cms_GA: 1253
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rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
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1253 | PRUITTHEALTH - EASTSIDE | 115391 | 2795 FINNEY CIRCLE | MACON | GA | 31217 | 2018-08-17 | 658 | J | 1 | 0 | RM0M11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and record review, review of the Georgia Board of Nursing Rule ,[DATE]-.02 Standards of Practice for Licensed Practical Nurses, review of the Standards of Practice for Registered Professional Nurses: ,[DATE]-.01, the facility failed to provide adequate supervision of certified nursing staff regarding the initiation and cessation of cardiopulmonary resuscitation (CPR) during an emergency situation for one resident (A), from a total sample of 19 residents. An Abbreviated/Partial Extended Survey investigating complaint GA# 560 was initiated on [DATE] and concluded on [DATE]. The complaint was substantiated with deficiencies. On [DATE], 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's Administrator and Director of Health Services (DHS) were informed of the Immediate Jeopardy on [DATE] at 3:30 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on [DATE]. The Immediate Jeopardy continued through [DATE] and was removed on [DATE]. The facility implemented a Credible Allegation of Compliance related to the Immediate Jeopardy on [DATE]. The immediate jeopardy is outline as follows: Resident (R) A had not executed an Advance Directive. R A experienced a change in condition on [DATE], becoming unresponsive while staff attempted to assist the resident out of the bathroom, after he had sustained an unwitnessed fall. Cardiopulmonary resuscitation (CPR) was initiated by certified nursing staff, and Emergency Medical Services (EMS) were notified. However, the resident's Advance Directive status was inaccurately assessed by licensed nursing staff as Do Not Resuscitate (DNR) and CPR was stopped, prior to the arrival of EMS services and in absence of physician's orders [REDACTED]. The inaccurate Advance Directive status of DNR was obtained by licensed nursing staff from an incorrectly labeled form included in the Medication Administration Record (MAR) book. The DHS pronounced the resident's death at the facility on [DATE] at 7:09 a.m. at which time she notified the physician and family. The DHS was not aware the resident's Advanced Directive status was inaccurate until notified by the family later in the morning of [DATE]. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE] in the areas of 42 CFR 483.10 Resident Rights, F580; 42 CFR 483.21 Comprehensive Resident Centered Care Plans, F656; 42 CFR 483.24 Quality of Life, F678; 42 CFR 483.35 Nursing Services, F726; 42 CFR 483.70 Administration, F835; and 42 CFR 483.75 Quality Assurance and Performance Improvement, F868, all at a Scope and Severity (S/S) of a [NAME] Additionally, Substandard Quality of Care was identified at 42 CFR 483.24 Quality of Life, F678. A Credible Allegation of Compliance was received on [DATE]. Based on observations, record reviews, interviews and review of the facility's policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed on [DATE]. The facility remained out of compliance at a lower scope and severity of D while the facility continued management level staff oversight of the advance directive system and continued education. This oversight process included the analysis of facility staff's conformance with the facility's Policies and Procedures governing the accurate acquiring of the necessary steps to ensure the continuity of care. In-service materials, policies and records were reviewed. Observation, record review and interviews were conducted with staff to ensure they demonstrated knowledge of facility Policies and Procedures. Findings include: Review of the Georgia Board of Nursing Rule ,[DATE]-.02: Standards of Practice for Licensed Practical Nurses, 1) The practice of license practical nursing means the provision of care for compensation, under the supervision of a physician [MEDICATION NAME] medicine, a dentist [MEDICATION NAME] dentistry, a podiatrist [MEDICATION NAME] podiatry, or a registered nurse [MEDICATION NAME] nursing in accordance with applicable provisions of law. Such care shall relate to the promotion of health, the prevention of illness and injury, and the restoration and maintenance of physical and mental health through acts authorized by the board, which shall include, but not limited to the following: e) Participating in the management and supervision of unlicensed personnel in the delivery of patient care. Review of the Georgia Board of Nursing ,[DATE]-.01: Standards of Practice for Registered