MOORESVILLE, NC- THE CITADEL MOORESVILLE

Based on record reviews and staff, Respiratory Therapist, Medical Director (MD) and clinical respiratory provider interviews the facility failed to provide necessary respiratory care and services to a resident with a compromised respiratory status who was dependent on bilevel positive airway pressure ([CONDITION(S)]).  The facility failed to clarify orders for the [CONDITION(S)] on admission or involve respiratory therapy and as a result the [CONDITION(S)] machine was not set up until the evening of [DATE]. In addition, the facility failed to complete and document on-going comprehensive assessments of the resident’s respiratory status and ensure Resident #1 had continuous oxygen. Review of Resident #1’s Death Certificate revealed he expired on [DATE] at 2:07 AM. The cause of death was listed as acute and chronic respiratory failure with [CONDITION(S)] (lack of oxygen).

A Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] #1’s non-invasive mechanical ventilator machine was to be worn at night and as needed during naps. The order included the settings for non-invasive mechanical ventilator machine to deliver the [CONDITION(S)] ventilation

Review of a nursing progress note dated [DATE] at 12:00 AM written by Nurse #3 revealed around 1:50 AM Resident #1 was found with his nebulizer mask on and unresponsive. The non-invasive mechanical ventilator mask was immediately reapplied, and his oxygen saturation level checked with no reading. CPR was initiated at 1:55 AM and 911 was called. EMS arrived to the facility at 2:00 AM and Resident #1 was pronounced as expired at 2:07 AM.

Nurse #3 stated the resident had a breathing treatment ordered for midnight however she didn’t administer it because she didn’t want to touch his non-invasive mechanical ventilator mask. Nurse #3 stated around 1:30 AM she walked by Resident #1’s room and saw he did not have his non-invasive mechanical ventilator mask on but had his nebulizer mask on with no supplemental oxygen hooked to it and no other tubing hooked.

Nurse #3 stated to her she had been scared to touch his non-invasive mechanical ventilator machine and that’s why she hadn’t administered his 12:00 AM breathing treatment.

Nurse #3 stated she had received no training regarding a non-invasive mechanical ventilator machine before or after the incident.

An interview conducted on [DATE] at 2:51 PM with the Admissions Coordinator for the facility revealed the facility was not supposed to admit residents with a non-invasive mechanical ventilator machine.