| 20 |
GREENBRIAR HEALTHCARE |
305005 |
55 HARRIS ROAD |
NASHUA |
NH |
3062 |
2017-09-07 |
281 |
D |
1 |
0 |
9SPV11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to follow the professional standard of practice for the assessment of a resident, for 1 resident in a survey sample of 1 resident. (Resident identifier is #1.) Findings include: Reference for the professional standard of practice for assessment documentation is: Fundamentals of Nursing, Potter-Perry, Mosby Elsevier, 7th Edition, St. Louis, Missouri, 2009, which revealed the following: Chapter 16 Nursing Assessment page 243. Data Documentation Data documentation is the last part of a complete assessment. The timely, thorough, and accurate documentation of facts is necessary when recording client data. If you do not record an assessment finding or problem interpretation, it is lost and unavailable to anyone caring for the client. If there is not specific information, the reader is left with only general impressions. Observation and recording of a client status is a legal and professional responsibility. The nurse practice acts in all states and the American Nurses Association Nursing's Social Policy Statement (2003) mandate, or require, accurate data collection and recording as independent functions essential to the role of the professional nurse. Review on [DATE] of Staff C's (Licensed Nursing Assistant) written statement dated [DATE] revealed the following: After breakfast I was told by my nurse (Staff D) that the resident was very tired and she put (Resident #1) in .chair because she could not convince the resident to lay down on (Resident #1's) bed. I (Staff C) checked on resident twice and reported to nurse (Staff D) that (Resident #1) was still sleeping A few hours after my nurse (Staff D) asked me (Staff C) to help her transfer the resident to . bed because (Resident #1) was hanging over .chairarm and she did not want (Resident #1) falling. The resident did not wake up during the transfer, after we got (Resident #1) on .bed, the visitor that was also in the room tried speaking to the resident at which the resident mumbled an unrecognized word. I (Staff C) checked on the resident two more times before my (Staff C) shift ended and reported to nurse (Staff D) that the resident was snoring. My nurse (Staff D) said let (Resident #1) sleep because (Resident #1) was very tired. Interview on [DATE] at approximately 4:25 p.m. with Staff C (LNA) regarding this incident, revealed that Staff C went to get Resident #1 in the morning after breakfast, went to (Resident #1's) room . resident not there. Thought resident went to get coffee. Later this LNA (Staff C) observed Resident #1 sitting in chair beside the bed and that the resident looked like a drunk. This LNA (Staff C) reported to the nurse what she observed and was told by Staff D to let (Resident #1) sleep . (because Resident#1) didn't sleep last night. Staff C revealed that this was not like Resident #1 and that Resident #1 usually doesn't sleep that late and is usually up & about. Staff C was told by the Staff D to leave Resident #1 alone and let Residen t#1 sleep. Staff C further revealed at this time that Staff D asked her to help transfer Resident #1 back to bed and reported that Resident #1 was leaning on staff for support and that Resident #1 was very limp with Resident #1's upper extremities, like (Resident #1) was zonked and staff had to lift Resident#1 into bed. During this transfer Staff C reported that the Resident #1 didn't say words . mumbled and staff were unable to understand Resident #1. Staff C checked Resident #1 and could hear (Resident #1) snoring. Resident #1 was not awake for lunch on [DATE]. Staff C was told by Staff D to let (Resident #1) sleep .(Resident #1) is very tired. The facility failed to assess Resident #1 at the time Resident #1 was transferred from the chair to the bed by two staff. Resident #1 was reported as limp, leaning on staff for support and mumblingduring this transfer when Resident #1 was usually independent in walking. Staff C revealed that Resident #1 was not himself/herself and not coherently talking with staff. Interview on [DATE] at approximately 2:15 p.m. with Staff A (Administrator) and Staff B (Assistant Director of Nurses) confirmed that Resident #1 had a change in condition on [DATE]. when Resident #1 was leaning on staff for support and was limp with his/her upper extremities and mumbling words staff could not understand during transfer from the chair to bed. Staff A and Staff B revealed that the facility failed to assess Resident #1 for a change in condition. Review on [DATE] of the incident report revealed a signed statement dated [DATE] by Staff D (Licensed Practical Nurse/Licensed Vocational Nurse) who documented the following: Morning routine (Resident #1) always up and about. As I went in my morning shift (Resident #1) kept talking to me as usual. (Resident #1) is always up in the morning and comes to talk to me