Nurses, 2. (a) 3. Plan care which includes goals and prioritized nursing approaches, or measures derived from the nursing diagnoses; (b) 3. Communicate, collaborate and function with other members of the health team to provide optimum care; 8. Assign and supervise only those nursing measures which the nurse knows, or should know, that another person is prepared, qualified, or licensed to perform; 9. Retain professional accountability for nursing care when delegating nursing intervention. The facility had a Do Not Resuscitate Policy: Georgia policy. The policy documented that CPR will be performed on all residents without a DNR order unless it is determined that CPR is not medically justified as determined by two nursing personnel, one of whom must be licensed. Not medically justified is defined to mean that when all of the conditions listed below are true, CPR will not be initiated, even if the resident does not have a DNR order documented on the chart, until the physician is notified, and orders are given to administer CPR. 1. Resident was found with no visible respiratory efforts 2. Resident was found with no vital signs 3. Resident was found unresponsive to verbal or painful stimulation. 4. Resident was found with fixed, dilated, and non-reactive pupils. 5. Resident was found with skin cold to touch. 6. Resident's decline in condition is sudden and not witnessed, and the resident is found without any signs of life. The facility also had a Cardiopulmonary Resuscitation (CPR), one-person policy. The policy documented that the facility provided basic life support, including initiation of CPR, to any resident who experiences [MEDICAL CONDITION] (cessation of respirations and/or pulse) in accordance with that resident's Advance Directive or in the absence of Advance Directives or a DNR order. The policy included to administer 30 chest compressions at a rate of 100 to 120 per minute. Push hard and fast. Open the airway and give 2 ventilations. Then find the proper hand position again and deliver 30 more compressions. Continue chest compressions until the emergency response team arrives or another rescuer arrives with a defibrillator or an automated external defibrillator (AED). Resident (R) A was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A review of the Advance Directives Checklist form, dated [DATE], revealed that the resident had not executed an Advance Directive and did not wish to discuss Advance Directives further at that time. The resident had a physician's orders [REDACTED]. R A was care planned for being at risk for falls, use of a wheelchair for mobility and able to ambulate short distances. A care plan was also in place, dated [DATE], for being at risk for respiratory complications. The care plan problem included that the resident would adjust his own oxygen setting and refuse to wear oxygen at times. During an interview on [DATE] at 12:07 p.m., a family member of R A stated that the resident was a full code and wanted to know why the resident was not sent to the hospital on [DATE]. R A experienced a change in condition on [DATE]. A Nurse's Note, dated [DATE] at 5:15 a.m., documented that a Certified Nursing Assistant (CNA) reported that the resident complained of shortness of breath and was sitting on the commode in the bathroom, not wearing his oxygen. The CNA applied the resident's oxygen nasal cannula and the resident returned to bed. The note further documented that the CNA reported that the resident returned to the bathroom and pressed the call light again. The resident again complained of shortness of breath and was not wearing his oxygen. The note continued to document that the CNA replaced his oxygen and exited the bathroom. A subsequent nurse's note on [DATE] at 5:20 a.m., documented that the resident was observed on the floor, in the bathroom, between the commode and the wall. The resident stated he could not get up. The note further documented that the resident was moved, by staff, from between the wall and commode and into his room and became unresponsive. The note continued to document that CPR was initiated and an oxygen saturation level and carotid pulse were unable to be obtained. At 5:30 a.m., 911 was notified and an ambulance dispatched while CPR continued to be performed. A 5:40 a.m. Nurse Note entry documented that a MAR record review indicated that the resident was a DNR and CPR was discontinued at that time. At 5:45 a.m., the DHS was notified that R A had expired and at 5:50 a.m., Emergency Management Services (EMS) personnel arrived and were notified that the resident was a DNR, therefore they left the facility. Nurse's Note entry document that the DHS arrived and pronounced the resident as