cms_GA: 317
Data source: Big Local News · About: big-local-datasette
| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 317 | ORCHARD VIEW REHABILITATION & SKILLED NURSING CTR | 115146 | 8414 WHITESVILLE ROAD | COLUMBUS | GA | 31907 | 2019-06-28 | 580 | D | 1 | 0 | EDYH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and record review the facility failed to notify the physician and/or the Responsible Party (RP) for two residents out of five, Resident (R)#5 and R#16, after significant change in medical conditions occurred with each resident. Progress note review revealed R#5 presented concerning vital signs on [DATE] at 10:33 a.m. and was discharged to the hospital on [DATE] at 8:37 p.m. Further review of the Progress notes and multiple interviews with facility personnel, including R#5's physician, revealed the physician was not notified of the change in R#5's condition, even after she was discharged to the hospital. Progress note review also revealed R#16 had bloody stool on [DATE] and [DATE]. Further review of the progress notes and staff interviews revealed no evidence the physician or RP were notified. Director of Nursing (DON) interview revealed that the only place a significant change of condition was documented would be in the progress notes. Findings include: 1. Review of the undated face sheet in the Electronic Health Record (EHR) revealed R#5 was admitted to the facility on [DATE] and discharged on [DATE]. Further review revealed her [DIAGNOSES REDACTED]. Review of an admission progress note dated [DATE] at 4:12 p.m. revealed her [DIAGNOSES REDACTED]. Review of R#5's [DATE] at 10:33 a.m. progress note revealed Respiratory Therapist (RT) HH wrote that R#5 had a low oxygen saturation (the amount of oxygen dissolved in the blood) of 84 - 88% and the resident was lethargic. Further review revealed the residents pulse rate was 140 - 155 beats per minute. Further review revealed RT HH notified the nurse. Review of the Mayo Clinic website found at: www.mayoclinic.org/symptoms/hypoxemia/basics/definition/sym- 930 revealed oxygen saturation (pulse ox) Values under 90 percent are considered low. Interview on [DATE] at 3:45 p.m. with Respiratory Therapist (RT) HH in the surveyor's workroom revealed that RT HH said that he had been an RT for [AGE] years and had been coming to this facility for three years. He stated he recalled R#5 and he had reviewed his note of [DATE] at 10:33 a.m. and agreed he wrote it. He stated the clinical picture was concerning at the time, especially the [MEDICAL CONDITION](high heart rate). He stated he shared his concern with LPN II, who was R#5's nurse that morning. He stated he advised her to check her vital signs in 30 minutes and to call the doctor if they had not improved. He stated he left the building shortly after that and did not know if she checked the vital signs or if she called the doctor. He stated, if the vital signs did not improve, the doctor should have been called. Review of the [DATE] 4:08 p.m. Physical Therapy progress note revealed Physical Therapist (PT) GG wrote he completed 63 minutes of exercise for R#5 and he monitored heart rate and O2 sat during session. He wrote he had checked with the nurse about the possibility of adding medication to bring down heart rate. Review of the [DATE] Physical Therapy Plan of Care revealed the PT GG provided physical therapy for R#5. Further review revealed R#5 had recently been in the hospital with [MEDICAL CONDITION] and declining condition. Further review revealed the family told PT GG R#5's heart rate had been in the 200s when she was in the hospital. Further review revealed R#5's vital signs were 84% oxygen (O2) saturation on room air and 96% with oxygen mask at 6 liters/minute (L/M), 150 beat per minute (BPM) heart rate with an irregularly irregular rhythm, blood pressure (B/P) ,[DATE], and no respiratory rate documented. Further review revealed PT GG listened to R#5's lungs and found diminished breath sounds, and mild bilateral rhonchi (coarse, rattling respiratory sound). Interview on [DATE] at 4:10 p.m. with PT GG in the surveyor's workroom revealed that PT GG stated he recalled R#5. He stated he saw R#5 two times on [DATE] in the morning and in the afternoon. He stated her vital signs, especially her heart rate and oxygen saturation were concerning, but he assessed the resident as able to do physical activity. He stated she was short of breath and had a low blood pressure but often the best way to improve blood pressure is to give the resident some exercise. He stated, looking back on it, the doctor should have been called. Review of the [DATE] at 8:37 p.m. progress note revealed the Assistant Director of Nursing (ADON) wrote she was called to R#5's room and R#5 was in bed with face mask O2 at 6 L/M, respirations 28 - 30, B/P ,[DATE], heart rate 133, temp 98.8, and O2 sat ,[DATE]%. Further review revealed 911 was called and resident left the faciity on [DATE] at 8:45. Review of a [DATE] at 8:36 p.m. physician's orders [REDACTED]. On [DATE] at 3:00 p.m. the ADON was interviewed in her office. She stated she was working late on [DATE] and s a CNA came and said they needed a nurse in R#5's room. She stated she assessed R#5 and called 911. She stated she did not get a doctor's order, nor did she need to. She stated, upon reviewing the progress notes for R#5, that the doctor or Nurse Practitioner (NP) should have been called after the RT assessed the resident at 10:33 a.m. on the morning of [DATE] because it was a significant change of condition and the clinical picture was concerning. On [DATE] at 3:15 