| 5089 |
NORTHEAST ATLANTA HEALTH AND REHABILITATION CENTER |
115504 |
1500 S JOHNSON FERRY ROAD |
ATLANTA |
GA |
30319 |
2016-01-21 |
281 |
J |
1 |
0 |
KRH911 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review, review of policy and procedure and review of the National Council of State Boards of Nursing [DATE] Georgia Practical Nurses Practice Act, it was determined the facility failed to ensure services provided met professional standards for one(1) of twenty-five (25) sampled residents (Resident #1). Observation of video surveillance of Resident #1's care on [DATE] revealed the resident pushing his call button and calling out Help Me multiple times for symptoms of shortness of breath and chest discomfort. Licensed Practical Nurse (LPN) MM told resident #1 to Stop pushing call light, what is wrong now? Resident #1 replied My heart at 4:46 a.m. LPN MM checked Resident #1's blood pressure at 4:54 a.m. and told Resident #1 that there was nothing wrong with him, he was having anxiety and that he just needed to calm down. Resident #1 continued to summon for help and call out Help Me. Certified Nursing Assistant (CNA) 11 entered Resident #1's room, asked him what he wanted, changed the resident's brief and removed his oxygen nasal cannula. Resident #1 was unresponsive when CNA 11 completed the brief change. CNA 11 called for the nurse and when LPN MM responded CNA 11 said, I came in, he died !. LPN MM appeared to check Resident #1's chest for respirations by placing her ear over his chest. LPN MM and CNA 11 left Resident #1's room, leaving him unattended. They did not perform CPR. CNA 11 returned to Resident #1's room and put the resident's pillow under his head, put his oxygen nasal cannula on his face, covered the resident with a sheet and raised the head of his bed. LPN LL entered Resident #1's room at 6:15 a.m. She placed a back board behind Resident #1 in bed. LPN LL manipulated an oxygen tank but was unable get it operational. The first chest compressions for CPR were performed by LPN LL at 6:34 a.m. The paramedics arrived at 6:38 a.m. Resident #1 was pronounced dead at 7:00 a.m. on [DATE]. (Refer F155, F157, F223) The facility failed to ensure professional staff provided timely necessary care and services to Resident #1 who requested assistance from LPN MM for shortness of breath and chest discomfort. The facility failed to identify a change of condition in Resident #1 and notify the Physician. The facility failed to perform Cardiopulmonary Resuscitation (CPR) when Resident #1 was first identified as having no pulse or respirations. The facility's failure has caused, or had the likelihood to cause, serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE]. The facility's Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy on [DATE] at 8:45 a.m. An acceptable Allegation of Compliance (AoC) was received on [DATE] and the State Survey Agency validated the Immediate Jeopardy was removed on [DATE] as alleged, The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. (Refer F155, F223, F282) Findings include: Review of the policy titled Medical Emergency Management, revised (MONTH) 2012 (SSP 0201.00) documented: The facility ensures residents receive timely and appropriate interventions in the event of a medical emergency. The staff take action to ensure that the residents Airway, Breathing and Circulation are maintained until emergency personnel arrive. Staff is aware of each residents advance directives prior to the administration of cardio [MEDICAL CONDITION] resuscitation. Once a medical emergency is identified, qualified staff assesses the resident, initiates the appropriate emergency procedure (s) and calls 911. The staff continues to provide care and monitor the resident until emergency personnel arrive. Review of the facility policy titled Changes in Resident Condition documented: The resident, physician and legal representative or designated family member are notified when changes in condition or certain events occur. Assess and document changes in condition in an efficient and effective manner. Provide assessment information to the physician, and provide clear comprehensive documentation Review of the National Council of State Boards of Nursing [DATE] Georgia Practical Nurses Practice Act revealed that LPNs may participate in the assessment, planning, implementation and evaluation of the delivery of health care services and other specialized tasks when appropriately trained and consistent with board rules and regulations. Record review for Resident #1 revealed an Advance Directives/Medical Treatment Decisions Acknowledgment of Receipt dated [DATE] indicated that the resident was a Full Code. