| 8273 |
CAPSTONE HEALTH & REHAB OF EASLEY |
425298 |
1850 CRESTVIEW ROAD |
EASLEY |
SC |
29642 |
2012-07-12 |
157 |
G |
0 |
1 |
PSVU11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interview, the facility failed to notify the physician timely for 1 of 9 residents reviewed with a change in their condition. The facility did not notify the physician when Resident #7, with history of respiratory distress, respiratory status changed. The findings included: The facility admitted resident #7 with [DIAGNOSES REDACTED]. Review of the nurses notes revealed the following documentation: 6/9/12 11:50 (no am or pm), Resident stated I don't feel well and I can't breathe. Resident also stated, Take me to the hospital! VS (vital signs) are as followed (sic): T (temperature) 99.6, P (pulse) 161, O2 (Oxygen) 51%, Resident diaphoretic and RR (Respirations) labored and uneven. Called on call NP (nurse Practitioner) ____ New order to send to ER. 6/12/12, 3:30 PM Resident returned to facility . The nurses notes throughout the resident stay described the resident's respirations as even and unlabored until 6/26/12. 6/26/12, 1230AM (late entry) Resp even and unlabored. 6/26/12, 3:00 AM (late entry) Resp shallow, lying in bed with eyes closed. Sleeping soundly, hard to arouse. O2 @ 2L (liters) NC (nasal cannula). There was no MD notification of shallow respirations or that the resident was difficult to arouse. 6/26/12, 640 AM (late entry) O2 88% inc. (increased) O2 to 3L, O2 increased to 92%. Informed on coming nurse of residents status. VS 156/70, 22, 91, 97.9. Will continue to monitor resident. There was no MD notification of the decreased oxygen saturation level or the decision to increase the oxygen flow rate for the resident with known [MEDICAL CONDITION]. 6/26/12, 8:15 (no am or pm) Resident noted to be diaphoretic, breathing labored, O2 Sat 83% on 3L/M,, increased O2 to 4L/M via N/C (nasal cannula) v/s 168/76 -92-29-98.8. Called NP (Nurse Practitioner) and spoke to her and she said to contact family and send out . The physician or nurse practitioner was not notified until 8:15 AM after the resident was noted to be diaphoretic and the resident's oxygen had again been increased to 4L/M. Review of the Resident's Physician orders revealed Oxygen was ordered at 2L/M. There was no Physician's order to increase the Oxygen rate for the resident with [MEDICAL CONDITION]. The resident was sent to the hospital and required intubation for respiratory distress. A Consultation report dated 6/29/12, contained transfer information from the hospital. The report stated, This patient .admitted on [DATE] with shortness of breath and [MEDICAL CONDITION], had to be intubated and was noted to have pneumonia During an interview with the Director of Nursing on 7/12/12 at approximately 3:00 PM, she provided a statement from the nurse on duty at the time of the transfer which stated the Nurse Practitioner was called at 7:45 AM. Review of the Standing Orders fir Dyspnea/Cyanosis, stated, Obtain resident vital signs, pulse oxygen level, note any [MEDICAL CONDITION], have recent and prior weights available, and then notify MD. If RN available, assess cardiac and lung sounds prior to contacting MD. |
2016-06-01 |