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THE SPRINGS – Resident had been SOB (Short of Breath) all day

THE SPRINGS, A GRACE LIVING CENTER COMMUNITY

LOCATED: 5800 WEST OKMULGEE, MUSKOGEE, OK 74401

THE SPRINGS, A GRACE LIVING CENTER COMMUNITY 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**

On 05/02/17 an Immediate Jeopardy (IJ) was determined to exist due to the facility’s failure to assess, monitor, and intervene for resident #1 who was experiencing respiratory distress. The resident was in respiratory distress for five hours before being transported to the hospital.

A hospital record, dated 10/05/16, documented at 7:32 p.m. the resident was pulseless. The record documented the resident’s time of death was 7:36 p.m.

The IJ situation was verified with the Oklahoma State Department of Health. On 05/02/17 at 5:01 p.m., the administrator (ADM) and the director of nurses (DON) were notified of the IJ situation regarding the resident not being transported to the hospital when experiencing respiratory distress.

Based on interview and record review, it was determined the facility failed to provide necessary care and services for one (#1) of five residents reviewed for highest levels of well-being. The facility failed to assess, monitor, and intervene for a resident experiencing respiratory distress.

The resident was experiencing respiratory distress with an oxygen saturation of 55%. The resident was in respiratory distress for five hours prior to being transported to the hospital. A hospital record, dated 10/05/16, documented at 7:32 p.m. the resident was pulseless. The record documented the resident’s time of death was 7:36 p.m.

The emergency management services (EMS) dispatch record, dated 10/05/16, documented at 7:18 p.m. upon arrival to the nursing facility the resident’s mental status was altered, the resident was experiencing SOB, [MEDICAL CONDITION], and [MEDICAL CONDITION]. The narrative documented the nurse reported the resident had been experiencing SOB the day before with low oxygen saturation. The narrative documented the nurse had ordered an Xray of the patient’s chest and it came back clear. The nurse stated when she arrived at work that day, the resident was again experiencing SOB and low oxygen saturation. The narrative documented upon the resident’s initial assessment the resident was unresponsive which was not normal for the resident. The narrative documented the resident’s lungs had coarse rhonci bilaterally in the upper lobes. The narrative documented there was a delay on the scene related to getting paperwork from the nurse. The narrative documented the resident was put on four liters of oxygen and the initial pulse oximetry was less than 50%. The resident was intubated and stayed in asystole during transport.

The hospital record, dated 10/05/16, documented the resident presented to the emergency department from the nursing home after [MEDICAL CONDITION]. The record documented the resident had been SOB all day and the previous night with oxygen saturations in the 50’s and improved to 70 after a breathing treatment. The record documented the resident had an oxygen saturation in the 50’s all day and upon arrival to the emergency room the resident was agonal (gasping respirations) and the resident’s oxygen saturation was in the 30’s. The record documented the resident arrested prior to transport to the emergency department. The record documented the resident was intubated during compressions and the patient was given [MEDICATION NAME]. The record documented the resident was still in asystole ([MEDICAL CONDITION]) upon arrival to the emergency department. The record documented at 7:32 p.m. the resident was pulseless. The record documented the resident’s time of death was 7:36 p.m.

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.

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 have helped many already and we can help you and your loved one as well by filing a state complaint, hiring a specialized nursing home attorney or helping you find a more suitable location for your loved one.

Contact us through our CONTACT FORM located on our website here below or on the sidebar 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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