OWENSBORO, KY – OWENSBORO CENTER

Based on interview, record review, and review of the facility’s policy, it was determined the facility failed to ensure a resident received adequate supervision and assistive devices to prevent accidents, for one (1) of three (3) sampled residents (Resident #1). Review of an Order Summary Form, dated ,[DATE], revealed Resident #1 was diagnosed with [REDACTED]. On [DATE], Resident #1 became unresponsive, asystolic (heart not functioning) after eating breakfast, resulting in cardiorespiratory arrest and [MEDICAL CONDITIONS]. The resident was transferred to the hospital by the Emergency Medical Service (EMS). Review of the Hospital emergency room (ER) Physician’s Notes, dated [DATE] at 8:09 AM, revealed Suspect hypoxemia from aspiration. Apparently large amounts of breakfast were pulled from the resident’s mouth by the EMS prior to intubation. I suspect the resident is acidotic from hypoxemia. The resident expired at the hospital on [DATE].

Interview with LPN #5, on [DATE] at 3:00 PM, revealed she was in the little dining room the morning of the incident. She stated she noticed Resident #1 had become short of breath and was coughing, so she took the resident back to his/her room and was going to administer a breathing treatment. Upon return to the resident’s room, she noticed the resident’s color was off so a code was called and she tried to get the suction machine together. LPN #5 stated she did not recall anyone doing respirations during the code, and they did not use an AED (automated external defibrillator) or the perform the [MEDICATION NAME] Maneuver. She stated she had only worked at the facility a few weeks and had never been through a code drill. Further interview revealed the code could have gone better if the suction machine had been set up. LPN #5 stated she had to locate the parts to the suction machine; the parts were in three (3) different drawers. She stated it would have made a difference if she could have suctioned the resident. The LPN stated she could not answer why she did not chart the event in the Progress Notes, but was sorry (she) did not chart.