| 87 |
ST JOHN'S LUTHERAN HOME |
275024 |
3940 RIMROCK RD |
BILLINGS |
MT |
59102 |
2019-08-22 |
580 |
G |
1 |
1 |
P5VQ11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the nurse failed to notify a physician for a change of condition that resulted in a hospitalization for 1 (#238) of 38 sampled and supplemental residents. Findings include: During an interview on 8/21/19 at 1:54 p.m., staff member J stated changes of condition such as swelling and desaturation, would be documented in notebooks used by physicians that round in the facility, and then the nurse would call a provider depending on the seriousness of the resident's condition. During an interview on 8/22/19 at 11:16 a.m., staff member B stated a resident that was exhibiting swelling and desaturation, would receive oxygen right away, because it is in the facility's standing orders. The staff are always to let the physician know when a resident exhibited new signs and symptoms by filling out the SBAR form in the folder that the physcians use when rounding in the facility. The nurse should then monitor and use good nursing judgement, in accordance with what the physician recommends, and orders for the resident. Review of resident #238's Respiratory Measurements showed the following: -On 6/20/19 resident #238 had a non-productive spontaneous cough, lungs were clear, and oxygen saturation was measured at 97% on room air. -On 6/26/19 resident #238's cough was described as, Able to clear secretions, Dry, Harsh, Non-productive, Sponateous, Strong. (sic) -On 6/27/19 resident #238's lungs were noted to be clear and diminished at the bases, and was noted to have had, difficulty breathing with activity, Difficulty breathing at rest, Shortness of breath. (sic) Resident #238's oxygen saturation was measured at 89% on room air. -On 6/28/19 resident #238's cough was occasional, productive, spontaneous, strong, and able to clear secretions. Resident #238's oxygen saturation was measured at 88% and 84% on room air. -On 6/29/19 resident #238's lungs were noted to be clear and diminished at bases. Resident #238's oxygen saturation was measured at 88% on room air. -On 6/30/19 resident #238's lungs were noted to have had crackles at the bases of both her lungs. Resident #238's oxygen saturation was measured at 88% on room air. -On 7/1/19 resident #238's cough was described as barking, productive, spontaneous, strong, and able to clear secretions. Resident #238's left lung was noted to have an expiratory wheeze. Review of resident #238's Physical Therapy Long Term Care Progress Notes, showed the following: - On 6/27/19, Pt (patient) desaturation to 87 after ambulation . - On 6/29/19, Pt (patient) continues to be on 1L of oxygen with activity. Review of resident #238's Care Management Progress Note, dated 7/2/19, showed resident #238 was sent to the emergency room related to, .increased [MEDICAL CONDITION] today and needing more supplemental oxygen, and persistant cough. She was admitted to (hospital) for acute [MEDICAL CONDITION] secondary to heart failure exacerbation. A request on 8/22/19 at 12:15 p.m., for physician communication and visit documentation of resident #238 was not provided by the facility. |
2020-09-01 |