State Findings:
Based on observation, interview, and record review, the facility failed to provide respiratory care consistent with professional standards of practices for one (Resident #16) of two residents reviewed for [MEDICAL CONDITION] care.
The facility failed to have a replacement [MEDICAL CONDITION] inner cannula at bedside for Resident #16 in case of accidental removal of the inner cannula.
An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was lowered on [DATE], the facility remained out of compliance at a severity level of no actual harm with the potential for more than harm that is not immediate jeopardy, and a scope of isolated, due to the facility was still monitoring the effectiveness of the Plan of Removal.
This failure could affect two residents with tracheostomies by placing them at risk of a delay in receiving life-saving treatment which could result in serious injury including death.
Observation on [DATE] at 1:26 p.m. revealed Resident #16 was lying in bed with a [MEDICAL CONDITION] in place. There were no inner cannulas at bedside.
Observation and interview on [DATE] at 1:28 p.m. with LVN G, charge nurse for Resident #16 on the day shift (6a-2p), revealed Resident #16 received tracheotomy care. She stated supplies needed at bedside included: a suction catheter,[MEDICAL CONDITION] kit, mask, and inner cannula. She stated she was not able to locate Resident #16’s inner cannula. She stated inner cannulas were used to control secretions. She stated the inner cannula was usually kept in the Ambu bag, but the evening nurse took the inner cannula out and did not replace the cannula. She stated [MEDICAL CONDITION] supplies were not kept on the medication cart but in the supply room. She stated in the case of an emergency she would call 911. She stated she documented on the TAR/treatment sheets that supplies were in the resident’s room at the beginning of her shift.
Interview on [DATE] at 2:51 p.m. with LVN G revealed she documented on the TAR/treatment sheet that Resident #16’s supplies were in her room. She stated she did not look, she just signed the treatment sheet and went on.
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NHAA is here to assist families, residents, and the community by sounding the alarm on issues like those found above. This nursing home and many others across the country are cited for abuse and neglect.
If you have or had 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.
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Personal Note from NHA-Advocates
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