DUBLIN, GA- SOUTHLAND HEALTHCARE AND REHAB CENTER

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 34318

Based on staff interviews, record review, and review of the facility policy titled Freedom of Abuse, Neglect, and Exploitation; Abuse Prevention: Fast Alerts, the facility failed to protect the resident’s right to be free from neglect by staff for one of seven sampled residents (R) (R1). Specifically, R1 had a significant change of condition while in respiratory distress and required further medical treatment. R1 expired less than four hours after being placed in his bed by staff.

On [DATE], a determination was made that a situation in which the facility’s noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents.

The facility’s Administrator, Director of Nursing (DON), and Corporate [NAME] President of Compliance and Regulatory Services were informed of the Immediate Jeopardy (IJ) on [DATE] at 4:18 pm. The noncompliance related to the IJ was identified to have existed on [DATE].At the time of exit on [DATE], an acceptable Immediate Jeopardy Removal Plan had not been received; therefore, the Immediate Jeopardy remained ongoing.

Findings Include:
Review of the policy titled Freedom of Abuse, Neglect and Exploitation; Abuse Prevention: Fast Alerts, dated [DATE], revealed Purpose. The purpose of this written Freedom of Abuse, Neglect, Exploitation: Abuse Prevention Standard is to outline the preventive and action steps taken to reduce the potential for abuse, mistreatment, and neglect of residents and the misappropriation of resident properly and to review practices and omissions which if allowed to go unchecked, could lead to abuse. This standard demonstrates a Zero tolerance of Abuse of any type or manner and will address accordingly. Neglect: Failure of a facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Overview: When a nursing home accepts a resident for admission, the facility has assumed the responsibility to 1. Adequately assess the resident’s condition. 3. Provide interventions or services to meet the resident’s needs from the time of admission.

A review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed R1 had a Brief Interview Mental Status (BIMS) score of 15, indicating intact cognition.

A review of the care plan for R1, with a canceled date of [DATE], revealed a focus area of Do Not
Resuscitate (DNR). The interventions included notifying the medical doctor as needed, communicating resident choice, and comfort measures.

A review of the progress notes for R1 dated [DATE] revealed Licensed Practical Nurse (LPN) BB
documented that staff was alerted to the resident room in response to R1 being unresponsive. Upon entry to the room, the resident was observed lying supine in the bed with the head of the bed elevated about 30 degrees. The resident had no pulse noted, his eyes were closed with no respirations noted. The resident has a DNR code status. The DON was notified of R1’s status.

A late entry dated [DATE] revealed a Registered Nurse (RN) Supervisor pronounced R1 deceased at 1:05 am. The RN Supervisor noted that he had attempted to notify the family five different times. The voicemail was not available. (Named) Funeral Home was notified.

A review of the Electronic Medical Record (EMR) for R1 revealed that there was no evidence of
documentation of vital signs or documentation of the event leading to R1’s death. The last documented vital signs were taken on [DATE].

Interview on [DATE] at 7:49 pm with Certified Nursing Aide (CNA) DD revealed that around 8:30 pm, R1 started asking for help. CNA DD stated the agency nurse assigned to R1 had left the building to get food. She stated she and CNA FF wheeled him to the front nursing station because they could not find his nurse. CNA DD further stated that two nurses (RN Supervisor and LPN CC) were at the nurse’s station and assessed R1 for pulse oxygenation and vital signs. CNA DD confirmed the RN Supervisor gave R1 oxygen and told R1 to stop talking. CNA DD described the resident as sweating, shaking, and holding his chest, begging for help. CNA DD stated that she held the resident’s hand and heard the two nurses discussing who would do the paperwork and stated neither nurse (RN Supervisor nor LPN CC) wanted to do the paperwork. CNA DD further revealed that the RN Supervisor stated that R1 was a DNR anyway, and both nurses (RN Supervisor and LPN CC) rolled R1 back to his room in his wheelchair and put him in the bed.

Interview on [DATE] at 10:57 am, the RN Supervisor revealed that he returned to the facility to pronounced R1. The RN Supervisor stated that when he returned to the facility and before pronouncing R1, he did an assessment by checking the carotid pulse, using his stethoscope, and checked the apical pulse and did not find a heartbeat. He stated the resident was cool to the touch. The RN Supervisor explained that at about 8:30 pm on [DATE], the facility was having a staffing issue at shift change. He stated they had initially told LPN BB to go home, but the nurse scheduled to work did not show up, and LPN BB ended up staying at the facility.

In a follow-up interview on [DATE] at 3:50 pm, the RN Supervisor revealed that R1 was coughing and talking, saying he was going to stop smoking. RN Supervisor stated that he thought it was a CNA who brought R1 to the front station, and R1 was stressing, saying he had a hard time breathing. He stated he was able to talk and repeatedly said he was going to stop smoking. He stated LPN CC put oxygen on the resident at two liters per minute. RN Supervisor further revealed that he was handling staffing issues, and LPN CC had said she had R1. RN Supervisor stated that R1 was taken back to his room by LPN CC and put to bed. RN Supervisor stated that he went to check on R1 before he left the facility, and his pulse oxygenation was 96 percent on 2 liters of oxygen. RN Supervisor revealed that he did not call the physician.

However, a review of the EMR revealed no evidence that the facility staff performed vital signs or an assessment.

