Patient's death prompts state probe of health care facility

During the states investigation, several discrepancies appeared in medical records and call logs about the timing with which staff at Lebanon Health and Rehab had notified the residents attending physician of a critical potassium level.

According to the daily nurses notes on March 8, the residents health deteriorated and was experiencing nausea and vomiting. Review of lab results for that day showed the resident had a critical potassium level of 8.4 mmol. Reports showed the lab representative notified an RN of the results at 5:57 p.m.

The daily notes indicated an RN attempted to notify the attending physician by answering service at 7 p.m. and the notes claimed the physician did not return the call until 7:45 p.m. The physician ordered the resident to be sent to the emergency room for evaluation.

However the state also checked the physicians answering service call log on March 8 and found that the call from Lebanon Health and Rehab was not received until 7:50 p.m., with the RN leaving a message for the physician.

Also, the nurses notes claimed that an ambulance had been called to the facility at 8:10 p.m. However, review of emergency services transport call records revealed the call was received at 8:37 p.m.

Further review of the records showed the ambulance arrived at 8:50 p.m., departed Lebanon Health and Rehab at 9:14 and arrived at the ER at 9:17 p.m.

There was also evidence found by the state through interviews with several staff members at Lebanon Health and Rehabilitation that indicated communication between staff was inadequate to ensure the well-being of the resident.

An interview with an RN indicated a call was received from the lab about the March 8 critical potassium level at 6 p.m. and the RN then relayed the information verbally to another RN, who indicated the information was understood.

In a subsequent interview with the second RN, the state report indicated that RN could not recall treatments, resident symptoms, or interventions provided for the resident from 6 until 8:37 p.m.

Lebanon Health and Rehabilitations policy states if the results of the lab tests are Abnormal or Critical Values, the attending Physician/Licensed Provider will be notified immediately at the time the results are received.

A telephone interview conducted by the state with the residents attending physician on July 27, confirmed that a critical potassium level of 8.4 would have required immediate emergency treatment. The facilitys Director of Nursing stated in an interview on the same day that the facilitys policy for reporting abnormal and critical lab values had not been followed.

The state report noted that between the critical lab report being received by the facility staff, and the ambulance arriving, two hours and 53 minutes had passed, resulting in a delay in treatment.

As the resident was being loaded into the ambulance on March 8, the report indicated vital signs ceased and resuscitation began and continued in the emergency room without success.

The report said the resident died due to Acute Cardiac Arrest at 9:35 p.m. on March 8.

Annaliese Impink, spokesperson for Sava Senior Care Consulting, LLC, parent company of Lebanon Health and Rehabilitation, told The Wilson Post that a survey team alleged that there were deficient practices related to lab management.

Lebanon Health and Rehabilitation Center does not necessarily agree with the survey teams findings; however, the facility developed a plan to address the findings as required by law, Impink said.

Impink also noted that Lebanon Health and Rehab is not aware of who made the complaint, or how it came to the departments attention.

According to an Action Plan submitted to the Department of Health, the lab management policy of Lebanon Health and Rehabilitation has been reviewed by the facilitys Medical Director with attending physicians on July 29.

The facility will be notified of critical lab results by the lab. The nurse will immediately notify the physician within 15 minutes of receipt. If the attending physician does not respond within 15 minutes, the nurse will then notify the Medical Director and the Director of Nursing, reads the Action Plan.

The plan indicated that most licensed nurses employed at the facility have been educated and the rest will receive education regarding various deficiencies that were cited at the clinic.

The state also cited deficiencies for three other residents that involved the administering of medication and failure to notify physicians or patient representatives of changes in lab results.

Also, the facility was cited for not providing care or services for the highest well being of its residents and for not keeping complete, accurate or accessible records.

The names of residents and Lebanon Health and Rehabilitation staff involved have been withheld by the state and were not personally identified in the report.

Staff Writer Patrick Hall may be contacted at