| 9241 |
GOLDEN LIVINGCENTER - GRAND ISLAND PARK PLACE |
285105 |
610 NORTH DARR AVENUE |
GRAND ISLAND |
NE |
68803 |
2013-03-21 |
309 |
J |
0 |
1 |
FG2G11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER: 175 NAC 12-006.09 Based on record review and interview, the facility staff failed to ensure a licensed nurse assessed the change in condition of 1 resident (Resident 09) who had become unresponsive and the facility staff failed to assess the resident after a medication error. The facility census was 55 and the survey sample size was 45. Findings are: Review of an ADMISSION RECORD dated 7/12/12 revealed Resident 09 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A. During an interview on 3/12/13 at 2:57 PM, Resident 09's child revealed that on Wednesday, 3/6/13, the child came to visit the resident during supper at about 6:00 PM. Resident 09's child revealed the resident was found in the dining room and was unresponsive even after the sternum rub (a method to check for a person's response by rubbing the sternum with the knuckles of the hand). Resident 09's child stated staff were in the area, but no one noticed, so the child took Resident 09 to the bedroom and started oxygen on the resident. Resident 09's child revealed the resident was taken to the hospital and given [MEDICATION NAME] (an intravenous medication that prevents or reverses the effects of opioids/narcotics including respiratory depression, sedation and [MEDICAL CONDITION]). Resident 09's child explained the resident returned to the facility later on 3/6/13, but the next day on 3/7/13, Resident 09 became unresponsive again and returned to the hospital. During an interview on 3/12/13 at 6:23 PM, Nursing Assistant (NA) -E revealed that, at about 6:00 PM on 3/6/13, the NA first thought Resident 09 was sleeping in the dining room. Then NA-E noticed the resident did not have oxygen (O2) on and NA-E was unable to wake the resident. NA-E described that Resident 09 had the head tilted back and the skin was bluish. NA-E revealed Resident 09's unresponsiveness was brought to Registered Nurse (RN) - F's attention. The RN was on break and RN-F told the NA to keep trying to wake Resident 09 and to pinch the resident's neck, but the RN did not go into the dining room to assess the resident. NA-E revealed that after attempts to awaken Resident 09 failed, RN-F was consulted and the NA was instructed to go get Licensed Practical Nurse (LPN) -P. NA-E revealed the NA had worked with Resident 09 for about 15 minutes. NA-E stated Resident 09 usually had O2 on and didn't go long without it. NA-E estimated Resident 09 had been without O2 for about 4 1/2 hours and then stated, if Resident 09 went too long without O2, the resident got ill. During an interview on 3/12/13 at 6:12 PM, LPN-P revealed, NA-E brought to the LPN's attention that Resident 09 wouldn't wake up on 3/6/13. LPN-P described Resident 09 was blue around the mouth and did not respond when the LPN pinched the resident's neck, but squinted when the LPN did the sternum rub. LPN-P revealed that Resident 09's child put O2 on the resident and an ambulance was called. During an interview on 3/13/13 at 1:56 PM, NA-K revealed that, at around 6:00 PM on 3/6/13, Resident 09 appeared to be sleeping at first with the head tilted back. Then Resident 09's child came in and didn't think Resident 09 looked right. NA-K revealed NA-E stated (gender) went to talk to RN-F; but RN-F did not come and look at Resident 09, but LPN-P did as soon as NA-E got the LPN. NA-K stated RN-F was the charge nurse for the dining room area, but did not see RN-F during this time, and didn't know where RN-F was. NA-K revealed Resident 09's fingers were a little blue. NA-K stated that Resident 09 did not use O2 all the times, but would sometimes later at night. During an interview on 3/20/13 at 3:35 PM, the Director of Nursing (DON) revealed Resident 09 did not have a physician's orders [REDACTED]. The DON stated even though Resident 09 did not have an order for [REDACTED]. During an interview on 3/13/13 at 11:25 AM, RN-F revealed Resident 09 had gotten sick while the RN was on break. RN-F explained NA-K came to the break room and reported staff couldn't wake Resident 09. Then RN-F told the NA to call the north nurse (LPN-P) to check on Resident 09. Then RN-F got a message that