Westmont Convalescent Center
Facility I.D. Number: 0030015
Date of Survey: 09/02/03
The facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of the resident, in accordance with each residents comprehensive assessment and plan of care. Adequate and properly supervised nursing care and personal care shall be provided to each resident to meet the total nursing and personal care needs of the resident.
General nursing care shall include at a minimum the following and shall be practiced on a 24-hour, seven day a week basis:
Objective observations of changes in a residents condition, including mental and emotional changes, as a means for analyzing and determining care required and the need for further medical evaluation and treatment shall be made by nursing staff and recorded in the residents medical record.
AN OWNER, LICENSEE, ADMINISTRATOR, EMPLOYEE OR AGENT OF A FACILITY SHALL NOT NEGLECT A RESIDENT.
These regulations are not met as evidenced by:
Based on record review and interview the facility:
(1) Failed to have physician orders for use of Oxygen for residents who are admitted with respiratory problems.
(2) Failed to closely monitor a residents vital signs after an episode of decreased (80%) oxygen saturation (02Sat.) (R3)
(3) Failed to have physician orders for the use of Oxygen at 4 Liters when a resident (R3) experienced acute respiratory failure.
(4) Failed to notify the residents (R3) Physician/ Medical Director immediately after the resident had experienced decreased level of 02 Sat., resulting in the resident experiencing respiratory distress. R3 expired on 6/2/03 due to Acute Respiratory Failure.
The example include:
I) Review of R3's chart face sheet indicated that R3 is a 51 year old male who was admitted to the facility on 5/30/03 for rehabilitation after he was hospitalized for Hypoglycemia and Pneumonia from 5/23/03 to 5/30/03. R3 had no Advance Directives and he was considered to be a Full Code. R3's medical problem list indicated he has multiple diagnoses including Chronic Atrial Fibrillation, Hypertension, Insulin Dependent Diabetes Mellitus, Peripheral Vascular Disease, Bilateral Below Knee Amputation, Old Cerebral Vascular Accident with right side weakness, Chronic Renal Failure, Coronary Artery Bypass Graft and Pneumonia. A review of R3's progress notes from 5/23/03 to 5/30/03 from the hospital indicated he received respiratory therapy daily to stabilize his Oxygen Saturation (02 Sat.) When R3 was admitted to the facility on 5/30/03 with respiratory problems there was no physician plan of care for administration of Oxygen to treat his respiratory condition even though he was receiving antibiotic therapy for the treatment of Pneumonia.
R3's 6/2/03 Nurses Notes were reviewed and they read as under:
At 5:30p.m. resident complained of difficulty of breathing...Oxygen Sat. 80%, started Oxygen at 4 liters per Nasal Cannula.
At 5:40p.m. Oxygen Sat. 94%.
At 8:00p.m. Resident found with no respiration, color cyanotic, no blood pressure or pulse obtained, 911 notified, Cardio Pulmonary Resuscitation (CPR) initiated by Staff, Fire Department and Paramedics and CPR continued to no avail, resident pronounced dead at hospital Emergency Room at 8:26.
Review of R3s ?Medical Certificate of Death Z2 noted R3's cause of death was (1) due to or as a consequence of Acute Respiratory Failure, (2) Atherosclerotic Heart Disease.
II) On 8/15/03 at approximately 3:20p.m. Z2, the facility Medical Director and on 8/14/02 at approximately 10:10a.m. Z1, the direct care Physician for R3 were individually interviewed over the telephone. Z1 and Z2 confirmed that none of the facility staff notified them when R3 suffered from Acute Respiratory Failure on 6/2/03. They agreed that R3's Nurse on duty (E5) on 6/2/03 at 5:30p.m. was negligent for not notifying either of them about R3's respiratory respiratory failure condition. Z2 further stated that E5 contacted him after R3 was pronounced dead in the hospital Emergency Room. Z2 also mentioned that he reviewed R3's record after his death and found no record of his vital signs after R3's Oxygen. Sat. level was brought up, and he should not have been left unattended for over two hour period of time. E5 should have contacted either Z2 or Z1 to plan emergency treatment and services at the hospital.
On 8/6/03 at approximately 3:30p.m. at first floor Nursing Station E5 was interviewed. E5 stated that she followed what E12, the Charge Nurse told her to do because she was new. E5 also stated that E12 told her if the residents (R3) Oxygen Sat. has improved just watch him, and she did not think about sending the resident to the hospital.
On 8/6/03 at approximately 3:15p.m. at second floor Nursing Sation E12 was interviewed. E12 stated that E5 is the one who was taking care of R3 when he went into respiratory failure. She would have better idea of his respiratory condition therefore she only guided E5 contact R3's physician to send him to hospital for further treatment. E12 admitted that on 6/2/03 she went to see R3 when she was summoned by E5 and noticed the resident was not breathing and found no blood pressure or pulse and initiated CPR to avail.
Review of facility Advance Directives indicated R3 has no Advance Directives and he was considered to be a Full Code. A review of the facility Code record from the use of Crash Cart it was indicated that the facility has no system to document the CPR Code procedure to show subjective and objective symptoms of a resident who is being coded/medications/ oxygen used, personnel involved in carrying out the Code procedure.
On 8/6/03 during the daily status meeting, concerns were discussed with facility administration staff. The facility Administrator stated that they were aware of the incident but no formal investigation had been conducted to analyze facility system.