CROWNPOINT HEALTH & REHAB CENTER
LOCATED: 1203 SOUTH BEND DRIVE, HORSESHOE BEND, AR 72512
CROWNPOINT HEALTH & REHAB CENTER was cited by the DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES for the following deficiencies:
PLEASE NOTE: The following highlighted quoted text is only a portion of the full report/survey submitted by DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES. The full report/survey can be found here.
FACILITY FAILED TO PROVIDE NECESSARY CARE AND SERVICES TO MAINTAIN THE HIGHEST WELL BEING OF EACH RESIDENT
LEVEL OF HARM –IMMEDIATE JEOPARDY
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Complaint # (AR 935) was substantiated (all or in part) in these findings:
Based on record review and interview, the facility failed to ensure Resident #1 received the necessary care and services to attain or maintain the highest practicable physical well-being. The facility failed to ensure nursing staff promptly responded to episodes of [MEDICAL CONDITION] as evidenced by the failure to assess, monitor and identify a significant change in condition; failure to immediately consult the physician regarding low oxygen saturation readings in order to provide the physician with necessary information to guide treatment; failure to administer as needed updrafts as ordered by the physician; and failure to ensure pulse oximetry readings were consistently completed and documented for 1 (Resident #1) of 4 (Residents #1, #3, #4 and #5) case mix residents who had orders for pulse oximetry monitoring. This failed practice resulted in Immediate Jeopardy which caused or could have caused serious harm, injury or death to Resident #1 who after experiencing an upper respiratory infection had episodes of [MEDICAL CONDITION] and expired on [DATE]; and had the potential to cause more than minimal harm for 34 residents who had orders for pulse oximetry, according to the room bed list provided by the Administrator at 1:56 p.m. on [DATE]. The Administrator was notified of the Immediate Jeopardy on [DATE] at 9:47 a.m.
On [DATE] at 11:13 a.m., CNA #1 was asked via telephone, did you work with (Resident #1)? She stated, yes, and had on several occasions. She was asked, Did you work with (Resident #1) on [DATE]? She stated, I did. The CNA was asked to describe the events prior to the resident’s expiration on [DATE]. She stated, we would go into his room when he called or when we delivered briefs or he put his call light on. We (CNAs) were in the room around midnight talking about the New York Ball drop and did vitals. Resident was short of breath, but I think that may have been from talking. He told me he would see me in the morning.
CNA #1 was asked, at what point did you last see the resident, make a room check? She stated, I saw him at midnight. Then I went in with the nurse around 4:30 or 5:00 a.m. She was asked, did you check on the resident between midnight and the time the visit was made with the nurse? She stated, No, I can’t say I did. I do remember the nurse calling me in there, but the resident was already gone; he was not breathing. When asked, CNA #1 declined and would not describe the resident at the time she entered the room. She only said, Resident was not breathing.
The DON was asked, how do you think (RN #1) should have handled the oxygen saturation of 84%? She stated, she should have gone back and rechecked his oxygen saturation, but she didn’t. She was asked, How often should a resident be checked or rounds be made on residents? She stated, every two hours, or at least peeked (in) on every two hours. I know, in this case, the nurse didn’t, but think the CNAs did.
The DON was asked, what is (Resident #1)’s SPO2 supposed to be? She stated, Greater or equal to 90%. She was asked, at what level should the MD be notified? The DON stated, Call MD if less than 90% and unable to get it back up. I would have resident TCDB, sit them up, updraft treatments and use any orders.
The DON was asked, did (RN #1) call the physician with the resident’s pulse oximetry of 84%? She stated, No she did not. She called the APRN after resident had passed away. I thought she notified the nurse practitioner, but she told me it was after the resident passed away, that she was confused about when she actually called her, but then stated it was after. That’s why she wrote this note late entry. She kept going back and forth on when she actually called.
The DON was asked, Have you in-serviced your nursing staff since the incident with (Resident #1) occurred on [DATE]? She stated, the only person I in-serviced was the person at fault for the pulse oximetry because she did not monitor or notify anyone about the pulse oximetry. I didn’t in-service any other staff; I did verbal consult, but I did not write it down on paper, but I did it as soon as I was aware that pulse oximetry was 84% and she didn’t do anything.
Personal Note from NHA-Advocates: NHAA shares with all the families of loved ones who are confined to nursing homes the pain and anguish of putting them in the care of someone else. We expect our loved ones to be treated with dignity and honor in the homes we place them. We cannot emphasize enough to family members of nursing home residents; frequent visits are essential to our loved ones’ well-being and safety. This nursing home and many others across the country are cited for abuse and neglect.
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