TWIN RIVERS NURSING AND REHABILITATION CENTER – OWENSBORO, KY

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, record review, and facility policy review it was determined the facility failed to implement the care plan for one (1) of twenty-one (21) sampled residents (Resident #4).

Resident #4 was care planned to receive Chest Percussion Therapy (CPT) Vest treatment every six (6) hours for twenty (20) minutes. However, there was no documented evidence the facility provided the treatment on [DATE] at 6:00 PM, on [DATE] at 6:00 AM and 12:00 PM; on [DATE] at 6:00 AM and 6:00 PM, on [DATE] at 12:00 PM and 6:00 PM; and on [DATE] at 12:00 AM (seven {7} of fourteen {14} treatments from [DATE] at 6:00 AM through [DATE] at 12:00 AM). On [DATE] at approximately 1:00 AM, the Resident #4 was found in cardiopulmonary arrest with Cardiopulmonary Resuscitation (CPR) initiated. Resident #4 was was hospitalized and placed on mechanical life support. Resident #4’s medical power of attorney’s (the resident’s sisters) removed the resident from life support and the resident expired on [DATE] at a local Hospice House.

The facility’s failure to implement the care plan has caused or was 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].