deceased at 7:09 a.m. and that the physician was notified at 7:15 a.m. and the resident's responsible party at 7:20 a.m. During an interview on [DATE] at 11:37 a.m., CNA HHH stated that R A could get up on his own and would normally get up on his own and then call for assistance with his oxygen. On [DATE] around 5:00 a.m., she responded to the resident's call light. The resident was in the bathroom and said he needed his oxygen, so she applied is oxygen tubing and exited the bathroom. She stated that the resident did not complain of shortness of breath. She responded to his call light a second time when she noticed it on, above his door, when she exited another resident's room. R A was lying in the bed and stated that he had wanted some assistance with pulling up his pants but had already pulled them up and was in the bed. CNA HHH stated that the resident had his oxygen on, did not complain of any shortness of breath and she left the room. CNA HHH stated a little later she responded to his call light a third time. He was in bathroom again, on the commode, and said he needed his oxygen, so she applied his oxygen tubing. She stated that he did not complain of any shortness of breath and that she reminded him that his oxygen tubing would reach into the bathroom, that he did not have to take it off when he went to the bathroom. CNA HHH stated that she exited the room and not even five minutes later, R A turned his call light on again. She went back into the bathroom and observed him lying on the floor beside the toilet, asking for help to get up. CNA HHH stated that she noticed at that time that his right arm was a grayish color and that was different for R [NAME] She stated that she left the resident's room to get Licensed Practical Nurse (LPN) OO. Additional help was also obtained from CNA QQ. CNA HHH stated that the resident remained alert but then became quiet while they were attempting to remove the resident from between the commode and the wall and he was unresponsive when they were able to get him out. CNA HHH stated that LPN OO instructed her to call the code so she left the room to call the code and obtain the crash cart. CNA HHH stated that when she returned to the room LPN OO was trying to obtain vital signs on the resident but there were none, so she (CNA HHH) initiated chest compressions on R A, and that LPN OO left the room to call the code again because LPN PP had not heard the first call, although LPN OO did not return to the resident's room. CNA HHH stated that she continued to provide chest compressions until she overheard LPN PP, who had arrived on the unit, state that the resident was a DNR, and then she stopped providing chest compressions. CNA HHH stated that she did not receive any supervision, guidance or instructions from the LPN's on initiating or stopping CPR. CNA HHH stated that she was not aware that once she started CPR, she could not just stop. The DNR status that was documented on the MAR record, referenced in the [DATE] 5:40 a.m. Nurse's Note entry, was not accurate and was not consistent with the Advance Directives Checklist form that documented that the resident had not executed an Advance Directive. A review of the facility investigation, initiated on [DATE], revealed that the DNR list that was included at the front of the MAR book had been incorrectly labeled. During an interview on [DATE] at 11:08 a.m., the former SSD, who came into the facility for the interview, confirmed that the DNR list was an error and should have been labeled as the behavior management list. There was no evidence that R A's condition met the criteria of not medically justified, as documented in the facility's Do Not Resuscitate Policy. There was also no evidence that an attempt was made to assess R A's Advance Directive status prior to CNA HHH initiating CPR and no evidence that supervision and guidance was provided to the CNA by the LPN's regarding initiating and cessation of CPR. In addition, facility staff failed to continue to provide continued chest compressions until EMS arrived, as documented in the facility's CPR, one-person policy. There was no evidence that an attempt was made to verify the accuracy of the DNR form maintained in the MAR book and Resident A's Advance Directive status, through a review of his clinical record, prior to the cessation of CPR. During interviews on [DATE] at 4:24 p.m. with Licensed Practical Nurse (LPN) OO and on [DATE] at 7:28 a.m. with LPN PP, both of whom were present and responded to the resident's change in condition on [DATE], both confirmed that they did not look for Advance Directive information in the resident's chart and neither instructed CNA HHH to begin or stop CPR. In