| 82 |
OAK HILL HEALTH & REHABILITATION CENTER |
415027 |
544 PLEASANT STREET |
PAWTUCKET |
RI |
2860 |
2017-12-20 |
600 |
J |
1 |
0 |
MUG111 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on surveyor observation, record review and staff interview it has been determined that the facility failed to provide services to avoid physical harm and emotional distress, defined as neglect for 1 of 44 sample residents, Resident ID # 84. Findings are as follows: 1. Surveyor observation on 12/14/2017 at 5:55 AM of the second floor nursing unit revealed Staff A, the unit nurse, in a dark area adjacent to the nursing station, stretched out on a small couch, eyes closed, not responding to verbal cues made by the surveyor. Surveyor interviewed nursing assistant, Staff B, at the time of the observation, who was present on the unit. Staff B approached the nurse on the couch, turned the light on and called his name. Staff A got up off the couch and proceeded to the bathroom. When he was questioned after the time of the observation, the nurse stated he was on his break. He stated he did not leave the unit because there was no one who could cover his break. He could not explain why he did not respond to verbal cues when laying on the couch with his eyes closed. Subsequent surveyor observation during medication pass with Staff A on 12/14/2017 at 6:40 AM revealed Resident ID # 84, sitting on the edge of the bed, short of breath, gasping for air with abnormal audible breath sounds, anxious and in respiratory distress. The nurse took a pulse oximetry reading which measures the blood oxygen level and it was 88% on 5 Liters (L) of oxygen via nasal cannula. Lippincott Manual of Nursing Practice, eighth edition, 2006, defines Respiratory Assessment as, assessment of respiratory status when administering inhalation medications. It states in part . Auscultate (listen to) the chest after administration of aerosol [MEDICATION NAME] to assess improvement in aeration and reduction in adventitious (abnormal) breath sounds. Review of the Medication Administration Record [REDACTED]. Staff A proceeded to administer the breathing treatment at 6:40 AM, but he did not perform a complete Respiratory Assessment following administration. The resident's pulse oximetry was assessed after the treatment and was 90% on 5 L of oxygen via nasal cannula. Neglect is defined at 483.5 as, the failure of the 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. Staff failed to conduct a respiratory assessment and to administer a necessary breathing treatment at 4:00 AM as was ordered by the physician. Failure to provide this necessary service resulted in the resident experiencing respiratory distress, as evidenced by the resident visibly gasping for air, abnormal breath sounds, a decreased blood oxygen saturation and anxiety. The failure of the nurse to provide these services and the resulting harm constitutes neglect. An interview was conducted with Staff A immediately following the observation, he could not explain why he did not administer the breathing treatment or perform a Respiratory Assessment at 4:00 AM as scheduled, nor could he explain why he did not perform a Respiratory Assessment after he administered the breathing treatment at 6:40 AM. Refer to F-695 for more information. |
2020-09-01 |