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] indicated that his Brief Interview Mental Status Score (BIMS) summary score was three (3), indicating severe cognitive impairment. Shortness of breath and trouble breathing were indicated on the assessment. The resident received oxygen therapy. The facility care planned Resident #1 for Respiratory Problems on [DATE] with Approaches/Interventions that included: Assess for shortness of breath and notify MD of any changes. Observation of the video surveillance was conducted on [DATE] at 1:00 p.m. in the office of the Attorneys representing Resident #1 and his family revealed on [DATE], CNA 11 notified LPN MM that Resident #1 was unresponsive at 5:28 a.m. CPR did not begin until 6:34 a.m. LPN 'LL and CNA 11 could be heard on the video discussing how long they would tell Emergency Medical Service (EMS) they performed CPR. They agreed to report that CPR had been performed on Resident #1 for one (1) hour. The paramedics arrived at 6:38 a.m. Resident #1 did not respond to resuscitation efforts of the paramedics and was pronounced dead at 7:00 a.m. Review of the Nursing Daily Skilled Summary dated [DATE] at 5:40 a.m. LPN MM documented that she was notified that the resident was not breathing by Resident Care Specialist/ CNA 11. LPN MM documented that Resident #1 had no pulse or respirations. LPN MM documented at 6:20 a.m. that the supervisor talked with the resident's son and informed him of Code in progress then son gave the address and name of mortician to call. LPN MM documented that 911 was called at 6:25 a.m. According to the Nurse's Notes documentation by LPN MM, the paramedics arrived at 6:40 a.m. and Resident #1 was pronounced via telephone by a hospital physician at 7:06 a.m. Interview with LPN LL on [DATE] at 5:33 a.m. revealed that she did not remember the night of [DATE] but that was her with the oxygen tank in the video. LPN LL stated that around that time the oxygen tanks were faulty. The oxygen was coming out where it should not have been. The tanks have been replaced since that time and they don't have the same type regulators. LPN LL said that she did not write any nurses notes about the events of [DATE]. Interview with LPM MM on [DATE] at 10:27 a.m. revealed she recalled that CNA 11 called her into Resident #1's room. CNA 11 told her that something seems to be wrong with Resident #1. LPN MM said that she went into the room, checked his pulse and looked for rise and fall of his chest. She added that Resident #1's skin looked ashen. She stated that when she observed that he wasn't breathing she went to the nurse's station and called LPN LL to tell her that they had to do CPR, then grabbed the chart to check if the resident was deemed a Full Code. She called the son to determine whether Resident #1 was a Do Not Resuscitate (DNR). The son said that he thought resident #1 was a DNR. LPN MM explained further that the Code status was under the Advance Directives tab in the record. She said there must have been a discrepancy with the paperwork. According to LPN MM when the nursing supervisor LPN LL arrived she started the Code and called 911; placed Resident #1 on a backboard and hooked the oxygen up to the resuscitation (Ambu) bag. LPN MM said that she was unsure how long the delay was to actually start the CPR. LPN MM admitted that she did not perform vital signs when she assessed Resident #1 and that there was no step by step documentation of the events of the night. Interview with the Medical Director on [DATE] at 2:30 p.m. revealed that CPR should have been initiated on Resident #1. Resident #1 was a Full Code according to the Medical Director, there was nothing on the chart otherwise. Interview with the Medical Director on [DATE] at 10:26 a.m. revealed that he did not recall being notified of Resident #1 ' s complaint of shortness of breath, anxiousness or chest discomfort on [DATE]. The facility implemented the following actions to remove the Immediate Jeopardy: 1. All residents had the potential to be affected. All resident records were audited (139 of 139) by the Director of Nursing and Unit Managers on [DATE] to determine that the resident had the right to formulate an advanced directive and the code status was clearly documented and consistently located in the resident's medical record for Cardiopulmonary Resuscitation (CPR) or Do Not Initiate Cardiopulmonary Resuscitation (CPR) as per the resident, responsible person (s) or Medical Power of Attorney (POA) wishes. No concerns were identified. 2. All resident Care Plans (139 of 139) were audited by a licensed nurse or Social Service director (SSD) on [DATE] to determine that resident code status was on the residents ' plan of care. Care Plans were updated by a licensed nurse upon discovery if corrective action was required. 3. Education was provided for all staff on two separate occasions, defined in the following timeline: On [DATE] at 8:00 a.m. the Administrator held Town Hall meetings with all staff that were scheduled to work. Seventy-seven staff members attended the [DATE] in-service. On [DATE] a second Town Hall meeting was held and thirty-seven staff members were re-educated. All staff that were unavailable for re-education will be provided re-education prior to initiating work assignment and new staff will be educated during his/her orientation process. Education included the following topics: -Call Light Response -How to report Abuse and Neglect -Cardiopulmonary Resuscitation -Advance Directives Policy -Changes in Resident Condition Policy -Code Blue Status -Stop and Watch. 