cms_OR: 89
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 89 | AVAMERE HEALTH SERVICES OF ROGUE VALLEY | 385024 | 625 STEVENS STREET | MEDFORD | OR | 97504 | 2019-06-20 | 684 | J | 1 | 0 | 90J611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > 1. Based on interview and record review it was determined the facility failed to promptly identify and intervene for an acute change of condition for 1 of 3 sampled residents (#5) reviewed for accidents. As a result of this deficient practice Resident 5 experienced a delay in being assessed and treated for [REDACTED]. An immediate jeopardy situation was called. Findings include: Resident 5 admitted to the facility in ,[DATE] with [DIAGNOSES REDACTED]. A Physician order [REDACTED]. Transfer to the hospital and or intensive care unit if indicated. All treatments including breathing machine. An Investigation dated [DATE] revealed the following: -At approximately 8:00 AM Staff 38 (RN) entered Resident 5's room, prior to breakfast, to check her/his blood sugars and administer insulin. The resident was discovered breathing heavily, unable to clear her/his throat. -Resident 5 was on two liters of continuous oxygen, her/his heart rate was 84 beats per minute and the resident was unresponsive, unable to sit forward to clear her/his throat. -Staff were alerted and came to assist, worked to clear Resident 5's airway while the charge nurse called 911 and prepared paperwork. -The ambulance arrived by approximately 8:05 AM and the investigation revealed The resident stopped breathing as paramedics entered. -CPR was performed for approximately 15 to 20 minutes by the paramedics and by 8:30 AM paramedics ceased lifesaving efforts. -Relatives were notified of the resident's passing and physician was notified. -The police conducted an investigation as the death was unexpected and the resident was not resuscitate (DNR). An Accident/Incident Interview Form dated [DATE] revealed Staff 37 (CNA) checked on Resident 5 at 6:30 AM and the resident was in the bed. The incident report indicated Staff 37 reported to Staff 39 (CMA) at 7:00 AM that Resident 5 was breathing heavy and Staff 39 indicated she would talk to Staff 38 (RN). The incident report further indicated Staff 37 was in the assisted dining when Staff 38 checked on the resident and called 911. An Accident/Incident Interview Form dated [DATE] revealed Staff 39 was alerted, by Staff 38 while she was in the residents room to check her/his blood sugars. Staff 39 entered the room with Staff 38 and the resident was making a gurgling sound. Staff 39 was asked to get the crash cart (a wheeled container carrying medicine and equipment for use in resuscitation) and by that time Staff 36 (Interim DNS) joined her in the room. Staff 36 and Staff 39 removed the resident's many pillows, laid the resident's head down enough to roll the resident onto her/his side. Staff 39 cupped the resident's back and performed finger sweeps per Staff 36's instruction and removed the resident's dentures and mucus. Two other CNAs were holding the resident and nurses were getting the suction machine together. Resident 5 stopped making noise as medics entered the room. An undated form typed out and signed by Staff 38 indicated on [DATE] she was working on the 200 hall and around 7:00 AM the nurse from the 300 hall needed assistance with treatments and Staff 37 reported to Staff 39 the resident was breathing heavily. Staff 39 was very busy and did not pass the message on to me (Staff 38). Staff 38 stated she entered Resident 5's room at approximately 8:00 AM as the breakfast trays were coming down the hallway. Staff 38 indicated she discovered the resident needing immediate attention, as the resident was unable to clear the fluid in her/his throat. An Investigation Note dated [DATE] conducted by Staff 36 (Interim DNS) revealed the following: -At approximately 8:00 AM on [DATE] Resident 5 had a change of condition with wet respiration's at a rate of 24 to 26 respirations per minute. The residents heart rate was 80 to 84 beats per minute. -Staff 37 last saw the resident at 7:00 AM and reported to Staff 39 Resident 5 was breathing hard. Interview of Staff 39 stated she/he was snoring, this was normal. -Staff 36 believed it was approximately 8:20 AM and Staff 38 alerted him Resident 5 needed suctioning. Staff 36 went to the resident's room and Staff 39 assisted to turn the resident on her/his right side while Staff 36 went to get the suction machine and AED (automated external defibrillator). -Staff 39 removed the resident's false teeth and cleared the resident's mouth. Prior to Staff 36 leaving the room to retrieve the suction machine and AED the resident's heart rate was 80 to 84 beats per minute with wet respirations at 24 to 26 respirations per minute. The resident was not responding even when repositioned. -Staff 36 was headed down the hall to get the suction machine and AED, the paramedics arrived and were given a report. Staff 39 indicated Resident 5 took her/his last breath just as the paramedics entered her/his room. -The paramedics performed life saving procedures which were unsuccessful and Resident 5 passed away. In an interview on [DATE] at 8:00 AM Staff 17 (CNA) stated she worked the