Interview on [DATE] at 3:07 pm with LPN BB revealed that on [DATE], she was assigned to D Hall, and R1 was on the E Hall. LPN BB stated that when she initially got to work, R1 was at the front station and was receiving care from two nurses she identified as the RN Supervisor and LPN CC. LPN BB stated that she noticed the resident was wearing oxygen. She stated that she proceeded to her assigned area on the D Hall. She further stated that after she passed her medications on D Hall, she went to get something to eat. LPN BB revealed that she came back from lunch, and the RN Supervisor told her that R1 was complaining of being unable to breathe and had shortness of breath and that he had put R1 back in his room. The RN Supervisor had reported to her that R1 had gone out to smoke and that he put oxygen on the resident for shortness of breath and R1 seemed calmer. LPN BB further revealed that she went to pass narcotics for the Certified Medication Assistant (CMA) NN on E Hall and noticed R1 was anxious and yelling that he wanted his bed flat. LPN BB stated R1 was okay with not having the bed flat, and the resident was still talking and
wanted his bed flat. LPN BB revealed that CMA NN came to her and told her that R1 was deceased . She stated when she walked into R1’s room, he had one hand gripping the rail of the bed, his eyes were closed, and he had the appearance of being asleep. LPN BB stated that she checked his radial pulse and didn’t feel a pulse and further revealed that when RN Supervisor and LPN CC put him in bed with oxygen, they made her think he was okay. LPN BB commented that her initial contact with R1 was only about him wanting to have the bed flat.

In a follow-up interview on [DATE] at 1:49 pm with LPN BB, she clarified that she arrived at work at about 6:30 pm and normally goes to dinner before it is dark outside. She continued to state that her nursing note was written about 5 to 10 minutes after R1 was without signs of life. She stated when she first went on D Hall, it was during a regular medication pass to give narcotics for CMA NN since that they could not pass narcotics or chart those medications.

Interview on [DATE] at 7:17 pm with CNA FF revealed that she was orienting CNA EE and was in a resident room. CNA FF stated she heard someone hollering down the hall, and it was R1 saying he couldn’t breathe and wanted to lie down. CNA FF stated R1 was coming down the hall saying help me help me, and he couldn’t breathe. CNA FF revealed she rolled him to the front nursing station because she didn’t see a nurse on the back hall. CNA FF stated she informed the RN Supervisor and LPN CC that R1 was saying he could not breathe. She stated LPN CC took R1’s vital signs, and his oxygenation saturation was 83 percent. She further stated that LPN CC applied oxygen to R1 via a nasal cannula. CNA FF stated that she then returned to her assignment. She stated at the end of her rounds, she observed that the RN Supervisor and LPN CC had put R1 in his bed with oxygen on and R1 was sitting in an upright position in bed. She further stated that at about 8:00 pm or 8:30 pm, she told LPN BB and CMA NN that R1 has a history of heart attacks. She stated that LPN BB stated that she would not send R1 out because the doctors would say why didn’t they (nurses) do what could be done in the facility before sending him to the hospital. In a continued interview, CNA FF stated she and CNA EE told LPN BB that R1’s oxygen was 83 percent. CNA FF stated that she and
CNA EE checked on the resident and then went to get their meal from about 11:00 pm to 11:30 pm. CNA FF revealed when she returned from lunch that LPN BB told her to get R1’s vital signs, and R1 had no pulse and no chest rise.

Interview on [DATE] at 9:40 am with LPN CC revealed that she was assigned to the A/C Hall from 7:00 am to 7:00 pm. She stated she passed her keys and gave a report to the front hall nurse. LPN CC stated she went to get a sheet to sign off, and R1 was in front of the nursing station with two CNAs. LPN CC further revealed that R1 looked short of breath and was sweaty, and she noticed the RN Supervisor was checking R1’s vital signs. LPN CC stated she couldn’t recall the specific values of the oxygen saturation but knew it was around 85 percent. She stated that, in general, R1 needed oxygen. LPN CC further stated she got the oxygen, put the resident on 3 liters of oxygen by nasal cannula, and told R1 that he was not alone. LPN CC stated that she was told that R1 was blind and had paralysis on the left side, and she told him to raise his right arm to help him breathe and stated the oxygen was helping. LPN CC further revealed that the RN Supervisor took R1 to the nurse assigned to the resident and she did not know the nurse. LPN CC stated that after 8:00 pm,
she walked to the other side of the facility and asked a nurse where R1’s room was. She stated the RN Supervisor was in the room alone with R1 and stated that he had reported to the night shift nurse. LPN CC revealed that she and the RN Supervisor assisted R1 into the bed and placed the head of the bed in the up position. When asked why she did not document, she stated that she was clocked out and didn’t document because R1 was not her patient, and she thought he was okay. LPN CC stated she was helping the night shift nurse and did not call the physician. LPN CC further revealed that R1 was stable, and a report was given to the assigned night shift nurse. When asked if she discussed the transfer paperwork, LPN CC stated that she discussed the code status of the DNR, and if it were an emergency, she would call 911 and then call the physician to tell him what she did for the resident.

Interview on [DATE] at 1:34 pm with Physician QQ revealed that a resident with an 83 percent pulse oxygenation should have been sent out immediately and needed an advanced level of care. Physician QQ stated that R1 had no respiratory care needs, was cognitive, and could verbalize his needs and tell you what was wrong. Physician QQ further revealed that this was the first he had heard that R1 had expired and stated that R1 was on his monthly follow-up for the next week. Physician QQ stated there was no excuse for this, and a DNR does not mean withholding care.

Interview on [DATE] at 2:12 pm with the DON revealed that R1 should have been sent to the hospital and the physician should have been called. The DON stated that she was not aware of R1’s death circumstances because the RN Supervisor had told her that R1 had passed in his sleep and was a DNR.

Interview on [DATE] at 3:18 pm with the Administrator revealed that he was unaware of R1’s death
circumstances until the surveyor started interviewing the staff. The Administrator stated that once he was made aware, he held an Ad Hoc meeting and began education on notification and documentation of changes in condition and code status.