CAMBRIDGE, OH – EMBASSY OF CAMBRIDGE

Based on closed record review, review of hospital records, review of the facility policy and procedures related to Notification, interviews with facility staff, Medical Director #81 and Certified Nurse Practitioner (NP) #80 the facility failed to seek proper, timely and adequate care and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility failed to timely report the abnormal lab result to the physician, failed to hold the resident’s routine dose of K+ and failed to immediately transfer the resident to the hospital for treatment following the identification of the abnormal laboratory result. This resulted in Immediate Jeopardy and serious life-threatening harm on [DATE] at 4:17 A.M. when the lab reported Resident #1 had a critical/ lethal high potassium level of 9.2 (normal 3.,d+[DATE].1) with no evidence the resident was immediately transferred to the hospital or evidence the physician was notified. On [DATE] at 10:10 A.M. the facility was notified by the laboratory, a repeat K+ level was 9.9 (critically/lethally high). There was no evidence the resident was immediately transferred to the hospital or the physician was notified at that time. On [DATE] at 11:55 A.M. on call Nurse Practitioner (NP) #80 ordered intravenous (IV) fluids and the medication, [MEDICATION(S)] (used to treat high K+ levels) for Resident #1 which were never initiated. Resident #1’s condition continued to decline and on [DATE] at 3:10 P.M. the resident was found without a pulse and cardiopulmonary resuscitation (CPR) was initiated. The resident subsequently expired at the hospital on [DATE] at 4:46 P.M. due to the critical lab values and no progression of treatment provided. This affected one resident (Resident #1) of three residents reviewed for change in condition/quality of care.

On [DATE] at 12:27 P.M. the Executive Director, Director of Nursing (DON), and Corporate Nurse #100, were notified Immediate Jeopardy began on [DATE] at 4:17 A.M. when the facility was notified of Resident #1’s critical/lethal K+ level of 9.2 with no evidence of timely or adequate medical intervention. Resident #1 continued to decline throughout the day, without timely medical care provided or physician notification completed. Resident #1 was found without a pulse at 3:10 P.M. and was pronounced dead at 4:46 P.M. at the hospital due to results of the critical labs values.