Resident 09 was being sent to the hospital, so RN-F finished the call to the ambulance and sent the LPN back to be with Resident 09. RN-F revealed (gender) did not assess Resident 09's change in condition. Review of Resident 09's Progress Notes dated 3/6/13 at 6:53 PM revealed (resident) was not responsive. upon my arrival (Resident 09) was blue in color and was gasping for air. (Resident 09) remained unresponsive even to painful stimuli. The entry was signed by LPN-P Review of the facility's VERIFICATION OF INVESTIGATION dated 3/13/13 revealed: - On 3/6/13 at approximately 6 PM resident was in West Dining Room, when staff note that (Resident 09) is difficult to arouse, staff attempt to wake resident and cannot, this information is relayed to (RN-F), whom instructs CNA's nursing assistants) in how to try to wake the resident, CNA attempts without success, and return to RN with update, at which point (the CNA) is instructed to notify the charge nurse for North Station; - interview with NA-E revealed did not know where RN-F was, but went to the break room purposely seeking the nurse. NA-E stated RN-F told the NA to go and try again, and was instructed to try pinching (Resident 09's) pressure points on shoulder. The interview revealed NA-E tried the pressure point pinching and it did not work, went back to the break room and reported concerns that Resident 09 did not respond and skin was tinted to RN-F, then NA-F only raised one eyebrow and instructed the NA to go get the LPN. B. Review of Resident 09's Progress Notes revealed: - 3/7/13 at 1:04 AM: resident returned to the facility at 2220 (10:20 PM); - 3/7/13 at 11:05 AM: Resident is asleep and difficult to arose. was lethargic, difficult to arose w/ (with) mottled hands and unable to speak clearly. sent resident to ER (emergency room ). - 3/7/13 at 6:27 PM: resident returned from ER this afternoon. Review of the EMERGENCY PHYSICIAN RECORD dated 3/7/13 revealed Resident 09: - Had been seen approximately 18 hours ago for same. [MEDICATION NAME] (patch that releases a narcotic medication to relieve pain) removed; - Clinical impression: Narcotic overdose - accidental. Review of a physician's orders [REDACTED]. Review of Resident 09's Medication Administration Record [REDACTED]. Review of Resident 09' Progress Notes revealed on 3/12/13 located fentynal patch 50 mcg on resident R (right) Back dcd (discontinued) patch at this time. During an interview on 3/13/13 at 9:05 AM, the Director of Nursing (DON) revealed the administration of the [MEDICATION NAME] to Resident 09 was a medication error and the resident should have been monitored for any adverse reactions. The DON revealed the monitoring was documented on the critical charting list, they just added (Resident 09) today (3/13/13) and hadn't done any assessment yet, but will do it later. Review of the critical charting list revealed no assessments of Resident 09's condition had been completed on 3/12/13 or during the morning of 3/13/13. Review of the facility's MEDICATION ERROR AND ADVERSE DRUG REACTION REPORTING dated 10/07 revealed Any new prescriber's orders are implemented, and the resident is monitored closely for 24 to 72 hours or as directed. ABATEMENT STATEMENT Based on the following, the facility has removed the immediacy of the situation: 1) Inservice training with all licensed nurses on the correct procedure for taking off physician's orders [REDACTED].>2) Inservice training with all staff, licensed or certified, who administer medications regarding the process for discontinuing narcotics; 3) Implementation of a checklist to be used that includes the 6 steps on how to process a physician's orders [REDACTED].>4) Implementation of a process to verify new and discontinued physician's orders [REDACTED].>5) All resident medications were checked against current physician orders [REDACTED].>6) Inservice training with all nursing staff on the identification of a change in resident condition and how to respond in an emergency situation; and 7) Inservice training with all staff, licensed or certified, on Critical Charting documentation related to for ongoing monitoring of residents' health conditions. The immediacy has been removed, however, the deficient practice has not been totally corrected. Therefore, the scope and severity has been lowered to D. |
2016-09-01 |