AVONDALE, AZ – ESTRELLA CENTER

Based on clinical record reviews, resident and staff interviews, facility documentation and policies and procedures, the facility failed to ensure one resident (#237) was free from neglect, by failing to provide the necessary nursing services when changes of condition occurred. The deficient practice resulted in a lack of nursing care being provided when a resident experienced a change of condition.

A general nursing note dated (MONTH) 20, 2019 at 10:15 p.m., by staff #30 revealed that she answered the resident’s call light and the resident complained of shortness of breath. Per the note, the resident’s oxygen saturation was 56%, and the resident was on oxygen at 6 LPM per nasal cannula. The intervention documented was that staff #30 gave the resident a breathing treatment.

Further review of the clinical record revealed there was no documentation of any other interventions which were done at that time other than a breathing treatment, there was no documentation of a thorough assessment of the resident which was done at that time, including a thorough respiratory assessment, and there was no documenation of any change of condition charting that was done.

In addition, there was no documentation that the resident’s physician/provider was notified of the resident’s change in condition/low oxygen level.

Review of the facility’s investigative report dated (MONTH) 26, 2019 included that a licensed practical nurse (LPN/staff #30) was the nurse on shift (on (MONTH) 20 evening shift through (MONTH) 21 night shift) and took care of resident #237. The report included that on (MONTH) 20, 2019 at 7:00 p.m., the resident complained of not feeling well (shortness of breath) and a breathing treatment was administered. (Although there is no clinical record documentation of this.) At 10:00 p.m., the resident complained of shortness of breath and oxygen saturation was 56% on 6 LPM of oxygen via nasal cannula. The resident was administered a breathing treatment. At 10:55 p.m., resident’s oxygen saturation was rechecked and was 79% on 6 LPM of oxygen via nasal cannula. At 12:52 a.m. on (MONTH) 21, 2019, the resident was observed to be pale with blue fingers and unable to get an oxygen saturation level and no heartbeat. At approximately 12:57 a.m., code blue was called and CPR was initiated. The EMS (Emergency Medical Services) came at 1:10 a.m. and at 1:28 a.m., the EMS medical director pronounced the death of resident #237.

Continued review of the facility’s investigative report revealed that staff #30 failed to document the SVN treatment at 7 p.m. and 10:15 p.m., failed to complete a change in condition for respiratory distress, did not place the [MEDICAL CONDITION] on the resident and admitted that she was unable to notify physician/provider until after the resident was pronounced dead. The report also included that staff #30 failed to adhere to Cardio [MEDICAL CONDITION] Resuscitation policy and procedure by delaying the initiation of Cardio [MEDICAL CONDITION] Resuscitation.