p.m. the DON was interviewed in her office. She reviewed R#5's progress notes with the surveyor and stated the doctor should have been called on [DATE] at 10:33 a.m. because the vital signs and clinical picture were concerning. She stated she agreed there was nothing in the record that indicated the doctor, or the NP was called. The DON agreed the clinical picture amounted to a significant change of condition. On [DATE] at 4:45 p.m. Licensed Practical Nurse (LPN) II was interviewed in the surveyor's work room. She stated she had been a nurse for one year. She stated she was R#5's nurse on the morning of [DATE]. She stated she did confer with RT HH that morning about R#5's vital signs. She stated she agreed these vital signs amounted to a significant change of condition and the doctor should have been notified. She stated she did not notify the physician or the RP of the change of condition. She stated she checked the vital signs at about noon and again at about 2:00 p.m. and found the heart rate had improved to about 120 and she was no longer concerned. She stated she agreed 120 was still a high heart rate. She stated she could not remember if she documented those vital signs. An interview was conducted with Registered Nurse (RN) JJ in the surveyor's workroom on [DATE] at 5:00 p.m. She stated she was the Unit Manager of the Rehab Unit where R#5 resided. She stated she had been reviewing the records and there was no question about it: the assessment the RT did on R#5 on [DATE] at 10:33 a.m. revealed a significant change of condition and the doctor should have been notified. She stated she expected her staff to assess accurately and to notify the physician or the NP when a concern was identified A telephone interview was conducted on [DATE] at 3:20 p.m. with the Medical Director (MD). He stated he had worked for the corporate entity for [AGE] years and knew the facility well. He stated he was R#5's physician. He stated the vital signs taken on [DATE] at 10:33 a.m. by the RT were concerning and he should have been called. He stated this would be considered a significant change of condition. He stated he did not recall being notified at any point about R#5's condition on [DATE], or even after she went to the hospital. He stated he expected to be notified of any change of condition for any of his patients. On [DATE] at 10:30 a.m. a telephone interview was conducted with the R#5's son. He stated he was R#5's Responsible Party (RP) and Power of Attorney (POA). He stated on [DATE] at 8:14 p.m. he went to visit R#5 at the facility. He stated he knew the exact time because he had just checked his iPhone. He stated when he entered R#5's room she was gasping for breath and in a bad way. He stated he went out in the hall and asked a staff member to get a nurse. He stated the nurse assessed R#5 and called 911. He stated no one called him at any time on [DATE] to advise him about R#5's condition. On [DATE] at 2:50 p.m. the MD was further interviewed in the conference room. He stated, upon reviewing R#5's progress notes and her admitting diagnoses, the RT should have notified him of R#5's [MEDICAL CONDITION](rapid heartbeat) on [DATE] after his 10:33 a.m. encounter. On [DATE] at 3:10 p.m. the ADON was further interviewed in the Rehabilitation hall. She stated she did not call the doctor after she sent R#5 to the hospital on [DATE]. 2. Review of the undated face sheet in the EHR revealed R#16 was admitted to the facility in (YEAR). Review of the progress notes revealed he was discharged to the hospital on [DATE], where he expired on [DATE]. Review of the [DIAGNOSES REDACTED]. Review of his [DATE] Annual Minimum Data Set (MDS) section C revealed he had a Brief Interview for Mental Status (BIMS) score of 8 out of 15, signifying moderate-to-severe cognitive impairment. Review of section H revealed he was always incontinent of bowel and bladder. Review of section N revealed he received anticoagulant medication. Review of R#16's [DATE] physician's orders [REDACTED]. Review of the [DATE] 9:37 a.m. nurses note revealed R#16 had one bloody stool during the night. Further review revealed that there was not any evidence the physician or RP were notified of this occurrence. Review of the [DATE] 3:54 p.m. nurses note revealed R#16 had rectal bleed on 11p.m. - 7 a.m. shift the night before and the [MEDICATION NAME] was not administered by the ,[DATE] shift. The oncoming nurse was made aware. Further review revealed no evidence the physician or RP were notified of this occurrence. Review of R#16's [DATE] care plan revealed he was at risk for bleeding/bruising related to anticoagulant therapy, rectal fistula, and history of rectal bleeding. Approaches included to monitor for bleeding and to notify spouse of rectal bleeding (sic). On [DATE] at 2:30 p.m. LPN PP was interviewed over the telephone. She stated she only worked as needed (PRN) but had worked for the facility for several years. She stated she recalled R#16. She stated she recalled R#16 having bloody stools but did not recall if she notified anyone about it. On [DATE] at 1:20 p.m. the DON was interviewed in her office. She stated the facility did not have documents that were specific to notifying the physician or RP of a significant change in condition. She stated these notifications should be in the progress notes. On [DATE] at 2:50 p.m. the MD was interviewed in the conference room revealed that he should be notified of rectal bleeding for any resident, whether on anticoagulants or not and that he would consider rectal bleeding to be a significant change. | 2020-09-01 |