| 14347 |
CRESTVIEW HEALTH AND REHABILITATION |
445409 |
2030 25TH AVE N |
NASHVILLE |
TN |
37208 |
2012-05-15 |
328 |
J |
|
|
LH9611 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation and interview, it was determined the facility failed to ensure that proper respiratory treatment and services were provided for 2 of 32 (Residents #66 and #138) sampled residents of the 32 residents included in Stage 1 and Stage 2. The facility failed to adequately assess and notify the physician of behaviors, anxiety, agitation, repeatedly low oxygen saturation results and resident's noncompliance with using the oxygen placed Resident #66 in immediate jeopardy. The findings included: 1. Review of the facility's "Oxygen, Administration" policy documented, "...To provide oxygen support when indicated via appropriate delivery device to achieve or maintain adequate oxygenation to the respiratory compromised resident... Document all appropriate information in the clinical record... Oxygen is a drug and, as such, there must be a physician's orders [REDACTED]. Review of the facility's "Pulse Oximetry, Monitoring of Residents" policy documented, "...Obtain physician order [REDACTED]. Review of the facility's "Change in Condition" policy documented, "...A resident's physician and legal representative or responsible party must be notified of a change in the resident's condition... Documentation of the Change in Condition will be made in the appropriate condition system folder in the Electronic Medical Record... Situations in which a physician... should be notified Immediately of a change in a resident's condition include... significant and unexpected change/decline in a resident physical, mental and/or psychosocial status..." Medical record review for Resident #66 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Nurses' notes documented the following: a. [DATE] at 3:50 AM - " [MEDICATION NAME] Tablet given for anxiety restless... stating that he can't sleep without medication..." [DATE] at 4:45 - 02 (oxygen) Saturation: 84% (percent) on 02." b. [DATE] at 7:47 AM - "..Resident has slept for only 1- (to) 2 hrs, sitting up in wheelchair, propel himself, up and down in hallway all night... confused and talkative... refused to rest in bed and put oxygen on 02 sat (saturation) checked ,[DATE]% on room air..." [DATE] at 2:32 PM - "...Resident noted to be very anxious this shift..." c. [DATE] at 8:41 AM - "resident has been up all through out the night... up and down the hallway and came to the nurses station several times and asked nurse something constantly... he would not stay in bed... He appeared to be very anxious, agitated. He was given [MEDICATION NAME] 0.5 mg (milligrams) at 2:01 am but that was ineffective... he is uncooperative with cares and very difficult to redirect..." d. [DATE] at 6:56 AM - "...noted his lower leg with feet swollen and respirations slightly dyspnic (dyspneic). He was asked to back in bed for leg elevation and put Oxygen nasal cannula on but he was not follow the directions..." e. [DATE] at 5:44 AM - "...PRN (as needed) MED (medication) GIVEN; [MEDICATION NAME] FOR AGITATION CONSTANTLY GETTING UP FROM CHAIR... FREQUENTLY REMOVING OXYGEN... SAT% 84... TRYING TO EAT OR DRINK WHATEVER IS IN REACH... GENERALLY CONFUSED... TEMP (temperature) 102.8..." f. [DATE] at 3:37 AM - "[MEDICATION NAME] given for anxiety UP from bed resisting instructions for safety... refusing to keep 02 on, refusing to call for ambulatory assistance... LUNG SOUNDS: crackles heard, lower bilateral lobes... pale, cool..." g. [DATE] at 8:48 AM - "Note: At 0605 am ...LPN (Licensed Practical Nurse) brought to my attention that resident was not breathing and that he did not have a pulse. Upon assessment of resident he was noted not to have a apical pulse, no blood pressure, no visible respiration... pronounced resident expired at 0655am..." The care plan dated [DATE] did not address the residents low oxygen saturations, lung sounds or elevated temperature. During a telephone interview in the Assistant Director of Nursing's (ADON) office on [DATE] at 6:15 PM, the physician stated, "Yes I remember (stated Resident #66's name), he was not there very long, don't remember seeing him after admission note..." The physician was asked if he was made aware of all the residents behaviors of agitation, anxious, resisting care, and refusing oxygen. The physician stated, "...am aware of some of his behaviors, told in a couple of conversations..." When he was asked if he was notified of the residents symptoms of elevated temperature, low oxygen saturations and lung sounds." The physician stated, "...No, can't say I know about the elevated temp, they have a protocol for that, 101 and above to call me... I know he had problems, wasn't there very long, don't remember being told he was not using oxygen..." During an interview in the ADON's office on [DATE] at 7 PM, the Director of Nursing (DON) stated, "...yes, I would expect nurses to notify and document the physician was made aware of behaviors, change in condition of residents." During an interview in the ADON's office on [DATE] at 9:40 AM, the physician stated, "...this guy (Resident #66) was aware but not reliable, had diastolic heart failure... if I had known just one day of those (documented behaviors) I would have sent him out. He needed to go back to the hospital..." There was no documentation that the physician was notified of Resident #66's repeated behaviors, anxiety and agitation. There was no documentation that the physician was notified of the resident's repeatedly low oxygen saturation results or of the resident being noncompliant with using the oxygen. The facility failed to adequately assess and notify the physician of behaviors, anxiety, agitation, repeatedly low oxygen saturation results and resident's noncompliant with using the oxygen usage which placed Resident #66 in an immediate jeopardy. 