cms_MT: 508
Data source: Big Local News · About: big-local-datasette
| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 508 | COPPER RIDGE HEALTH AND REHABILITATION CENTER | 275060 | 3251 NETTIE ST | BUTTE | MT | 59701 | 2018-07-31 | 678 | D | 1 | 0 | GLJS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to ensure staff provided CPR to a resident who was a full code for 1 (#1) of 7 sampled residents. Findings include: Resident #1 was admitted to the facility after a fall at home resulting in a [MEDICAL CONDITION] and a left hip arthroplasty. Review of resident #1's admission records showed he was admitted to the facility to be evaluated and treated with physical and occupational therapy. The admission orders [REDACTED]. The orders were signed by NF1. Review of resident #1's POLST showed the form was not completed. At the bottom of the form was written, Does not want to address at this time and was signed by resident #2's wife and staff member D. The form was not dated. Review of resident #1's nurse's note, dated [DATE] without a time noted, showed, up took meds, meal on wing went to P/T, Ret to Rm. Hoyer into bed went to remove sling Pt became limp color pale. called to room last breath no pulse no B/P expired wife Dr. notified Wife visited him. Review of resident #1's Record of Death showed the date of death as [DATE] at 9:05 a.m. During an interview on [DATE] at 1:45 p.m., staff member D stated resident #1's wife wanted him to be a full code. She stated in the past his wife stated to resident #1 that he didn't want a code but reminded him of how well he came out of the hospital. Staff member D stated the POLST was addressed during the care plan meeting on [DATE] and resident #1 was sleeping throughout the meeting. She stated resident #1's wife kept waking him and would try to talk to him. Staff member D stated resident #1's wife did not want to make the decision for him. She stated resident #1 wanted to go to bed and did not want to address completing the POLST. Staff member D stated if a resident coded, and was a full code, CPR would be administered. Review of resident #1's Care Conference form, dated [DATE], showed resident #1, his wife, and a staff member from nursing, therapy, activities, social services, and dietary attended. The form showed in the notes section, offered/reviewed POLST-declined. During an interview on [DATE] at 3:05 p.m., staff member C stated if a resident is a full code staff is to initiate CPR. Staff member C stated she called resident #1's wife at the time staff had found resident #1 without a pulse and respirations. She stated resident #1's wife said to send him to the hospital, and then said no, and stated she did not know what to do. Staff member C was then told by staff member D that resident #1 had no pulse. Staff member C stated resident #1's wife said she did not know what to do. Staff member C stated she told her she should come and say her goodbyes. Staff member C stated staff members F and H were present also. Staff member C stated she did not know why they did not do CPR. She stated resident #1 was very fragile. Staff member C stated resident #1's wife had stated she knew resident #1 was never going to come home. Staff member C stated if the provider would have been there he wouldn't have had staff provide life saving measures such as CPR for resident #1. During an interview on [DATE] at 4:30 p.m., resident #1's wife stated resident #1 told her he was tired. He was ready to go. She stated she was told his heart failed. She stated when the facility called her at the time he coded he died during the phone call. She stated she thought if he had gone in the ambulance he would have died anyway. During an interview on [DATE] at 5:15 p.m., staff member F stated the CNAs came and got her at the nurse's station and took her down to resident #1's room. She stated she looked at him and checked his pulse and there was nothing. She stated she checked his chest and he had no respirations. She stated he was clinically dead. She stated she did not perform CPR for resident #1 because he was expired. She stated a full code meant she should have started CPR and called a code. She stated resident #1 had stated several times he was tired. She stated she personally could not see performing CPR for him. She stated she should not have made that choice for him. Staff member F stated she was due for her CPR certification and was attending a class on Thursday. A request was made for documentation that showed staff member F's had a current CPR re-certification. No additional information was submitted. During an interview on [DATE] at 2:05 p.m., NF1 stated he had treated resident #1 for several years. NF1 stated the POLST was not completed because resident #1 had dementia and was not able to make cognitive decisions. He stated performing a code and CPR for resident #1 would have been a crime against humanity. He was declining. Review of the facility BLS Log showed staff members B, H, and D were CPR certified. | 2020-09-01 |