficient fluid intake to maintain proper hydration and health. It is important to maintain adequate nutritional status, to the extent possible, to ensure each resident is able to maintain the highest practicable level of well-being. The early identification of residents with, or at risk for, impaired nutrition or hydration status may allow the interdisciplinary team to develop and implement interventions to stabilize or improve nutritional status before complications arise.
Discussion Points
- Review nursing policies and procedures to ensure that the procedures are comprehensive and competency-based. Update as needed.
- Train all nursing staff on your policies and procedures for nursing skills, and ensure that each nurse demonstrates competency in providing care. Ensure that nurses have access to the nursing policies and procedures for easy reference. Ask staff if there are areas within their responsibilities where they would like to receive additional training, and provide the requested instruction. Document that these trainings occurred and file in each employee’s education file.
- Periodically conduct audits to ensure that each nurse’s competency is evaluated upon hire and at least annually thereafter per your facility’s policy. Also audit to ensure residents are receiving sufficient nutrition and hydration and that their doctors’ orders are being followed.
*This news alert has been prepared by Med-Net Concepts, LLC for informational purposes only and is not intended to provide legal advice.*