2. Medical record review for Resident #138 documented an admitted [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED].>(greater than) 92% (percent)." Observations in Resident #138's room revealed the following times when Resident #138 was not receiving oxygen at the rate prescribed by the physician: a. [DATE] at 7:30 AM, oxygen at 2 liters per nasal cannula. b. [DATE] at 5:30 PM, oxygen at 1.5 liters. c. [DATE] at 8:45 AM, oxygen at 1.5 liters per nasal cannula. d. [DATE] at 12:00 PM, oxygen at 1.5 liters per nasal cannula. The care plan dated [DATE] did not address oxygen use or need for oxygen saturation monitoring. The facility was unable to provide documentation of oxygen saturation results. During an interview in the ADON's office on [DATE] at 9:00 AM, the Director of Nursing stated, "Would expect nurses to have the correct oxygen rate and to do the oxygen sats as ordered." 3. On ,[DATE] through (-) ,[DATE] an annual re-certification survey was completed. The facility was cited with an Immediate Jeopardy (IJ) at F328 with a scope and severity of a "J". The facility's failure to assess and provide the necessary care and services to provide the highest practicable physical, mental and psychosocial well being of the resident displaying mental difficulty, placed the facility in immediate jeopardy due to these failures. An extended survey was completed on [DATE]. The Administrator (Adm), the Director of Nursing (DON), and the Regional Nurse Consultant were informed of the IJ in the Assistant Director of Nursing's (ADON) office on [DATE] at 7:35 PM and on [DATE] at 11:55 AM. An Allegation of Compliance (AOC) was received from the facility on [DATE] at approximately 5:25 PM. The AOC the facility presented to the survey team documented the following corrective measures put in place: 1. Inservicing 100 percent (%) of the licensed nursing staff and Certified Nursing Assistants (CNA) began on [DATE] on the following topics: a. Verbal questions and answers with staff. b. Physician notification and Responsible Party notification. c. Change of Condition. d. Recognizing signs/symptoms of respiratory and cardiac distress. e. Behavior Management. The inservicing was conducted by the Adm, DON, and the Nurse Educator/ADON. All new hires will be inserviced during orientation. 2. Auditing/Monitoring tools developed will be used for follow-up and continued monitoring for the following areas: a. Behavior Quality Assurance /Performance Improvement (QA/PI) tool. b. Weekly At Risk QA/PI Log. c. Care Plan Audit. d. Oxygen orders and use. e. Nursing Notes Audit For Change of Condition. f. Alert Charting Log. g. Event Log. 3. All results of audits/inservices will be reviewed by the Administrator for any aberrant results. The results from the audits/ inservices will be reported monthly to the QA/PI committee for review to ensure compliance. The Administrator and Director of Nursing will conduct weekly review of audits with any abnormal results being investigated and resolved immediately. The QA/PI Committee will ensure compliance by trending audits and making recommendations. 4. Corporate staff will assist with onsite visits to review the facility staff (Administrator) progress on obtaining and maintaining compliance. Corporate staff will assist and review policies, procedures, educational material as needed in order to ensure the facility acquires and maintains compliance. An exit conference was conducted with the Adm, DON, Regional Director of Operations, Vice President of Clinical Services, three Regional Nurse Consultants and the ADON in the therapy room on [DATE] at approximately 7:30 PM. The facility staff were informed of the survey findings of the IJ identified on [DATE]. The surveyors determined the IJ was abated on [DATE] at 9:30 AM, based on the facility's acceptable AOC. The surveyors verified the AOC was in place by review of the facility's documentation of 100 percent completion of all staff inservices for notifications, condition changes, recognizing signs and symptoms of respiratory and cardiac distress and review of findings on audit tools which were initiated on [DATE] and completed on [DATE]. The IJ was abated as of [DATE]. Non-compliance of the Immediate Jeopardy continues at a scope and severity of a "D" level for F328 for monitoring of corrective actions. The facility is required to submit a plan of correction for this tag. |
2014-01-01 |