addition, there was no evidence that the DHS verified R A's Advance Directive status prior to pronouncing his death on [DATE] at 7:09 a.m. During an interview on [DATE] at 1:45 p.m., the DHS confirmed that she did not verify the resident's Advance Directive status prior to pronouncing his death on [DATE]. During an interview on [DATE] at 11:47 a.m., the Medical Director stated that he would have expected the nurses, including the nurse who pronounced the resident's death, to have look at the resident's clinical record for the Advance Directive status. Cross refer to F678 A facility investigation was initiated on [DATE] and the following concerns were identified and evidenced through review of Nurse consultant email dated [DATE] stating Eastside will proceed with a self-imposed jeopardy for the following: A facility investigation was initiated on [DATE] and the following concerns were identified: 1. Failure to notify the resident's responsible party of a change in condition timely. 2. Failure to continue CPR once started, without a stop order from the physician. 3. Failure to have accurate DNR lists in the front of the MAR. The facility implemented the following actions to address their identified concerns: 1. A complete audit of all residents' charts to confirm the accurate advance directive status. The audit will include physician's orders [REDACTED]. The Advance Directive facility checklist will be used to record the audit. New admissions will have their Advance Directive status verified and documented on admission. New admissions will be verified for accuracy by the DHS or Clinical Care Coordinator (CCC). New admissions will be added to the audit tool and continued until substantial compliance is maintained for three months. Issues identified as a result of the audits will be corrected immediately. 2. Education provided to the Social Worker (SSD) related to the importance of accuracy of Advance Directive status and completeness of all required paperwork including the list of DNR's in front of the MAR. 3. Education to Registered Nurses (RN) that will be on-call to pronounce, that will include coming to the facility immediately even if they are told the resident was a DNR. 4. Education to nurses regarding once CPR is started (even if in error), it cannot be stopped unless a Physician order [REDACTED]. When looking to confirm an Advance Directive status during an emergency, the chart must be opened and reviewed; looking for Advance Directive paperwork and an order on the POF. Never rely on the list in front of the MAR. 5. These audits and education pieces will be brought to daily stand-up meetings and reviewed by the Administrator. Results will be brought to QAPI monthly for three months or until substantial compliance is obtained for three months. Review of the facility's implementation of action related to the self-imposed jeopardy that record review revealed the actions were incomplete, and that residents were still at risk including: Care plans did not accurately reflect Advanced Directives, the survey team identified a resident who had no Advance Directive Sheet in their record and that only Licensed Nurses had been educated. An interview on [DATE] at 3:30 p.m. with the Administrator and the DHS revealed that the facility Policy and procedure titled Do Not Resuscitate Policy had not been reviewed or updated as of [DATE]. Therefore, this action did not remove the IJ related to accuracy or documentation of Advance Directives. The facility implemented the following actions to remove the Immediate Jeopardy per the A[NAME] dated [DATE] related to competency of staff: The facility failed to ensure that all licensed staff were competent regarding the protocol for CPR. The LPN failed to supervise certified staff members during CPR. LPN exited the room where certified staff were performing CPR to page for additional nursing staff, review the DNR listing in the Medication Administration book and call 911 and failed to return. 1. LPN OO will be terminated on [DATE] 2. Licensed and certified staff were educated by the DHS and Clinical Care Coordinator (CCC) from [DATE] through [DATE] including one newly hired staff on [DATE], on Do Not Resuscitate Policy: Georgia and Advance Directives: Georgia. Fourteen of 14 LPN's were educated as of [DATE] (100%), seven of eight RN's (87.5%) were educated as of [DATE], and 29 of 34 active CNA's completed education as of [DATE] (85%). 3. All newly hired licensed and certified staff will be educated during orientation. Licensed and certified staff who have not received this education, due to scheduled vacation, FMLA, and as-needed work status will not work until this education is completed. 