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PEMBROKE, KY – PHYSICIAN ORDERS MEDS STAT; RESIDENT RECEIVES MEDS 17 HOURS LATER; RESIDENT DIES

CHRISTIAN HEIGHTS NURSING AND REHABILITATION CENTER

LOCATED: 124 WEST NASHVILLE ST., PEMBROKE, KY 42266

CHRISTIAN HEIGHTS NURSING AND REHABILITATION 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 SERVICES IN ACCORDANCE WITH ACCEPTABLE STANDARDS OF PRACTICE RELATED TO FOLLOWING PHYSICIAN’S ORDERS

Level of harm – Immediate Jeopardy

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview, record review, and facility policy review, and review of the Kentucky Board of Nursing Advisory Opinion Statement, AOS #14, it was determined the facility failed to provide services, in accordance with acceptable standards of practice related to following physician’s orders, for ten (10) of seventeen (17) sampled residents (Residents #2, #3, #6, #10, #11, #12, #13, #14, #15 and #16 ), and one (1) unsampled resident (Unsampled Resident A). Physician’s orders had not been consistently followed related to medication administration and physician ordered treatments. It was determined the facility failed to ensure medications were administered as prescribed by their physician and according to acceptable standards of practice for nine (9) residents;

Continuing:  On [DATE], the physician ordered Resident #11 to receive Solu-Medro (steroid) 40 milligrams (mg) intramuscular (IM) and [MEDICATION NAME] (antibiotic) 500 mg intravenously (IV) every 24 hours stat (immediately). However, the facility failed to administer the medication until [DATE]. The resident expired on [DATE].

Continuing:  Closed record review revealed the facility admitted Resident #11 on [DATE] with [DIAGNOSES REDACTED]. On [DATE] at 10:57 PM, per Nursing Notes, LPN #5 assessed the resident and noted the resident was experiencing labored breathing. The Advanced Practitioner Registered Nurse (APRN) was notified on [DATE] at 11:30 PM and stat orders were received to medicate the resident with Solu-[MEDICATION NAME] 40 mg intramuscularly (IM), and [MEDICATION NAME] 500 mg IV every 24 hours. Review of the [DATE] MAR and Nursing Notes, revealed the medication was not administered stat on [DATE] as per the physician’s order but was administered on [DATE] at 5:49 PM approximately seventeen (17) hours later. Further review of the Nurse’s Notes, dated [DATE] at 6:24 PM, revealed the resident was noted to have a fixed facial expression. Cardiopulmonary resuscitation(CPR) was initiated and continued until Emergency Medical Services (EMS) arrived. Resuscitation was unsuccessful and the resident expired. Interview conducted with the Administrator, on [DATE] at 3:20 PM, revealed the oncoming licensed staff failed to obtain the stat Solu [MEDICATION NAME] which was in the EDK box and administer the medication.

FACILITY FAILED TO ENSURE RESIDENT WAS PROVIDED ADEQUATE SUPERVISION TO PREVENT ACCIDENTS DURING A TRANSFER

Continuing: Based on interview, record review, and review of the facility’s policy and procedure, it was determined the facility failed to ensure one (1) of seventeen (17) sampled residents (Resident #1) was provided adequate supervision to prevent accidents during a transfer with a mechanical lift. On 03/30/14, State Registered Nurse Aide (SRNA) transferred Resident #1 with a mechanical lift without assistance, as per facility policy and the resident’s right foot became stuck between the (2) two metal bars on the lift. The SRNA failed to report the incident. On 04/03/14, the resident complained of pain to the right foot and an x-ray was ordered. The resident was diagnosed with [REDACTED]. The findings include: Review of the facility’s policy titled Safe Handling and Movement Policy, last revised 10/31/13, revealed all patient transfers with mechanical lifts will be done with a minimum of two (2) persons or as specified in the patient’s plan of care. Additionally, the policy revealed that injuries from patient handling and movement should be reported.

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.

Contact us through our CONTACT FORM located on our website here or call our toll free hot line number: 1-800-645-5262

You can make a difference even if your loved one has already passed away.

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2 Responses to “PEMBROKE, KY – PHYSICIAN ORDERS MEDS STAT; RESIDENT RECEIVES MEDS 17 HOURS LATER; RESIDENT DIES”

  1. StormRavn says:

    This is such a common problem in nursing homes. They want to get the maximum amount of profit from each client, and they fail to hire adequate staff to care for these people. I also feel that as well as ordering steroids, and antibiotics the client should have had breathing treatments ordered as well, as steroids, even given IV take some time to work. This facility sounds like a place that has been running on a bare bones staff for some time, and should be fined at the very least for this

    • Don Delaney says:

      The head of the nursing home should be held accountable. My wife worked there last year and had to quit because the management was horrible and only cared about their time off.

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