night shift on [DATE] and stated she recalled the resident having a difficult time breathing and her/his breaths were closer together. In an interview on [DATE] at 1:32 PM Staff 37 stated the morning of [DATE] she remembered checking on the Resident 5 around 6:30 AM to see if the resident was awake and the resident's breathing sounded like a chain smoker, the resident would stop breathing for a moment and then start up again. The resident was making a moaning sound and this breathing pattern repeated. She stated the night shift reported to her Resident 5 was having a hard time breathing and restless sleep. Staff 37 tried to ask the resident if she/he was ok, however the resident would not respond. It was like the resident was in a deep sleep, like an unconsciousness state. She stated she reported this to Staff 39 and Staff 39 was going to report to the nurse right away. In an interview on [DATE] at 11:01 AM Staff 38 (RN) stated the morning of [DATE] Staff 37 did not report anything to her regarding Resident 5 having difficulty with breathing. Staff 38 entered Resident 5's room around 8:00 AM to administer her/his insulin and the resident was unresponsive, breathing but very heavy and wet breathing. Staff 38 attempted to arouse Resident 5 but she/he was unresponsive. She immediately went and got help. She first spoke with Staff 39 and stated the resident did not sound good and then retrieved Staff 36. Staff 36 stayed in the room to assist with the resident while she called 911. Paramedics arrived and took over. The paramedics stopped life saving procedures at approximately 8:20 AM. In an interview on [DATE] at 2:44 PM Staff 36 stated Staff 38 came to his office at approximately 7:55 AM and indicated Resident 5 was not acting right. He arrived and entered the resident's room and the resident's breathing was 18 to 20 breaths per minute, very wet and her/his heart rate was 80 to 84 beats per minutes. Multiple staff were in the room and the resident was not responding to anything verbal. He directed an RN to check the resident's blood sugar and he went to retrieve the AED and suction machine. On his way back to the room the paramedics arrived, took over and began cardiopulmonary resuscitation (CPR). Staff 36 further stated in his investigation he recalled Staff 37 reported to Staff 39 Resident 5 was breathing funny. When he spoke with Staff 39 she indicated Resident 5 always snored and breathed heavy in the morning and that was normal. He further indicated after his investigation he felt Resident 5 had no change of condition and felt the incident happened suddenly and staff responded appropriately. On [DATE] at 12:54 PM Staff 1 (Administrator) and Staff 2 (DNS) were informed of the failure to promptly identify and intervene for an acute change of condition for Resident 5. The failure constituted a situation of immediate jeopardy to the health and welfare of residents. A plan of correction was requested to immediately protect residents from having a delay in assessment when an acute change of condition occurred which could result in a resident's death. On [DATE] at 8:37 PM a final immediate plan of correction was received from the facility. The facility's abatement plan of correction included: -Inservices to be completed with all CNA and CMA staff regarding alerts in the electronic system and that all identified changes are put into an alert for Licensed Nurse (LN) follow-up and for significant changes of condition (resident short of breath, stopped breathing, loss of consciousness, had a critical vital sign) to walk the nurse to the room. -Inservices to be completed with all LN staff regarding change of condition, including notification to the responsible party and provider, to check the dashboard (the electronic medical record) frequently, at a minimum every shift and to monitor for alerts triggered by CNA/CMA staff. -Inservice to be completed with Resident Care Manager (RCM) regarding monitoring of 24 hour report daily to ensure all noted changes have a change of condition completed and follow up is addressed and all education to be provided by DNS or RN designee via face to face or phone/verbal prior to clocking in or being present in resident areas. -Date of compliance [DATE]. -DNS responsible for assuring compliance. On [DATE] at 2:30 PM the facility's implementation of the abatement plan was verified with staff interviews to ensure the staff were educated on a change of condition. On [DATE] at 10:19 AM the Staff 1 and Staff 2 were notified the immediate jeopardy was implemented removing the immediate risk to resident's health and welfare. 2. Based on interview and record review it was determined the facility failed to implement and follow physician orders [REDACTED].