COLLIERVILLE, TN – COLLIERVILLE NURSING AND REHABILITATION, LLC

Based on policy review, medical record review, observation and interview, the facility failed to provide necessary mechanical ventilator (a machine used to assist or replace spontaneous breathing) equipment and supplies for residents with tracheostomies (an opening in the front of the neck with a tube inserted into the windpipe to help you breathe) that required mechanical ventilation and failed to provide the necessary mechanical ventilator audible, external alarm system and response processes that Resident #1 required; failed to provide monitoring processes of continuous pulse oximetry (a process to measure the oxygen level in the blood) and end tidal [MEDICATION(S)] (the level of [MEDICATION(S)] that is released at the end of an exhaled breath) when a resident had breathing problems; or end tidal [MEDICATION(S)] (CO2) monitoring for Resident #2 and #3 who required invasive mechanical ventilation. Staff provided care without obtaining orders from the Physician for Resident #4, who had required a mechanical ventilator, returned from the hospital without a ventilator; and the facility failed to ensure 6 of 9 respiratory staff (Respiratory Therapist (RT) #1, #2, #3, #4, #5, and #6) and 3 of 3 agency nurses (Licensed Practical Nurses (LPN) #1, #2, and #3) had the competencies to monitor residents on mechanical ventilation and to set up mechanical ventilation. The facility’s failure resulted in Immediate Jeopardy for 4 of 8 sampled residents (Resident #1, #2, #3, and #4) on mechanical ventilators and placed all eight residents requiring invasive mechanical ventilation at risk due to the potential of serious harm, injury, or death to a resident.

Immediate Jeopardy (IJ) is a situation in which the provider’s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury harm, impairment, or death to a resident.

The Administrator, Director of Nursing (DON) and Regional Director of Clinical Services were notified of the Immediate Jeopardy (IJ) for F-695 on 9/15/2021 at 3:41 PM, in the DON office.

The facility was cited Immediate Jeopardy at F-695.

The facility was cited F-695 at a scope and severity of K, which is Substandard Quality of Care.

The Immediate Jeopardy was effective from 9/9/2021 through 9/17/2021.

An acceptable Removal Plan for F-695, which removed the immediacy of the jeopardy, was received on 9/17/2021 at 11:00 AM, and was validated onsite by the surveyor on 9/18/2021 through observations, record review, review of audits, and staff interviews.