cms_NE: 6433

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.

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rowid facility_name facility_id address city state zip inspection_date deficiency_tag scope_severity complaint standard eventid inspection_text filedate
6433 THE AMBASSADOR LINCOLN 285066 4405 NORMAL BLVD LINCOLN NE 68506 2016-02-29 328 J 1 0 5EYL11 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference: 175 NAC 12-006.09D6 Based on interviews and record reviews, the facility failed to ensure an Oximeter (oxygen saturation monitoring device) was turned 'on' and functioning to alert staff of the declining oxygen saturation level for Resident 1. Facility census was 76. Findings are: A. Review of Admission report in the Medical Record for Resident 1 revealed an admission to the [MEDICAL CONDITION] Unit on 2/8/16. Resident 1's code status was changed to Do Not Resuscitate on 2/11/16 per Resident 1 Power of Attorney. Resident 1 had medical [DIAGNOSES REDACTED]. - Pneumonia, - Extreme [MEDICAL CONDITION], - Hypoventilatio[DIAGNOSES REDACTED] with severe obstructive sleep apnea, - History of Chronic [MEDICAL CONDITION] (an incision in the windpipe for artificial opening through the neck to allow passage of air or evacuate secretions), - History of Motor Vehicle Accident with chronic disability. - [MEDICAL CONDITION] requiring mechanical ventilation,(an appliance for artificial respiration/ breathing) - weaning protocol, guarded prognosis given the obesity hypoventilation history and [MEDICAL CONDITION] (without oxygen) [MEDICAL CONDITION], - previous [MEDICAL CONDITION] ( [MEDICAL CONDITION]), - Heart Failure, and - [MEDICAL CONDITION]. A Facsimile (FAX) communication report dated 2/16/16 to Resident 1's Pulmonologist (Respiratory tract/Lung disease specialist) revealed a request, (MONTH) we [MEDICAL CONDITION] (administration of air or oxygen through cannula tube in the patients neck opening) trials daytime. The Physician ordered that the facility would advance [MEDICAL CONDITION] trial for Resident 1 for daytime only but the resident required the [MEDICAL CONDITION] (machine for non-invasive form of mechanical ventilation therapy for sleep apnea) at night. Review of facility investigation report for Resident 1 from the incident on 2/20/16 revealed an unexpected death of Resident 1 when found at respiration check to be without pulse or lung sounds and oximeter machine was not on at time of Resident 1 being found. Interview with Director of Nursing on 2/29/16 at 10:45am revealed that Resident 1 was very sweaty and the pulse oximeter device kept slipping off of Resident 1 on 2/20/16 which was a common occurrence. The oximeter monitor device was applied to Resident 1's ear lobe as Resident 1 did not tolerate the device when applied to fingers. Review of nursing notes for Resident 1 on 2/29/16 of entries recorded on 2/22/16 revealed: - 12:30pm facial area moist, oximetry ear probe kept sliding off ear, ear was dried and probe put back on several times during the shift. The room temperature was lowered for Resident 1's comfort. - 4:00pm resident was repositioned and secretions suctioned. The Sa02 (oxygen level) monitor read 92 - 97% with FI02 (forced air with ratio of blood oxygen and inspired (breathed in) oxygen through a tube) @ at 35% [MEDICAL CONDITION]. - 5:00pm Resident 1 restless and received a pain pill and repositioning. - 5:40pm Resident 1 checked and sleeping comfortably. Review of Resident 1 medical record for treatment note charting by Respiratory Therapist from 2/20/16 revealed: - 6:20pm went to provide breathing treatment scheduled and found (Resident 1) was laying on the ear probe for the oximeter, which was turned off. Put the ear probe on ear and turned on the oximeter. While waiting for the oximeter to read SA02 (saturation of oxygen level in blood) noted was blue in the lips and not responding when change stoma pad (dressing over [MEDICAL CONDITION]). Tried to feel for a radial (arm) or carotid (neck) pulse and listened for breath sounds. Didn't hear any or feel a pulse. Quickly went to get the nurses down at the nursing station. We all went back down to room. Turned O2 (oxygen) up to 100% (was at 35% via [MEDICAL CONDITION] mask for ventilator weaning). Still not getting respirations. Pupils were fixed and dilated. Was on the cool mist Nebulizer 35% 02 since 6:55 am. The facility policy for Ventilator weaning dated (MONTH) 2014 required non -invasive monitoring including: oximetry for Sp02 (saturation of oxygen available in the blood to support respiratory function) and heart rate with the level of Sp02 to be greater than 90%. B. Review of the Facility Systems with Director of Nursing and [MEDICAL CONDITION] Unit Manager (Respiratory Therapist) on 2/29/16 between 1:30 pm and 2:45 pm revealed that the facility took the following actions to review systems to correct the immediacy of care concerns on the evening of 2/22/16 and 2/23/16 - 1. Checked all oximetry machines the evening of 2/20/16. Signed documents recorded that the facility Respiratory Therapist on the evening/night shift (6:00 pm - 6:00 am) went to each room, checked all the oximeters in all the patient's rooms, and determined all were on and in working condition including the oximeter used for Resident 1. 2. All staff including Nursing staff and Respiratory Therapists, were provided education on 2/23/16 including: Pulse Oximetry Protocols review with staff and discussion of Treatment Record recording of oximetry, Respiratory Therapy orders, exception reports and obtaining clarification orders from physicians and review of Ventilator Weaning Protocol. 3. A second inservice on Medication Errors (including oxygen) was conducted for all staff at the facility on 2/26/16. The meeting also included further information and updating on Respiratory Care Protocols. 4. Internal Investigation of Resident 1's death and resultant staff disciplinary action was given to the two professional/licensed nurses working the day shift of 2/20/16. The personnel files of Nursing Staff J and K were reviewed for this disciplinary action. 5. Facility staff obtained specific physician orders [REDACTED]. for all six residents residing on the [MEDICAL CONDITION] unit requiring ongoing oximetry. These orders included: check Oxygen Saturations twice daily and record; change oxygen site monitoring every morning; Keep Oxygen saturation greater than 90%. The newly obtained clarification orders for the oximetry readings were audited by the Respiratory Manager and also an outside Respiratory Therapist over a three week time period. 6. The Respiratory Unit staff were conducting change of shift rounds in each resident's room to review that resident specific assignment sheet criteria were in place. 7. Staff Interview with Respiratory Therapist (RT) - D on 2/29/16 at 2:58 pm revealed that the oximetry monitors were always positioned in the open metal basket above the residents' bed so the monitor readings could easily be visualized each time staff walk by the rooms. This compilation of correction methods placed the facility in compliance with correction as of 2/23/16 when all staff re-education was provided for Respiratory protocols. 2019-02-01