#s 1, 14 and 20) reviewed for pressure ulcers and medications. This placed residents at risk for delayed treatments and unmet needs. Findings include: a. Resident 1 admitted to the facility in ,[DATE] with [DIAGNOSES REDACTED]. A review of the ,[DATE] TARS revealed the following: -A ,[DATE] TAR instructed staff to apply [MEDICATION NAME] (an ointment) to the right ischial tuberosity (the sit bones) and cover with a non-adhesive foam dressing every day shift, evening shift and as needed. -Records revealed no treatments were provided on ,[DATE], ,[DATE], ,[DATE], ,[DATE] and ,[DATE]. A ,[DATE] TAR instructed staff to apply [MEDICATION NAME] (an ointment) to the coccyx (the tailbone) every shift. -Records revealed on evening shift no treatments were provided on ,[DATE], ,[DATE], ,[DATE], ,[DATE] and ,[DATE]. A ,[DATE] TAR instructed staff to apply [MEDICATION NAME] (antifungal) cream two percent to the face topically two times a day for seborrheic (crust or scale on the skin) [MEDICAL CONDITION]. -Records revealed no treatments were provided on ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE] and ,[DATE]. A ,[DATE] TAR instructed staff to apply [MEDICATION NAME] (corticosteroid) .025 percent topically to the face two times daily for seborrheic [MEDICAL CONDITION]. -Records revealed no treatments were provided on ,[DATE], ,[DATE], ,[DATE],,[DATE],,[DATE] and ,[DATE]. A ,[DATE] TAR instructed staff to check oxygen saturation every shift. -Records revealed no checks were completed on evening shift or night shift for ,[DATE] or ,[DATE]. A ,[DATE] TAR instructed staff to administer oxygen at two liters per nasal cannula continuous every shift. -Records revealed no oxygen saturations were checked or completed on evening shift ,[DATE], ,[DATE], ,[DATE] or ,[DATE]. On [DATE] at 12:30 PM the ,[DATE] TAR was reviewed with Staff 11 (RNCM) for the missing treatments above. She acknowledged the missing documentation and was unable to provide any additional information or documentation. She stated staff were expected to follow physician orders. A review of the ,[DATE] TARs revealed the following: A ,[DATE] TAR instructed staff to apply [MEDICATION NAME] cream to the scrotum, inner thighs topically every shift for irritation, fungal infection and itching until resolved. -Records revealed no treatments were provided on ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE] and ,[DATE]. A ,[DATE] TAR instructed staff to apply [MEDICATION NAME] to the coccyx (the tailbone) every shift for preventative care and a history of skin break down. -Records revealed no treatments were provided on ,[DATE], ,[DATE] and ,[DATE]/. A ,[DATE] and ,[DATE] TAR instructed staff to apply [MEDICATION NAME] (a mild antiseptic) [MEDICATION NAME] to the Left Hallux (big toe) topically every day and evening shift for skin care. -Records revealed no treatments were provided on: ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE] and ,[DATE]. A ,[DATE] TAR instructed staff to document sleep every shift while the resident was on a stimulant. -Records revealed not documentation was completed on ,[DATE],,[DATE], ,[DATE] or ,[DATE]. On [DATE] at 12:30 PM the ,[DATE] TAR was reviewed with Staff 11 (RNCM) for the missing treatments noted above. She acknowledged the missing documentation and was unable to provide any additional information or documentation. She stated staff were expected staff to follow physician orders. b. Resident 20 admitted to the facility in ,[DATE] with [DIAGNOSES REDACTED]. Review of the facility's Bowel Care Protocol, revealed residents who did not have a bowel movement (BM) would be identified and placed on a BM report. -Evening shift would run the look back report for residents who did not had a bowel movement for two consecutive days. -Evening shift staff would administer Milk of Magnesia (a laxative) if no results, then; -Day shift would administer a suppository if no results, then; -Fleet enema would be given. If no results, complete a focused assessment of the abdomen and complete a digital exam and notify the doctor if needed. -Suppositories and enemas are not to be given on night shift unless it is a resident's request. Review of Resident 20's bowel records revealed from [DATE] through [DATE] (four days) and [DATE] through [DATE] (four days) Resident 20 did not have BMs documented. Review of the ,[DATE] MARs revealed Resident 20 did not receive Milk of Magnesia (MOM) per Bowel Care Protocol. On [DATE] at 1:02 PM Staff 11 (RNCM) acknowledged the bowel protocol was not followed. c. Resident 14 was admitted to the facility in with [DIAGNOSES REDACTED]. [DATE] and [DATE] physician orders [REDACTED]. A ,[DATE] MAR indicated [REDACTED]. On the following days Resident 14's blood pressure or heart rate was not checked before administering the medication: -[DATE] Blood pressure and heart rate not checked one out of three instances. -[DATE] Blood pressure and heart rate not checked one out of three instances. -[DATE] Blood pressure and heart rate not checked one out of three instances. -[DATE] Blood pressure and heart rate not checked one out of three instances. -[DATE] Blood pressure and heart rate not checked one out of three instances. -[DATE] Blood pressure and heart rate not checked one out of three instances. -[DATE] Blood pressure and heart rate not checked one out of three instances. -[DATE] Blood pressure and heart rate not checked one out of three instances. No other documentation was found in the clinical record Resident 14's blood pressure or heart rate was checked as ordered on the above dates. On [DATE] at 10:27 AM Staff 11 (RNCM) stated she would review for additional information. No additional information was provided. | 2020-09-01 |