SAN ANTONIO,TX- LEGENDS OAKS HEALTHCARE AND REHABILITATION CENTER

During an interview on [DATE] at 1:28 p.m., Nurse Practitioner A stated she would have preferred to be notified if a resident was receiving [MEDICATION(S)] more consistently than usual. NP A stated she was supposed to be notified of any abnormal results. NP A stated if she had known Resident #1’s abnormal KUB results showed a small bowel ileus earlier she would have ordered for Resident #1 to be sent out immediately. NP A stated a small bowel ileus is life-threatening and elaborated, a nursing home would not have been equipped. [Resident #1] would need to be NPO, an NG tube, decompress her stomach, daily KUB. And none of that could be done in the Secure Nursing Facility setting.
During an interview on [DATE] at 2:49 p.m., NP A confirmed if she had sent Resident #1 to an acute care hospital sooner, it would have prevented any negative outcomes.

During an interview on [DATE] at 11:50 a.m., Assistant Director of Nursing F stated during NP A’s visit on [DATE], NP A had come to their office to request Resident #1’s KUB results. ADON F confirmed she and LVN G provided the results to NP A. ADON F stated she, LVN G and NP A reviewed the KUB result together. ADON F stated At first, I seen the top of the x-ray results and said that looks good. [NP A] asked me to continue reading to the bottom of the paper. I verified the result, that [Resident #1] had a small bowel ileus. ADON F stated DON L was not notified of the abnormal x-ray results because DON L was not in the building. ADON F confirmed that it would have been LVN C’s responsibility [current nurse on duty] to notify DON L or the ADON’s F or J, but LVN C did not . ADON F stated the process for receiving and reporting abnormal results was to document the issue on the 24-hour report, notify the provider, and follow up. ADON F confirmed that a small bowel ileus was considered an urgent result. ADON F confirmed the KUB was ordered on the [DATE] and was able to recall that ADON J printed the result out and gave it to the charge nurse, LVN C, to report at the clinical meeting the next day, [DATE]. ADON J stated, My understanding the results came in – in the afternoon- no results available at shift change. ADON J confirmed LVN C had documented the results were normal, and LVN reported Resident #1 was stable. ADON F revealed was she unaware if LVN C had reviewed the results, and reiterated LVN C had the results with her at the clinical meeting on [DATE]. ADON F stated, I guess [LVN C] missed the lower part that was on the result page. ADON F confirmed that the provider was not notified same day regarding Resident #1’s x-ray result, and further confirmed that she believed the bottom part of the x-ray results was missed or not read thoroughly. ADON F stated that even I did not read it (x-ray results) fully and providers should be notified immediately after results are received in hand.

During an interview on [DATE] at 6:48 p.m., LVN C stated she never reviewed the results of Resident #1’s abnormal KUB, dated [DATE], because RN E told her the KUB results were fine. LVN C stated, I never seen the results. LVN C explained when a nurse receives any results, regardless if the results are normal or abnormal, the nurse would inform the provider. LVN C confirmed the results and notification to the provider would require documentation in the medical record, which was not completed.

During an interview on [DATE] at 11:32 a.m., RN E stated Resident #1 had episodes of nausea and vomiting the last few days before discharge. RN E recalled Resident #1’s KUB ordered on [DATE] showed a small obstruction in the colon. RN E stated because the obstruction was small and Resident #1 was going to the restroom, she did not report it to the provider. RN E elaborated, I did not consider it urgent because [Resident #1] was having [bowel movements.] RN E confirmed she gave Resident #1 [MEDICATION(S)], then Resident #1 vomited, and Resident #1 reported feeling better. RN E stated she gave a copy of Resident #1’s KUB, dated [DATE], to LVN C. RN E elaborated she told LVN C that Resident #1 had a small bowel obstruction and Resident #1 was having bowel movements. When asked if there was anything further, she should have done, RN E stated, No, I treated the signs and symptoms and [Resident #1] was fine.

RN E and LVN C failed to notify Resident #1’s provider, NP A, of Resident #1’s abnormal radiology results after resident had experienced nausea and vomiting and been administered anti-nausea medication for 3 days. As a result, Resident #1 was eventually transported to an acute care hospital and expired.