LOCATED: 4747 ALBEN BARKLEY DRIVE, PADUCAH, KY 42001
BARKLEY 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 WRITE AND USE POLICIES THAT FORBID MISTREATMENT, NEGLECT AND ABUSE OF RESIDENTS AND THEFT OF RESIDENT’S PROPERTY
LEVEL OF HARM –IMMEDIATE JEOPARDY
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview, record review, review of the facility’s policies, and review of the Kentucky Board of Nursing (KBN) Advisory Opinion Statement (AOS) #36, it was determined the facility neglected to provide care and services that were necessary when one (1) of three (3) sampled residents (Resident #1) was found unresponsive. Resident #1 was not provided Cardio/pulmonary resuscitation (CPR) after a Code Blue was called.
Certified Nurse Aide (CNA) #1 and CNA #2 found Resident#1 unresponsive on [DATE] at 6:01 PM when they entered the resident’s room to pick up the supper tray. The CNAs summoned Registered Nurse (RN) #1 who initiated a Code Blue by announcing it on the intercom and calling 911 (Emergency Medical System) for an ambulance. RN #2 had responded to the Code Blue and was already in Resident #1’s room when RN #1 returned to the resident’s room. RN #1 and RN #2 discussed that Resident #1 was a full code; however, they failed to initiate rescue ventilations or chest compressions. RN #2 returned to the, [DATE] Hall nursing station and RN #1 returned to the, [DATE] Hall nursing station to make notifications.
EMS arrived to Resident #1’s room at 6:16 PM finding the resident alone, unresponsive and no staff present. Upon requesting Resident #1’s code status, RN #1 informed Paramedic #1 that the resident was a full code. When Paramedic #1 asked why the Code had been stopped, RN #1 walked away without giving Paramedic #1 an answer.
Paramedic #1 immediately returned to Resident #1 and CPR was initiated. Resident #1 was transported to the emergency room (ER) with CPR in progress and the ER continued CPR until the resident was pronounced dead at 6:51 PM.
The facility’s failure to ensure residents were free from mistreatment or neglect has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE]. The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance (AoC) was received on [DATE], and the State Survey Agency validated the Immediate Jeopardy was removed on [DATE], as alleged. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (POC); and, the facility’s Quality Assurance (QA) monitors the effectiveness of the systemic changes.
Interview with CNA #1, on [DATE] at 3:00 PM, revealed on [DATE], he was assisting Resident #1 with the supper meal and the resident was not acting right . He stated he informed RN #1, who was in the dining room, and the RN looked at the resident and told CNA #1 to stop feeding the resident and leave his/her head in the upright position. CNA #1 stated he left to assist another resident and when he and CNA #2 returned to gather the resident’s supper tray they found Resident #1 unresponsive. CNA #1 stated he immediately informed RN #1, who was still in the dining room, and she returned to the resident’s room. He stated RN #1 instructed him to get RN #2 and he went to the, [DATE] Hall nursing station to get her. CNA #1 stated when he returned to Resident #1’s room, RN #1 and RN #2 were discussing the resident’s code status. He stated RN #2 asked RN #1, Do you really want to crack his/her ribs? It’s obvious he/she is dead. CNA #1 stated RN #1 and RN #2 did not start rescue ventilations or chest compressions. Further interview revealed the RNs left the room. When the EMS arrived, they questioned the resident’s code status, started CPR, and left with Resident #1 in the ambulance.
Interview with CNA #2, on [DATE] at 10:50 AM, revealed she and CNA #1 were picking up supper trays on [DATE]. When they entered Resident #1’s room, they found the resident unresponsive. CNA #2 stated CNA #1 went to get RN #1. She stated when she opened Resident #1’s eyes, they were not moving and the resident’s pupils were big. She stated Resident #1’s skin was warm when she touched him/her. CNA #2 stated she told RN #1 to call a Code Blue and RN #1 went to the nursing station and announced a Code Blue over the intercom. RN #1 told CNA #1 to go get RN #2. CNA #2 stated she lifted the sheet over the resident to assist placing the CPR backboard under the resident while RN #2 was searching for the bag used for rescue breathing. She stated RN #2 wanted oxygen set at 10/L and CNA #2 set the regulator for 10/L. CNA #2 said RN #2 asked RN #1 (when RN #1 re-entered the room), which one of them was going to do compressions. CNA #2 stated they discussed CPR, and one of the RNs said, Let’s agree that we did the CPR and be done with it. CNA #2 stated she had touched Resident #1’s chest and it felt warm and the resident’s tongue was not sticking out of his/her mouth.
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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