cms_NE: 5522

In collaboration with The Seattle Times, Big Local News is providing full-text nursing home deficiencies from Centers for Medicare & Medicaid Services (CMS). These files contain the full narrative details of each nursing home deficiency cited regulators. The files include deficiencies from Standard Surveys (routine inspections) and from Complaint Surveys. Complete data begins January 2011 (although some earlier inspections do show up). Individual states are provides as CSV files. A very large (4.5GB) national file is also provided as a zipped archive. New data will be updated on a monthly basis. For additional documentation, please see the README.

This data as json, copyable

rowid facility_name facility_id address city state zip inspection_date deficiency_tag scope_severity complaint standard eventid inspection_text filedate
5522 SORENSEN CARE AND REHABILITATION CENTER, LLC 285107 4809 REDMAN AVENUE OMAHA NE 68104 2016-11-14 309 J 1 0 7EEE11 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number: 175 NAC ,[DATE].09 Based on record review and interview, the facility failed to assess and provide emergency treatment as needed for Resident 1. Sample size was five residents. The facility Census was 66 The facility policy titled Clinical Health Status Version# 5, dated with an effective date of [DATE] revealed: The process for identification of change of condition included gathering objective data and documenting assessment findings, resident and physician and family notification. A record review of the Admission Record, dated (MONTH) 3, (YEAR), revealed that Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of a Nurse's note dated [DATE] at 10:30 AM by Registered Nurse (RN) B revealed Resident 1's vital signs were a temperature of 97.2 degrees Fahrenheit. Resident 1's blood pressure had been ,[DATE] and a pulse was 108. Resident 1's respiration rate was 18 breaths per minute and had an oxygen saturation of 96% on room air. Resident 1 was alert and oriented. Resident 1 was independent with transfers and ambulated with a walker. Resident 1 was independent with activities of daily living (ADL's). Resident 1 had no shortness of breath and did not require oxygen. Resident 1 had no complaints of pain and was using the telephone and talking with family and friends. A record review of Resident 1's medical record, titled Progress Note dated [DATE] at 6:00 AM, written by Licensed Practical Nurse (LPN) A, revealed that Resident 1 was yelling and was having trouble breathing. The on-duty, Nursing Assistant (NA) requested that the nurse report to Resident 1's room. Resident 1's oxygen saturation was 84% (Lippencott's Nursing Center states that SpO2, or pulse oximetry, is normal when in the range of 97 to 99 percent). Resident 1 presented with good color and was assisted to bed. An assessment of Resident 1's lungs revealed clear sounds in the upper lungs bilaterally and diminished sounds in lower lungs bilaterally. Oxygen was applied by nasal cannula (a device used to deliver supplemental oxygen or increased airflow to a patient or person in need of respiratory assistance) at 2 liters. Resident 1's oxygen saturation was then 91%. Resident 1 was reassured and made comfortable in bed. Resident 1 had voiced no additional distress. An interview with LPN A on [DATE] at 4:40 PM revealed that Resident 1 had been under the care of LPN A for three nights. LPN A revealed that Resident 1 had initially, called for help due to having problems breathing at 3 AM. LPN A confirmed that Resident 1 had called for help three times from 3:00 AM till 5:15 AM. LPN A revealed that NA C called over to the west nursing station at 5:15 AM and informed staff that Resident 1 needed help right away and Resident 1 was having difficulty breathing The NA stated that Resident 1 was screaming that Resident 1 was unable to breathe. LPN A revealed at 5:15 AM a check of Resident 1's oxygen level had been performed and it was 84% but came up to 91% after oxygen had been applied. LPN A confirmed that Resident 1 did not have an order for [REDACTED]. LPN A confirmed that no vital signs except the oxygen saturation had been performed on Resident 1 during the three visits to Resident 1's room, for respiratory distress. LPN A confirmed the inhaled medication that was administered to Resident 1 was not documented and that the time it was administered could not be recalled. LPN A confirmed that Resident 1's physician was not notified of the Resident's change in condition. Interview with NA C on [DATE] at 3:40 PM revealed that Resident 1 had turned on the call light at 3:00 AM. Resident 1 had requested an inhaler. NA C revealed that LPN A had arrived within 5 minutes and was observed administering Resident 1's inhaler. NA C revealed that Resident 1 called again and complained of feeling sick and unable to breathe. NA C revealed that LPN A did come at 3:50 AM but another resident had required assistance and NA C had left the room. Resident 1 came out into the hall at 5:15 AM and was screaming. Resident 1 was not feeling good and had trouble breathing. NA C revealed that LPN A had come back to Resident 1's room and checked an oxygen level, and applied some oxygen. Interview with RN D on [DATE] at 12:08 PM revealed that Resident 1 had stopped breathing during RN D's shift on [DATE] at 7:15 AM. RN D revealed that NA [NAME] had called for assistance and that Resident 1 had been found on the toilet and was not responsive. RN D revealed that Resident 1 was without pulse, not breathing, and cool in extremities. RN D revealed that the NA was told to stand-by while RN D had gone to the EMR to check on Resident 1's Code Status (to perform Cardio [MEDICAL CONDITION] Resuscitation (CPR) or Not to perform CPR). RN D revealed that the EMR stated that Resident 1 was a Full Code (Do perform CPR). RN D revealed that NA [NAME] was told to perform CPR and that RN D called 911. RN D revealed that upon looking into the paper chart there had been a document that had been signed by Resident 1's family, and that it stated Resident 1's wish had been Do Not perform CPR. RN D revealed that while checking the chart the 911 crew had arrived and RN D told the 911 crew that Resident 1 did not wish to have CPR. The NA [NAME] was told to stop CPR. RN D stated that the resident had not been revived with the CPR. Interview on [DATE] at 12:18 PM with the Director of Nursing (DON) confirmed that when vitals were recorded it would be found in the nursing notes of the nurse who had taken the vitals. The DON confirmed that no vitals other than oxygen saturation had been performed on Resident 1 on [DATE] from 3 AM to time of death at 7:15 AM. The DON confirmed that an assessment/evaluation would be expected of the nursing professional when a resident was having difficulty breathing or respiratory distress. The DON confirmed that the assessment/evaluation for Resident 1 would have been expected to include blood pressure, pulse rate, respiration rate, temperature, and a head to toe assessment. The DON confirmed that a notification to physician and family should have been done and that this did not occur for Resident 1. The Immediate Jeopardy was abated on [DATE] after the following interventions were put in place: - A Head-to-Toe assessment cheat sheet was put in place. - All licensed nursing staff on duty were educated on acceptable clinical assessment procedures as well as resident change in condition procedures. - All licensed nursing staff were to be educated on acceptable clinical assessment procedures as well as resident change in condition procedures before working their next shift. 2019-11-01