4. On [DATE] additional educational in services were conducted for all staff members. A total of one hundred and fourteen staff members were trained. Education included the following topics: -Call Light Response -How to report Abuse and Neglect -Cardiopulmonary Resuscitation -Advance Directives Policy -Changes in Resident Condition Policy -Code Blue Status -Stop and Watch. 5. On [DATE] Random Call light audits were conducted by the Interim Director of Nursing and the Social Services Director. 6. On [DATE] a second audit of all residents' Advance Directives. 7. On [DATE] Social Worker conducted fifteen resident interviews regarding resident care with no concerns voiced by the residents. 8. The Director of Nursing, Unit Managers, Staff Development Coordinator will perform random audits weekly of five (5) residents for how long 8 weeks then monthly for two (2) months, then frequency determined by the QAPI recommendations: - Change of Condition -Advance Directives -Oxygen Verification. 9. The Social Services Directors, Unit Managers, Staff Development Coordinator will perform random resident interviews utilizing Abacus Tool weekly. 10. The Administrator will review the Change of Condition, Advance Directives, Oxygen Verification, Resident Abuse and Neglect, as well as the Resident Interviews audit tools weekly for four weeks then monthly for two months to determine compliance. 11. The Administrator will report and discuss the audit results monthly in the monthly Quality Assurance Performance Improvement (QAPI) meetings. The State survey agency validated the implementation of the facility's Credible Allegation of Jeopardy Removal (CAJR) as follows: 1. Review of an audit log dated [DATE] revealed the Social Service Director and Unit Managers reviewed all resident's records related to Advanced Directives to ensure clear documentation related to Advanced Directives. State Survey Agency conducted a 100% audit of all resident health records for Advance Directive Code Status performed on [DATE] by survey team. All health records clearly indicated resident Code Status. 2. All resident Care Plans (139 of 139) were audited by a licensed nurse or Social Service director (SSD) on [DATE] to determine that resident code status was on the residents' plan of care. Care Plans were updated by a licensed nurse upon discovery if corrective action was required. Interviews with the Interim DON on [DATE] at 3:22 p.m. revealed that the facility performed a 100% chart audit of resident Care Plans related to Advanced Directives. 3 & 4. Education was provided for all staff on two separate occasions. Education included the following topics: -Call Light Response -How to report Abuse and Neglect -Cardiopulmonary Resuscitation -Advance Directives Policy -Changes in Resident Condition Policy -Code Blue Status -Stop and Watch. The documentation for the Staff Education Meetings that were held on [DATE], [DATE], [DATE], [DATE] and [DATE], and [DATE] that were submitted by the interim DON were reviewed by the State Agency. 5. On [DATE] Random Call light audits were conducted by the Interim Director of Nursing and the Social Services Director. State Survey Agency observed the random call lights audits in progress on [DATE] and reviewed the facility's Audit Log. 6. On [DATE] a second audit of all residents' Advance Directives. State Survey Agency conducted a 100% audit of all resident health records for Advance Directive Code Status performed on [DATE]. All health records clearly indicated resident Code Status. 7. On [DATE] Social Worker conducted fifteen resident interviews regarding resident care with no concerns voiced by the residents. Interview with the Facility Administrator on [DATE] at 5:00 p.m. confirmed that the resident interviews were conducted as indicated with no additional concerns voiced by residents. 8. The Director of Nursing, Unit Managers and Staff Development Coordinator will perform random audits weekly of five residents then monthly for two months then frequency dependent upon QAPI recommendation. - Change of Condition -Advance Directives -Oxygen Verification. Interview with the Interim DON on [DATE] at 3:22 p.m. confirmed that the results of the random audits would be reported to the QAPI committee each month. 9. The Social Services Directors, Unit Managers, Staff Development Coordinator will perform random resident interviews utilizing Abacus Tool weekly. Interview with the Interim DON on [DATE] at 3:22 p.m. confirmed that the results of the random resident interviews would be reported during the weekly at risk meetings. That information is then brought to the QAPI committee each month. 10. and 11. The Administrator will review the Change of Condition, Advance Directives, Oxygen Verification, Resident Abuse and Neglect, as well as the Resident Interviews audit tools weekly for four weeks then monthly for two months to determine compliance. The Administrator will report and discuss the audit results monthly in the monthly Quality Assurance Performance Improvement (QAPI) meetings. Interview with the facility Administrator on [DATE] at 5 p.m. confirmed that he would review the audit tools and report to the QAPI committee each month. |
2019-01-01 |