4. The facility DHS, Nurse managers and/or Administrator will conduct mock code drills including AED function/usage, and the supervisory role of the nurse during the code, weekly for four weeks and monthly for two months. The results will be communicated by the DHS or Administrator at QAPI monthly for three months. The State Survey Agency validated removal of the Immediate Jeopardy as follows: 1. Record review of the personnel file for LPN OO on [DATE] confirmed a separation noticed dated [DATE]. 2. Review of the in-service sign in sheets with the CCC on [DATE] at 1:20 p.m. revealed that on [DATE], [DATE] and [DATE] that 100 % of the RNs, LPNs, and that 29 CNAs had been in-serviced on the new policy and procedures to verify code status of residents via the resident's chart, change in condition, nursing runs the code, that once CPR is started then it cannot be stopped without a doctors order and that mock code procedure had been put into place. The facility provided evidence that four mock drills had been conducted by [DATE], with sign-in sheets and evaluation had been completed. The mock codes drills will continue. 3. An interview with the CCC on [DATE] at 1:20 p.m. confirmed that one new staff member had been hired on [DATE] and verified through sign-in sheets that the new staff person had been educated. The CCC confirmed that any new staff, or any staff, not already in-serviced, would be in-serviced on the new policy and procedure for checking the Advanced Directive Status, change in condition, and nursing runs a code and that once CPR is started it cannot be stopped without a doctor's order chart prior to working. 4. Observation on [DATE] at 11:50 a.m. of a Code Blue being announced in a resident's room over the intercom. Observation of the mock drill in progress by the surveyor revealed that the DHS and Corporate Nurse Consultant were guiding the nurses and CNA's on roles which included: providing CPR and rescue breathing on CPR mannequin, role delegation, step by step instruction on use of AED (Automated External Defibrillator) use, continuation of CPR until mock EMS arrival to take over, notifying the MD, family and charting afterwards. The DHS made a point to clarify that licensed nurse oversees the code, should be in the room with the resident. The mock drill list was reviewed with staff. Staff present ran smoothly through the drill. Review of the Mock Code Drills education checkoff sheet revealed the following: date, time, number of participants (see sign in sheet), nurse in charge on scene, nurse assigned duties, crash cart present and AED utilized and reviewed, scribe assigned and writing, paged code, chart brought to room or reviewed for code status, 911 called, MD and RP called and documented in chart, crash cart restocked and sealed. Record review of Mock Drill form dated [DATE] and interview with the DHS on [DATE] at 1:45 p.m. confirmed the Mock Drills will be conducted weekly for four weeks then monthly for two months. The DHS confirmed that she will present the findings to the QAPI committee monthly. Interviews were conducted with Licensed Practical Nurses (LPN) and Registered Nurses (RN) on [DATE] at 2:15 p.m. with LPN TT and LPN BB, [DATE] at 2:25 p.m. with LPN EEE and LPN UU, [DATE] at 3:45 p.m. with RN FF and LPN KK, [DATE] at 4:00 p.m. with LPN HH, [DATE] at 11:18 a.m. with LPN MM and on [DATE] at 11:30 a.m. with LPN LLL, the Minimum Data Set (MDS) Coordinator revealed that they had participated in in-services on the new policy and procedures for verifying a resident's Advance Directive via the resident's chart, not to discontinue CPR once started even if in error, and the process for conducting a code and roles during the code. They confirmed knowledge that the licensed nurse oversees the code and should not leave the room during the code. They confirmed participating in a Mock Code Drill. Interviews were conducted with Certified Nursing Assistants (CNA) on [DATE] at 2:04 p.m. with CNA XX and CNA ZZ, [DATE] at 2:10 p.m. with CNA GG and CNA VV, [DATE] at 2:35 p.m. with CNA DD and CNA YY, [DATE] at 2:39 p.m. with CNA WW and CNA II, [DATE] at 3:35 p.m. with CNA DDD, [DATE] at 3:40 p.m. with CNA JJ and CNA CCC, [DATE] at 4:00 p.m. with CNA BBB, and [DATE] at 4:05 p.m. with CNA AAA revealed that they had participated in in-services on the new policy and procedures for verifying a resident's Advance Directive via the resident's chart, not to discontinue CPR once started even if in error, and the process for conducting a code and roles during the code. They were aware that the licensed nurse is in charge of the code and should give direction to them during the code. They confirmed participating in a Mock Code Drill. | 2020-09-01 |