NHC HEALTHCARE, MADISONVILLE
LOCATED: 419 NORTH SEMINARY ST, MADISONVILLE, KY 42431
NHC HEALTHCARE, MADISONVILLE 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 ENSURE EACH RESIDENT WAS PROVIDED THE NECESSARY CARE AND SERVICES
Level of harm – Immediate Jeopardy
Based on interview, record review, review of the facility’s policy and procedure, review of the Hospital emergency room Note, and review of a Provisional Report of Death, it was determined the facility failed to ensure each resident was provided the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the plan of care for one (1) of nine (9) sampled residents (Resident #1). The facility failed to provide ongoing assessments and monitoring for Resident #1 when a significant change in condition was identified. On 07/25/14, at approximately 1:50 PM, Resident #1 was found in his/her room by facility staff unresponsive and cyanotic (low oxygen causing bluish discoloration of the skin). The resident’s oxygen saturation was sixty-nine percent (69%) (normal 90-100) on room air, blood pressure was 79/45 (normal 118/68), and heart rate was 136 (normal 60-100) beats per minute (bpm). There was no documented evidence the physician was called to notify her of the resident’s significant change in condition; however, at 2:25 PM, thirty-five (35) minutes later, a text message was sent to the physician. At 3:45 PM, a physician’s orders [REDACTED]. At 5:30 PM, approximately three (3) hours and ten (10) minutes after the resident’s significant change in condition, Resident #1 was noted to be cyanotic, with labored respiration and an oxygen saturation of seventy-four percent (74%). The Physician was notified and a new order was received to send Resident #1 to the emergency room (ER). The resident was transferred to the hospital where he/she was admitted to the Critical Care Unit with the [DIAGNOSES REDACTED]. (Refer to F-157) The facility’s failure to ensure each resident received necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the plan of care has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 08/07/14 and determined to exist on 07/25/14.
Continuing: Interview with the Director of Nursing, (DON) on 08/07/14 at 3:25 PM, revealed that based on the documentation the resident was not capable of determining if he/she was going to the hospital. Further interview revealed the DON stated, I do expect the staff should have sent the resident out to the hospital, absolutely. She stated the facility did not have a policy to address what to do when a resident refused to be sent to the hospital. Additionally, she stated the nurse should have not sent a text message to the physician and should have phoned him immediately. Interview with the Administrator, on 08/07/14 at 4:04 PM, revealed he expected the staff to phone the physician in a crisis situation, rescue the resident, and transfer the resident out to the hospital.
FACILITY FAILED TO PROVIDE ADEQUATE SUPERVISION TO PREVENT ACCIDENTS
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 policy and procedure, and review of the Hospital History and Physical, Hospital emergency room Note it was determined the facility failed to provide adequate supervision to prevent accidents for two (2) of nine (9) sampled residents (Resident #1 and Resident #2).
Continuing: Resident #2 had a fall with injury and was noted at the time of the fall, to have a shuffling gait, which was a side effect of the Haldol. Resident #2 was diagnosed with [REDACTED]. The physician was notified of the shuffling gait; however, was not notified of the Consultant Pharmacist’s recommendation. The physician ordered Cogentin, a medication to help reduce the side effects of the antipsychotic medication, Haldol. Resident #2 had a second fall three (3) days later on [DATE] resulting in three (3) additional fractures (his/her humerus, radius, and ulna). The physician was not made aware of the recommendation until [DATE], after the resident had sustained two (2) falls with injury. On [DATE], the facility assessed Resident #1 as dependent on two (2) staff for transfers; however, review of the care plan revealed an intervention for one (1) to two (2) staff to transfer. On [DATE], Resident #1 was lowered to the floor during a transfer when he/she was being transferred by one (1) Certified Nursing Assistant (CNA). Resident #1 sustained a fracture of the right fibula (leg bone) after the fall. The resident was assessed as having a significant decline in ADLs and expired at the facility on [DATE]. The facility’s failure to provide adequate supervision to prevent accidents has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE] and was determined to exist on [DATE].
Personal Note from NHAA 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.
You can make a difference. If you have a loved one living in this nursing home or any other nursing home where you suspect any form of abuse or neglect, contact us immediately. We can help you file a state complaint, hire a specialized nursing home attorney or help you find a more suitable location for your loved one.
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