| 8274 |
CAPSTONE HEALTH & REHAB OF EASLEY |
425298 |
1850 CRESTVIEW ROAD |
EASLEY |
SC |
29642 |
2012-07-12 |
328 |
G |
0 |
1 |
PSVU11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review, observations and interviews, the facility failed to provide appropriate services for 1 of 1 residents with acute change in respiratory status and 2 of 8 residents with oxygen concentrators. Resident #7 with known respiratory distress did not receive timely intervention for changes in her respiratory status. Resident #1 and one additional random resident did not have filters in place in their oxygen concentrators. The findings included: The facility admitted resident #7 with [DIAGNOSES REDACTED]. The resident had a history of [REDACTED]. On 6/26/12, the resident was noted to have shallow respirations and was difficult to arouse at 3:00 AM. There was no assessment done to check breath sounds or vital signs once the resident had been noted to be difficult to arouse and had shallow respirations. At 6:40 AM, the resident oxygen saturations were down to 88%, the nurse increased the oxygen flow and failed to notify the physician. There was no no documentation that an assessment had been done. 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 for the second time 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. Review of Perry and Potter, Clinical Nursing Skills & Techniques, 7th Edition, Copyright 2010, Assessment of Signs and Symptoms Associated with [MEDICAL CONDITION] included: Apprehension, anxiety, behavioral changes, decreased level of consciousness, confusion, drowsiness, altered concentration, increased pulse rate and depth of respiration or irregular respiratory patterns, decreased lung sounds, adventitious lung sounds (e.g., crackle, wheezes), elevated blood pressure evolving to decreased blood pressure, Pulse Oximetry (SpO2) less than 90%, Dyspnea, Use of accessory muscles of respiration, rib retractions, cardiac [MEDICAL CONDITION], Pallor, Cyanosis, increased fatigue, Dizziness and clubbing of nails resulting from prolonged, chronic [MEDICAL CONDITION]. The medical record documented the resident's Oxygen Saturation had dropped below 90%. The nurse increased the Oxygen flow on a resident with [MEDICAL CONDITION] without consulting the physician. There was no indication the resident had been assessed for respiratory status which included breath sounds. There was no description of the residents' inspiration or expiration, skin color, or types of breaths. During an interview with the Director of Nursing on 7/12/12 at approximately 11:15 AM, she confirmed she would have expected an assessment to have been done, when the nurse documented the residents respirations were shallow and she was difficult to arouse. The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Observation during the Initial Tour on 7/9/12 at approximately 6:45 PM revealed Oxygen concentrators in use in rooms [ROOM NUMBERS] that did not have filters in place. There was a white dust like material within the slots where the filter should have been. Observations on 7/11/12 at 9:05 AM and 7/12/12 at 8:55 AM revealed Oxygen in use in room [ROOM NUMBER] for Resident #1 with no filter in place on the concentrator. Observation on 7/12/12 at 8:48 AM revealed Oxygen in use in room [ROOM NUMBER] with no filter in place. On 7/12/12 at approximately 9:00 AM, Licensed Practical Nurse (LPN) #1 verified there were no filters in place for both concentrators in use in rooms [ROOM NUMBERS]. He stated that both of them should have a filter on the back of the concentrator. When asked, he stated that nursing staff usually document the cleaning of the filters on the treatment sheets. Review of the July 2012 Treatment Administration Record for Resident #1 revealed an entry which stated Clean O2 (Oxygen) filter every night, Start Date: 7/07/12. The entry had been initialed as having been completed on 7/10, 7/11, and 7/12. Review of the Treatment Administration Record for the resident in room [ROOM NUMBER] revealed no documentation related to cleaning or changing an Oxygen filter as verified by LPN #1. |
2016-06-01 |