SALYERSVILLE, KY – SALYERSVILLE NURSING AND REHABILITATION CENTER

Based on interview, record review, and review of the facility’s policy, it was determined the facility failed to ensure that one (1) of twenty-seven (27) sampled residents (Resident #907) received treatment and care in accordance with professional standards of practice and the resident’s comprehensive person-centered care plan, and the residents’ choices. Nursing staff assessed

Resident #807 on 03/16/19 at approximately 8:00-9:00 AM to have a change in mental status. The nurse stated the resident was staring and could not get words out. However, the facility failed to notify the resident’s physician in a timely manner, as required by the resident’s plan of care and failed to reassess the resident’s condition. At approximately 2:30 PM on 03/16/19, the resident’s daughter arrived at the facility and the resident could not form complete sentences and was unable to tell staff or his/her daughter his/her name. The resident’s daughter insisted the resident be sent to the hospital. The hospital assessed the resident to be overly sedated, requiring [MEDICATION NAME] (treats narcotic overdose) to reverse sedation secondary to pain medications administered at the nursing facility. After administration of the [MEDICATION NAME], the resident woke up with significant improvement of arousal and alertness.

Interview with Licensed Practical Nurse (LPN) #2 on 04/01/19 at 6:53 PM and 04/02/19 at 3:38 PM, revealed she was Resident #907’s nurse on 03/16/19. She stated sometime between 8:00 AM and 9:00 AM, she was administering Resident #907’s medications (including [MEDICATION NAME]) and the resident experienced a change in condition. LPN #2 stated the resident had taken his/her oral medication and she was attempting to administer the resident’s inhaler, when the resident began staring at her and could not form sentences. According to LPN #2, the resident usually talked to her and was alert and oriented, but that morning the resident would try to speak, but had a hard time getting his/her words out and the resident did not recognize her. Continued interview with LPN #2 revealed she assessed the resident periodically throughout the day for worsening in condition; however, she failed to document any further assessments that were made. LPN #2 stated she sent a fax (facsimile) to the resident’s physician about the changes in the resident, even though it was Saturday and the physician’s office was not open. She stated she did not speak to Resident #907’s Physician until after the resident’s daughter arrived at the facility at approximately 2:30 PM, at which time the resident’s condition had worsened and she received an order to transfer the resident to the emergency room for evaluation.