KINDRED TRANSITIONAL CARE & REHAB – WALNUT CREEK
LOCATED: 1224 ROSSMOOR PARKWAY, WALNUT CREEK, CA 94595
KINDRED TRANSITIONAL CARE & REHAB – WALNUT CREEK 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 PROPERLY CARE FOR RESIDENTS NEEDING SPECIAL SERVICES, INCLUDING: INJECTIONS, COLOSTOMY, UREOSTOMY, ILEOSTOMY, TRACHEOSTOMY CARE, TRACHEAL SUCTIONING, RESPIRATORY CARE, FOOT CARE AND PROSTHESES
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review the facility failed to provide the proper [MEDICAL CONDITION] treatment and care for Resident 1, by not following their own policy and procedure for [MEDICAL CONDITION] change and failed to provide effective resuscitation for an unsuccessful [MEDICAL CONDITION] change.
This failure resulted in Resident 1’s subsequent death.
Review of the clinical record showed Resident 1 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident 1 had a [MEDICAL CONDITION] and was dependent on a ventilator (a breathing machine).
The Director of Respiratory Therapy (DRT), Respiratory Therapist (RT) 1, RT 2, and Medical Doctor (MD) 1 performed a scheduled [MEDICAL CONDITION] change ordered for Resident 1. DRT documented vital signs for Resident 1’s prior to the [MEDICAL CONDITION] change as followed: oxygen saturation level 99% (normal: 95-100%), heart rate was 73 beats/minute (normal: 60-100), respiratory rate was 14 breaths/minute (normal: 10-20). RT 2 stated Resident 1 did not have any respiratory issues prior to the [MEDICAL CONDITION] change.
In an interview on 6/23/16 at 11:45 a.m., an Expert Respiratory Therapist Consultant (ERTC) from the Respiratory Care Board of California stated Resident 1 had the signs and symptoms (the low oxygen saturation, fast heartbeat, change in color of skin, the inability for RT 2 to suction via the [MEDICAL CONDITION], and the tissue [MEDICAL CONDITION]) that indicated her [MEDICAL CONDITION] was in the wrong place. Furthermore the ERTC stated the continuous resuscitation of Resident 1’s [MEDICAL CONDITION] when not in the correct place would lead to oxygen not going to the lungs and into the tissue space, which would lead to subsequent death if not corrected. The ERTC stated the facility’s staff should have recognized that Resident 1’s [MEDICAL CONDITION] was not in the right place from the signs and symptoms that were present, and should have removed the [MEDICAL CONDITION], cover Resident 1’s stoma and provided oxygen to Resident 1’s mouth with a BVM.
Record review of the Coroner’s Report, dated 3/31/16 showed, Autopsy (an examination used to determine the cause of death) findings: Perforation (a hole made by piercing) of posterior wall of esophagus (throat) and trachea due to improper placement of [MEDICAL CONDITION], with tip of [MEDICAL CONDITION] impacting fifth cervical vertebrum (the upper spine that form the neck). These findings are consistent with placement of the tube in the esophagus with perforation. There is also evidence of the [MEDICAL CONDITION] causing perforation of the trachea and entry of the tip of the tube into the lower esophagus. Cause of Death: Acute [MEDICAL CONDITION], with bilateral collapsed lungs, due to improper placement of
[MEDICAL CONDITION], with tracheal and [MEDICAL CONDITION] perforation.
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.