| 19 |
GREENBRIAR HEALTHCARE |
305005 |
55 HARRIS ROAD |
NASHUA |
NH |
3062 |
2017-09-07 |
157 |
D |
1 |
0 |
9SPV11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to notify the physician with a change of condition of a resident resulting in a hospitalization , for 1 resident in a survey sample of 1 resident. (Resident identifier is #1.) Findings include: Review on [DATE] of Resident #1's (MONTH) (YEAR) Care Plan revealed DPOA (Durable Power of Attorney) was activated [DATE]. The ADL Self Care Performance . section of this Care Plan revealed that Resident #1 was independent with transfers, toilet use, personal hygiene, oral hygiene and eating. This Care Plan also revealed that Resident #1 was an elopement risk/wanderer . Review on [DATE] of Resident #1's Care Plan revealed further that Resident #1 uses antidepressant medication with the Interventions/Tasks listed as Monitor/document/report to MD (medical doctor) prn (as needed) s/sx (signs/symptoms) of depression .slowed movement .disrupted sleep, fatigue, lethargy .changes in cognition . and in the section for . anti-anxiety medications r/t (related to) anxiety . with the Interventions/Tasks listed as . ANTIANXIETY SIDE EFFECTS: Drowsiness, lack of energy .confusion and disorientation .Implement interventions based on results of behavior assessment. Review on [DATE] of the nursing Progress Notes dated [DATE] at 23:36 revealed the following; Resident (Resident #1) had gone out with daughter today. (Resident #1) came back around ,[DATE]. Shortly after (Resident #1) came back, (Resident#1) started to obsess about .daughter . (Resident#1) couldn't sit still for more than 5 to 10 minutes before (Resident#1) got up and continued with .anxiety . After the LNA (Licensed Nursing Aide) got (Resident #1) in bed, (Resident #1) was quiet for a while, but then came back out into the hallway after 2100 still obsessed . Review on [DATE] of the nursing Progress Notes dated [DATE] for Resident #1 revealed the following three individual entries: when the writer was given off report to the on coming nurse, the friend came to visit and was concern (sic). Both the on coming nurse and the writer checked up on the resident and resident was lethargic and non responsive. Immediate response was taken . At approximately 1630 this writer was paged to unit by Charge nurse. Nurse stated that the resident was unresponsive and had vomited. This writer entered the room and observed the resident lying on L (left) side w/scant amount of emesis and drool next to mouth. Resident had a visitor in the room. Upon initial assessment of pupil dilatation this writer noted that pupils were unreactive and requested that 911 be called. LNA (Licensed Nursing Assistant) was instructed to get O2 (oxygen) tank and place resident on 4 liters r/t (related to) O2 saturation in low 80's. This writer also began sternal rub w/o (without) positive effect. This writer left the resident with another RN (Registered Nurse) on the unit to inquire on the status of emergency transport and paperwork. Upon return to the room, the daughter had arrived .Another attempt to arouse resident was made and O2 saturation once again checked. O2 saturation had increased to 93%. EMTs (Emergency Medical Technician) then arrived on unit and took over. At 16:35, this nurse was called down to the resident's room. Resident was in bed on . left side, snoring, emesis and drool on the sheets around . face, unresponsive. Notified supervisor who came right up. Pupils unreactive, ,[DATE], Pulse 118, 86% O2 (oxygen) RA (room air), resp (respirations) 18, temp (temperature) 99.5. Resident is a Full Code. Called 911 . Review on [DATE] of Staff C's (Licensed Nursing Assistant) written statement dated [DATE] revealed the following: After breakfast I was told by my nurse (Staff D) that the resident was very tired and she put (Resident #1) in .chair because she could not convince the resident to lay down on (Resident #1) bed. I (Staff C) checked on resident twice and reported to nurse (Staff D) that (Resident #1) was still sleeping A few hours after my nurse (Staff D) asked me (Staff C) to help her transfer the resident to . bed because (Resident #1) was hanging over .chairarm and she did not want (Resident#1) falling. The resident did not wake up during the transfer, after we got (Resident#1) on .bed, the visitor that was also in the room tried speaking to the resident at which the resident mumbled an unrecognized word. I (Staff C) checked on the resident two more times before my (Staff C) shift ended and reported to nurse (Staff D) that the resident was snoring. My nurse (Staff D) said let (Resident#1) sleep because (Resident#1) was very tired. Interview on [DATE] at approximately 4:25 p.m. with Staff C (LNA) regarding this incident, revealed that Staff C went to get Resident #1 in the morning after breakfast, went to (Resident #1's) room .