AUGUSTA, GA-HARRINGTON PARK HEALTH AND REHABILITATION

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 39844

Based on record review, staff and family interviews, review of audio and video recordings, and review of the facility policy titled Abuse Prohibition, the facility failed to ensure one resident (R) (R#1) was protected from neglect from licensed nursing staff, by failing to promptly assess a decline in respiratory status. Specifically R#1 exhibited symptoms of respiratory distress, became hypoxic and unresponsive, and required emergency intubation by the Emergency Medical Services (EMS) prior to transport to the hospital. R#1 required a tracheostomy for breathing and insertion of a gastrostomy tube for nutrition.

On 4/4/2023, a determination was made that a situation in which the facility’s noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment, or death to residents.

The facility Administrator, Director of Nursing (DON), and the Regional Nurse Consultant were informed of Immediate Jeopardy on 4/4/2023, at 10:07 a.m. The noncompliance related to the Immediate Jeopardy was determined to have existed on 1/15/2023.

At the time of exit on 4/6/2023, an acceptable Immediate Jeopardy Removal Plan had not been received, therefore the Immediate Jeopardy remained ongoing.

Findings include:

Review of the policy titled Abuse Prohibition reviewed 12/30/2022 revealed the intent is to preserve each patient’s right to be free from mistreatment, neglect, abuse, or misappropriation of property.

Neglect is defined as the absence or omission of services to the degree that it harms or threatens with harm the physical or emotional health of a disabled adult or elder person. The center will identify, correct, and intervene in situations in which abuse, neglect and/or misappropriation of patient property is more likely tooccur. This will include an analysis of the deployment of staff on each shift in sufficient numbers to meet the needs of the patients, and assure the staff assigned has knowledge of individual patient’s needs.

Review of the clinical record revealed R#1 was admitted to the facility on [DATE] with diagnoses of but not limited to fracture of left femur, pneumonitis, chronic diastolic (congestive) heart failure, hypertensive chronic kidney disease, encephalopathy, dysphagia, diabetes, atrial fibrillation, and epilepsy.

Review of the care plan dated 1/4/2023 revealed there is no evidence that a care area or problem
addressing residents’ respiratory status was developed. The resident was admitted with a diagnosis of pneumonitis and congestive heart failure. Further review revealed resident was a Full Code.

Review of December Physician Orders (PO) dated 12/28/2022, revealed an admitting diagnosis of aspiration pneumonia, with a custom order for swallowing precaution-high risk for aspirations.

Review of Nurses Note dated 1/15/2023 at 2:27 p.m. written by the DON revealed assessment noted fluid filled lungs with cough that he was unable to produce and spit out. Eyes were closed and he was unresponsive to verbal stimuli. The DON notified Nurse Practitioner (NP) WW and ordered to send R#1 to the ER for evaluation.

Review of video recording provided by family member of R#1 revealed the video shows family member sitting outside of his room. The family member asked an unidentified staff member why the DON had not come back to check on him. The unidentified staff member stated the DON was notified and will be in to see him when she is finished with wound care on another resident. The family member indicated she had asked for oxygen to be placed on him because his oxygen level is low. The family member used her personal pulse oximeter to check his oxygen level. At 1.32 seconds into the video, LPN CC was seen slowly bringing in an oxygen concentrator and supplies into the room. R#1 was visible on the video and was noted to be in respiratory distress, with an audible wet cough with grunting sounds. LPN CC removed the plastic bag from the oxygen concentrator and was heard telling receptionist MM to bring her another concentrator, due to the knob coming off. She proceeded to open the oxygen supplies, without noted urgency. There was no evidence on the video that LPN CC assessed the resident nor obtained vital signs or oxygen saturation level. During further review of the video at 4.20 seconds, the DON arrived outside of the residents’ room and began to argue back and forth with the family member of R#1. The DON indicated she was going to call the police and asked the family member to leave. Continued review of the video does not show the DON enter the room to assess the resident or speak to LPN CC about her concerns. At 10.9 seconds into the video, First Responders arrived at the facility. The video ended at 10 minutes and 37 seconds. During the 10 minute 37 second length of the video, there was no evidence that R#1 was assessed by the DON, or the LPN and no evidence oxygen was administered. The video is not time stamped.

Review of the ER report dated 1/15/2023 revealed resident arrived at the ER via ambulance at 4:59 p.m. He was unresponsive and hypotensive. He was intubated in the field. His oxygen saturation rate was at 100% and his blood pressure was 85/61 and was febrile. He had a GCS of three. Chest x-ray indicated a right lower lobe infiltrate. Labs were consistent with severe dehydration. Other concerns included acute and chronic renal failure, septic shock, and dehydration. He remained intubated, and a central line was inserted in the ER. He was admitted to the hospital intensive care unit (ICU).