and the LNA's. (Resident #1) looked exhausted but I had been told (Resident #1) usually doesn't get much sleep in the night. Around 9:30 - 10:00 I told (Resident #1) . try (sic) to take a nap (Resident #1) was sitting in (sic) the couch in front of elevators and was ambulating and walked to . room. Sat down in the recliner because (Resident #1) refused to be in bed. (Resident #1) was fine @ (sic) that time and then .friend (name omitted) came to visit .friend said we should come in went to see (Resident #1) and (Resident #1) was sleeping, no hard breathing noted, no high respirations no sweating or excessive sweating noted. The snoring was normal. Not deepen at this time @ (sic) 11:00. Resident was transferred 1200 (sic) from the recliner to bed. Resident usually doesn't eat much through the day. (Resident #1) didn't eat breakfast or lunch. Resident usually can take a nap during the day. The LNA and I checked up on resident throughout the day. The resident did not throw up the times that I rounded . pupils were reactive when I checked upon (Resident #1). After giving report to the on coming nurse (Resident #1's) friend came to us and said something is wrong we went to see (Resident #1) was on . left side emesis (sic), . was breathing heavily, .was sweating profusely so immediate action was place called 911 supervisor was called and (unreadable writing) and doctor. Interview on [DATE] at approximately 11:20 a.m. with Staff D, Staff D stated the events occurring on [DATE] that lead up to Resident #1 being transported out to the hospital: Staff D stated that she had come in to her shift and was told that Resident #1 had not slept well the previous night. When Staff D left report Resident #1 approached her to talk and then Resident #1 went downstairs as Resident #1 usually does to get breakfast. When Resident #1 came back upstairs Resident #1 sat on the couch in front of the elevators and dozed off. Staff D approached Resident #1 and encouraged Resident #1 to go back to Resident #1's room and take a nap. Resident #1 ambulated back to room and sat in the recliner - this was around 10:30 a.m. Around 11:00 a.m. Staff D was approached by Resident #1's family friend who stated she was concerned about Resident #1 as he/she was sleeping in the recliner chair in the room and was slumped over the side of the chair and was not responsive. Staff D asked Staff C (LNA) to assist Staff D in getting Resident #1 into bed for a nap. Staff D and Staff C arrived in Resident #1's room and stood and pivoted Resident #1 into bed. Resident #1 did not wake up or respond to this transfer. Once Resident #1 was in bed Resident #1 opened one eye, looked at the family visitor and mumbled something to her that was unintelligible then Resident #1 appeared to be sleeping. Staff D was asked if Staff D had performed an assessment of Resident #1 and Staff D stated that she had performed an assessment that appeared to be normal but that she had another resident that was in crisis and needed to be sent out to the emergency room . Staff D stated that she did not document the assessment because she was too busy with the other resident and had forgotten. Staff D was asked if the way Resident #1 had presented during Staff D's shift was the way Resident #1 usually presented and Staff D stated, No, generally (Resident #1) was up and about walking around and socializing. Staff D went on to explain that later in the day the family friend had returned, probably around 4:00 p.m. and asked Staff D to come see Resident #1 because Resident #1 was not responding and had vomited in the bed. Staff D performed an assessment at this time of Resident #1 who was found on Resident #1's left side in vomit and drool around face, unresponsive, pupils were not reactive, blood pressure was ,[DATE], pulse was 118 and oxygen saturation on room air was 86% and Resident #1 had a temp of 99.5. On call MD was notified and 911 called for transport. The shift supervisor for the facility was notified of the situation. Staff D stated that the resident was transported to the hospital and died approximately 23 hours later. Interview on [DATE] at approximately 4:25 p.m. with Staff C (Licensed Nursing Assistant) regarding the events of [DATE] with Resident #1, Staff C stated that she was concerned throughout her shift and notified Staff D a couple of times that the resident was still sleeping. Staff C stated that she did assist Staff D with transferring the resident around 11:00 a.m. from the recliner chair to the bed because Resident #1 was hanging over the side of the recliner. Staff C stated that during this transfer the resident acted like a drunk person, was limp and leaning on staff as Staff C and Staff D pivoted him/her into bed. Staff C stated that Resident #1 did not wake up during this transfer but did mumble something once he/she had been transferred to bed but Staff C could not understand what Resident #1 had said and then Resident #1 slept. |
2020-09-01 |