(Resident #1) not there. Thought Resident #1 went to get coffee. Later observed Resident #1 sitting in chair beside bed and that the Resident #1 looked like a drunk and acted like a drunk person, limp and leaning on staff . Staff C reported to Staff D what she observed and was told let (Resident #1) sleep because (Resident #1) didn't sleep last night. Staff C reported at this time that this was not like Resident #1 and that Resident #1 usually doesn't sleep that late and is usually up & about. Staff C was told by Staff D to leave Resident #1 alone and let Resident #1 sleep. Staff C further revealed during this interview that Staff D asked Staff C to help transfer Resident #1 back to bed and reported that Resident #1 was leaning on staff for support and that Resident #1 was very limp with Resident #1's upper extremities, like (Resident #1) was zonked and staff had to lift Resident #1 into bed. Staff C revealed that during this transfer Resident #1 didn't say words .mumbled and staff were unable to understand Resident #1. Staff C revealed that Staff C checked Resident #1 and could hear (Resident #1) snoring. Staff C revealed that Resident #1 was not awake for lunch on [DATE]. Staff C was told to let (Resident #1) sleep .(Resident #1) is very tired by Staff D. Staff C revealed during this interview that when Staff C rendered care after lunch at the time of change of shift to check and change (check for urination and change under garment) Resident #1 was rolled on the bed to change undergarment. Staff C revealed that a clean undergarment was applied to Resident #1 and that Resident #1 was not awake, did not stir or verbalize anything during this task. Interview on [DATE] at approximately 2:15 p.m. with Staff A (Administrator) and Staff B (Assistant Director of Nurses) confirmed that Resident #1 had a change in condition on [DATE] when Resident #1 was leaning on staff for support and was limp with upper extremities and mumbling words staff could not understand during transfer from the chair to bed. The facility failed to notify the physician at the time Resident #1 had a change in condition which was confirmed by Staff A and B during interview on [DATE]. Staff A reported that facility staff were educated on the procedure for What is a change in condition and When to Notify on [DATE]. Surveyor:[NAME]B. Review on [DATE] of Resident #1's incident revealed a signed statement dated [DATE] by Staff D (Licensed Practical Nurse/Licensed Vocational Nurse) who documented the following: Morning routine (Resident #1) always up and about. As I went in my morning shift (Resident #1) kept talking to me as usual. (Resident #1) is always up in the morning and comes to talk to me and the LNA's. (Resident #1) looked exhausted but I had been told (Resident #1) usually doesn't get much sleep in the night. Around 9:30 - 10:00 I told (Resident #1) . try (sic) to take a nap (Resident #1) was sitting in (sic) the couch in front of elevators and was ambulating and walked to . room. Sat down in the recliner because (Resident #1) refused to be in bed. (Resident #1) was fine @ (sic) that time and then .friend (name omitted) came to visit .friend said we should come in went to see (Resident #1) and (Resident #1) was sleeping, no hard breathing noted, no high respirations no sweating or excessive sweating noted. The snoring was normal. Not deepen at this time @ (sic) 11:00. Resident was transferred 1200 (sic) from the recliner to bed. Resident usually doesn't eat much through the day. (Resident #1) didn't eat breakfast or lunch. Resident usually can take a nap during the day. The LNA and I checked up on resident throughout the day. The resident did not throw up the times that I rounded . pupils were reactive when I checked upon (Resident #1). After giving report to the on coming nurse (Resident #1's) friend came to us and