LOUISVILLE, KY – REGENCY CENTER

Based on interview, record review, and facility policy review it was determined the facility failed to ensure nursing staff performed Respiratory Assessments for one (1) of three (3) sampled residents of a total sample of fifty-six (56) residents (Resident #106).

Interview and record review revealed nursing failed to monitor and assess for respiratory decline that included auscultation of lung sounds, evidence of sleep apnea, [MEDICAL CONDITION] in extremities, and/or weight fluctuations related to Resident #106’s [DIAGNOSES REDACTED].

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.