PADUCAH, KY – RIVER HAVEN NURSING AND REHABILITATION CENTER

Based on interview, record review, and review of facility policy, it was determined the facility failed to provide treatment and care in accordance with professional standards of practice, for one (1) of three (3) sampled residents (Resident #1). Licensed staff failed to monitor Resident #1 after they identified Resident #1 was sweaty, had a heart rate (pulse) of 135 (normal ,[DATE]); blood pressure (B/P) of ,[DATE] (normal:104-,[DATE]-86); oxygen saturation of 79% on room air (normal: 95%); respiratory rate of 26 (normal:,[DATE]); and, blood sugar was 301 on [DATE] at 5:50 AM. The facility notified the Emergency Medical Services (EMS): however, the facility’s licensed staff failed to stay with Resident #1 until the Emergency Medical Services (EMS) arrived. The licensed staff left the resident delegating the task of staying with the resident to a Certified Nursing Assistant (CNA); and the CNA also left the resident alone. EMS arrived and when they entered the resident’s room, the resident was alone, was not breathing, had no pulse, and his/her eyes were fixed and dilated. Cardiopulmonary Resuscitation (CPR) was initiated without success.

The facility’s failure to provide appropriate care, treatment, and monitoring has caused, or is 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].

An acceptable Credible Allegation of Compliance (AoC), related to the Immediate Jeopardy, was received on [DATE] alleging the Immediate Jeopardy was removed on [DATE]. The State Survey Agency validated the AoC and determined the Immediate Jeopardy was removed on [DATE]. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (PoC); and, the facility’s Quality Assurance (QA) monitors the effectiveness of the systemic changes.

Interview with Certified Nursing Assistant (CNA) #2 on [DATE] at 2:44 PM and on [DATE] at 1:30 PM, revealed when making regular rounds on [DATE] at 5:30 AM, she noticed Resident #1 did not seem like himself/herself, had a blank stare, was short of air (SOA), sweaty, and when asked if the resident wanted air turned on the resident stated Yes. CNA #2 stated she knew it was 5:30 AM, as she had just checked the clock in another resident’s room close to Resident #1’s room and this was her regular rounding schedule. CNA #2 revealed she notified LPN #3, who was in charge of that hall (Hall 200) of this change in the resident. She stated LPN #4, who had come over from Hall 300, came in the room with LPN #3 to check the resident. CNA #2 stated LPN #3 placed oxygen on the resident and instructed her to stay with the resident while the nurses went to make calls and do paperwork. She further revealed LPN #3 and the day shift nurse (LPN #1) went by the resident’s door and said they were going to count narcotics and LPN #3 asked her one time how things were going, but she did not remember what time that was. She revealed she was right outside the resident’s door the whole time because the nurses asked her to stay with the resident, but she did leave the room to go answer a call light as she was the only CNA on the hall. CNA #2 stated the other CNA that was working was sick and left at 3:00 AM and the resident who pressed the call light was prone to falls. She stated she left the room around the time EMS arrived. The CNA stated when EMS arrived, one of the EMS personnel (EMT #1) said to her that Resident #1 was not breathing and she went to get LPN #4, and told LPN #4, I need you now. CNA #2 stated when she went in room this time, the resident was unresponsive and pupils fixed and dilated and she knew the resident was gone.