said something is wrong we went to see (Resident #1) was on (Resident #1's) left side emesis (sic), . was breathing heavily, .was sweating profusely so immediate action was place called 911 supervisor was called and (unreadable writing) and doctor. Interview on [DATE] at approximately 11:20 a.m. with Staff D, Staff D stated the events occurring on [DATE] that lead up to Resident #1 being transported out to the hospital: Staff D stated that she had come in to her shift and was told the Resident #1 had not slept well the previous night. When Staff D left report Resident #1 approached her to talk and then Resident #1 went downstairs as Resident #1 usually does to get breakfast. When Resident #1 came back upstairs Resident #1 sat on the couch in front of the elevators and dozed off. Staff D approached Resident #1 and encouraged Resident #1 to go back to his/her room and take a nap. Resident #1 ambulated back to his/her room and sat in Resident #1's recliner - this was around 10:30 a.m. Around 11:00 a.m. Staff D was approached by Resident #1's family friend who stated she was concerned about Resident #1 as she was sleeping in the recliner chair in the room and was slumped over the side of the chair and was not responsive. Staff D asked Staff C (LNA) to assist Staff D in getting Resident #1 into the bed for a nap. Staff D and Staff C arrived in Resident #1's room and stood and pivoted Resident #1 into bed. Resident #1 did not wake up or respond to this transfer. Once Resident #1 was in bed Resident #1 opened one eye, looked at the family visitor and mumbled something to her that was unintelligible the Resident #1 appeared to be sleeping. Staff D was asked if Staff D had performed an assessment of Resident #1 and Staff D stated that she had performed an assessment that appeared to be normal but that she had another resident that was in crisis and needed to be sent out to the emergency room . Staff D stated that she did not document the assessment because she was too busy with the other resident and had forgotten. Staff D was asked if Staff D notified Resident #1's physician and Staff D stated she had not as she believed Resident #1 was just tired based on the report she had received during morning report. This writer asked if the way Resident #1 had presented during Staff D's shift was the way Resident #1 usually presented and Staff D stated, No, generally (Resident #1) was up and about walking around and socializing. Staff D went on to explain that later in the day the family friend had returned, probably around 4:00 p.m. and asked Staff D to come see Resident #1 because Resident #1 was not responding and had vomited in Resident #1's bed. Staff D performed an assessment at this time of Resident #1 who was found on left side in vomit and drool around face, unresponsive, pupils were not reactive, blood pressure was ,[DATE], pulse was 118 and oxygen saturation on room air was 86% and Resident #1 had a temp of 99.5. On call MD was notified and 911 called for transport. The shift supervisor for the facility was notified of the situation. Staff D stated that the resident was transported to the hospital and died approximately 23 hours later. Interview on [DATE] at approximately 4:25 p.m. with Staff C (Licensed Nursing Assistant) regarding the events of [DATE] with Resident #1, Staff C stated that she was concerned throughout her shift and notified the Staff D a couple of times that the resident was still sleeping. Staff C stated that she was told by Staff D to just let Resident #1 sleep as she did not sleep well the night before and was just tired. When asked Staff C if Resident #1 had lunch and Staff C stated that Resident #1 did not as Staff C had been instructed not to wake Resident #1 because Resident #1 was so tired. Staff C stated that she did assist Staff D with transferring the resident around 11 a.m. from the recliner chair to the bed because Resident #1 was hanging over the side of the recliner. Staff C stated that during this transfer the resident acted like a drunk person, she was limp and leaning on staff as Staff C and Staff D pivoted Resident #1 into bed. Staff C stated that Resident #1 did not wake up during this transfer but did mumble something once Resident #1 had been transferred to bed but Staff C could not understand what Resident #1 had said and then Resident #1 slept. |
2020-09-01 |