LOUISVILLE, KY – REGENCY CENTER

Based on interview, record review and facility policy review, it was determined the facility failed to identify a change in condition for one (1) of thirteen (13) sampled residents.

Review of Resident #8’s clinical record revealed the facility admitted the resident with the [DIAGNOSES REDACTED]. Review of Resident #8’s Nursing Documentation, dated [DATE] at 10:55 PM, revealed a shift note for Exacerbation of Respiratory Condition, which stated the resident’s lungs were not clear and rhonchi were heard upon auscultation and the resident had a nonproductive cough. However, this change in respiratory status was not communicated to the physician.

On [DATE] at 12:06 AM, Resident #8 was out of bed, found to be unsteady on his/her feet, and experienced shortness of breathe. Nursing applied oxygen, assisted the resident to bed, raised head of bed up, administered steroids and pain medication. However, nursing did not notify the physician of a change in condition.

Review of Resident #8’s weights revealed, on [DATE], the resident weighed two-hundred and forty-five (245) pounds and [DATE], the resident’s weight increased to two-hundred fifty-two (252) pounds. However, the facility did not notify the physician of Resident #8’s seven (7) pound weight gain over a two-day period.

Review of Resident #8’s Blood Test results from a lab draw, on [DATE], revealed the resident’s [NAME] Count was 14.4 (4.5 to 10.8 normal range/elevated white count indicated the body was working to destroy an infection) and nursing did not provide test results to the physician.

In addition, Resident #8 declined therapy services on the morning of [DATE], and voiced concerns of not feeling well to staff. However, nursing did not assess the resident for respiratory or cardiovascular change in condition nor did they notify the physician. Later that afternoon staff found the resident unresponsive on the floor and life saving measures were performed.

The resident was transferred to an acute care hospital and expired.

The facility’s failure to notify the physician of a resident’s change in condition has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on [DATE] and was determined to exist on [DATE]. The facility was notified of the IJ on [DATE].

Interview with Licensed Practical Nurse (LPN) #6 on, [DATE] at 12:25 PM, revealed on [DATE] she was assigned to care for Resident #106 and was unaware of the resident’s recent [DIAGNOSES REDACTED]. In addition, she could not remember if she assessed Resident #106 for [MEDICAL CONDITION] either. LPN #6 stated after the 10:30 AM assessment, she did not re-assess the resident again until later when she found him/her deceased , during her evening shift around 7:00 PM. LPN #6 stated she performed a Sternum rub; however, the resident did not respond.

During continued interview with LPN #6, she stated during the day shift on [DATE] she cared for twenty-three (23) residents; however, on this day, she worked a double shift and during second shift an additional ten (10) residents were added to her assignment. The LPN stated Resident #106 required a Respiratory Assessment and his/her extremities required assessments for swelling/[MEDICAL CONDITION]. The LPN stated she recalled the resident had a water pitcher but was unsure if he/she was on fluid restrictions. The nurse stated it was impossible for us nurses to check everything, it was challenging and to perform actual assessments on everybody was not always possible. She stated on most weekends the facility was understaffed and had many call-ins, which made it hard on the nurses.

NAME], or the nebulizer treatment. She stated she did not follow facility policy related to physician notification related to the resident’s change in respiratory status.