Country Villa Riverview Rehabiliation and Healthcare Center
2005 River St Susanville, CA 96130
Citation Number: 230010390
Citation Date: 02/13/2014
Violation Date: 10/9/2012
Class: A
Penalty: $10,000

CLASS A CITATION -- PATIENT CARE

F328 483.25(k) TREATMENT/CARE FOR SPECIAL NEEDS

The facility must ensure that residents receive proper treatment and care for the following special services:

Injections;
Parenteral and enteral fluids;
Colostomy, ureterostomy, or ileostomy care;
Tracheostomy care;
Tracheal suctioning;
Respiratory care;
Foot care; and
Prostheses.

The facility failed to ensure Resident 3 received proper and necessary respiratory care and treatment when, during a field trip, Resident 3's oxygen tank ran low and needed to be changed, and the facility staff in attendance were unable to connect the regulator (a device that regu lates the amount of oxygen delivered) to a new/full oxygen tank. Resident 3 experienced symptoms of hypoxia and respiratory distress requiring emergency medical treatment from an ambulance crew and was transported to the hospital.

Resident 3 was admitted to the facility on 1/19/11 with diagnoses that included congestive heart failure (the heart being unable to move the blood through the body adequately), Chronic Obstructive Airway Disease (COPD-narrowed air passages in the lungs which obstructs her breathing and causes shortness of breath), Bipolar disorder, and tobacco use disorder (chain smoker). A review of Patient 3's Minimum Data Set, (MDS -a resident assessment tool), dated 10/22/12, showed that she could make her needs known, that she was competent to make her own decisions, and as such, was her own responsible party.

On 12/3/12 at 11:45 am, Resident 3 stated that in 10/2012, she and a group of about ten patients were taken on a field trip to the local casino for lunch and gambling. When it was time to go back to the facility, the transport van was summoned back to the facility. The van left with plans to return to the casino to transport the residents back to the facility. A few minutes after the van left, the Activities Director (AD) noticed that Resident 3's oxygen tank was running low of oxygen. The resident was receiving continuous oxygen at high rate of flow requiring frequent oxygen tank changes. A new tank was present, but none of the staff in the group knew how to attach the regulator onto the new oxygen tank. An off duty Licensed Vocational Nurse (LVN), who works at the facility, happened to be at the casino with her husband and assisted in putting the regulator on the new oxygen tank. Resident 3 stated that she told one of the staff that she did not feel well and the next thing she remembered was waking up in the ambulance.

During an interview on 12/3/12 at 12:30 pm, AD stated that Resident 3 had just gotten over pneumonia and had taken her last antibiotic that morning. AD stated that Resident 3 had been hospitalized twice in 10/2012 with respiratory infections which were not uncommon for her, due to her chronic lung disease. AD stated that Resident 3 had severe respiratory disease and required the use of supplemental oxygen at 5-6 liters per minute, 24 hours a day. Due to the high flow rate, Resident 3 needed a new oxygen tank every few hours and used five to six tanks a day. AD stated that Resident 3 was one of 10 residents who attended a casino outing on 10/9/12. When it was time to leave the casino, the transport van was unexpectedly summoned back to the facility, prior to the residents boarding. Just after the van left, AD noticed that Resident 3's oxygen tank was running low. A new tank was available, however, no one present knew how to put the regulator on the new tank. Resident 3 complained that she did not feel well and an ambulance was called. AD stated that Resident 3 began shaking like she was having a seizure, then lost consciousness just as the ambulance arrived.

The ambulance report, dated 10/9/12, showed the ambulance crew arrived at the scene at 1:33 pm, and found Resident 3 sitting in her wheelchair, her skin color was blue (indicating a lack of oxygen), her breathing was angonal (life threatening pattern of breathing), and she was unable to open her eyes or make sounds and movements. The ambulance crew initiated emergency respiratory resuscitation (the use of oxygen and breathing equipment) and at 1:50 pm, transported Resident 3 to the emergency department at the local hospital. Resident 3's condition was initially treated at the local hospital and from there she was flown to a regional hospital for ongoing care.

On 12/3/12 at 3:30 pm, a phone interview was conducted with Licensed Vocational Nurse (LVN) A. LVN A stated that she and her husband were having lunch at the casino on her day off. She heard a commotion and realized it was people from the facility where she worked. She went over to them to see if she could help and saw staff fumbling with the regulator, trying to get it on a new oxygen tank. LVN A noticed Resident 3's lips were turning purple and she was starting to lose consciousness. LVN A stated that she was able to get the regulator on the new oxygen tank just as the ambulance arrived. On 12/3/12 at 4:00 pm, after a phone interview with the van driver, each of the five staff members present during the 10/9/12 field trip incident were individually asked if they knew how to change the regulator on the oxygen tank at the time Resident 3's oxygen tank needed to be changed and when Resident 3 became hypoxic: the Administrator stated, "No," the Activities Director stated, "No," Activities Assistants D and E stated, "No," the Janitor stated, "No," and Social Services Director stated, "No."

Therefore, the facility failed to ensure Resident 3 received proper and necessary respiratory care and treatment when, during a field trip, Resident 3's oxygen tank ran low needing to be changed and the facility staff in attendance were unable to connect the regulator to a new/full oxygen tank. Resident 3 experienced symptoms of hypoxia and respiratory distress requiring emergency medical treatment from an ambulance crew and was transported to the hospital.

These violations presented an imminent danger of death or serious harm to the patient or a substantial probability that death or serious physical harm would result.