| 8679 |
GRETNA CARE CENTER |
285146 |
700 HIGHWAY 6 |
GRETNA |
NE |
68028 |
2013-12-04 |
309 |
J |
0 |
1 |
T6KG11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC ,[DATE].09D Based on observations, record review and interview, the facility failed to provide CPR (Cardiopulmonary Resuscitation) in accordance with the resident's signed and documented advanced directives for Resident 77. In addition, the facility failed to identify code status on room name plates with as identified in the facility policy for Resident 51 and Resident 31. Resident census was 57. Findings are: Resident 77 was admitted to the facility on [DATE] according to the Face Sheet. Resident was admitted for rehab and nursing support related to L knee non-displaced lateral tibial plateau fracture according to the Discharge summary under the category nursing summary/discharge instructions. Resident 77 died on [DATE]. Resident 77 was assisted with ADL's (Activities of Daily Living) and participated with activities and therapy during resident stay at the facility. A document entitled Preferred Intensity of Medical Care and Treatment dated [DATE] and signed by the resident's daughter and POA (Power of Attorney) for Healthcare stated: I have fully discussed my future options for medical care and treatment, with both my physician and the facility. I have been informed of the benefits and risks of such options, and the potential consequences, and I am fully aware of my right to determine the course of my future treatment. Having considered all of these factors, I hereby direct my caregivers to honor my intentions with respect to the following treatments, should the need arise, all of which have been explained to me. An X marked the area of Resuscitate (Full Code) and Hospitalize. The document was signed by the resident's Healthcare Power of Attorney and witnessed by a facility representative. The physician signed the document and dated it on [DATE]. Record review of the Nurses Notes dated [DATE] at 2110 revealed the Med pass nurse went into the resident's room to give HS (hour of sleep) medications and found the resident with eyes open, unresponsive and no heart rate. No respirations, poor color. RN (Registered Nurse) C was called to the resident's room to examine the resident. Resident 77 was last checked at 8:55 pm. No unusual behaviors noted and no complaints at that time. At 9:15 pm, the PA (physician's assistant) was notified and stated: [DIAGNOSES REDACTED]. The Nurses Notes did not indicate that CPR was initiated. Resident 77's family and the Sheriff were notified of the resident's death. An additional note added to the Nurses Notes and dated [DATE] at 10:35 pm stated: Additional information regarding expiration: CPR was not initiated due to condition of body when found. MD aware. Family voiced no concerns. An interview with RN C was held on [DATE] at 3:07 PM. RN C was asked to indicate what she would do if she found a resident unresponsive. RN C responded that RN C would attempt to arouse the resident if the resident was unresponsive. RN C would then check the chart for a yellow sticker which is the facility indicator to initiate CPR. RN C would tell someone to call 911, initiate CPR, and grab someone to assist. RN C revealed that RN C had experienced a recent occurrance where the resident was a full code but when RN C found the resident, the resident had no heartbeat or respirations and pupils were fixed. RN C did not initiate CPR due to the resident's condition. When the physician was notified, the physician stated that nurses would not have been able to do anything anyway. An interview with the DON (Director of Nursing) on [DATE] at 3:20 PM revealed that the expectation of the DON would be that if a resident or responsible party has signed a document requesting full code, that a full code would be initiated. The DON stated CPR class recertification touches on when to initiate CPR. The residents who have requested full code status have a yellow round sticker on the resident chart and a yellow round sticker on the nameplate of the door of the resident's room. Review of the policy number CL-NUR-1804 entitled Emergency: Initiation of Code Blue and dated [DATE] indicated the following: 1.0 Purpose - To provide an organized, systematic process to notify appropriate staff emmgers of the need for assistance during a potential life-threatening situation. 2.0 Fundamental Information Equipment - Emergency Cart, Emergency oxygen supply, telephone 3.0 Procedure - 1. Follow clinical practice guidelines for CPR 2. Utilizing the overhead paging system, announce Code Blue (location); Repeat 2 times. At minimum, the following individuals are to respond: Physician (if in facility), Director of Nurses, Charge Nurse, Respiratory Therapist (not applicable in all facilities. 3. A designated team leader will direct other staff members to assist with making phone calls, assure the emergency cart is brought to the scene and assure the safety of other residents in the area. 4. A licensed staff person must remain with the resident at all times. 5. Call 911 for emergency transfer to an acute care center. 6. Contact the resident's physician for further orders. 7. Contact the resident's responsible party to inform him/her of the change of condition. 8. Continue CPR efforts until the ambulance service arrives or until spontaneous respirations, pulse and blood pressure return. 9. Transport resident to the acute care center. 4.0 Documentation - In the progress notes, record: When and why the Code Blue was initiated If CPR was initiated, when and how long the resident received it Resident response and any complications Any interventions taken to correct complications Date, time of physician and responsible party notifications Resident disposition 5.0 Company related guidelines Perry/Potter reference manual: CPR; One-Person and/or Two-Person rescue Choking Manual ventilation (Ambu Bag) Interview with LPN (Licensed Practical Nurse) E on [DATE] at 3:45 PM indicated this LPN would initiate CPR and yell for help if (gender) were to find a resident unresponsive with the absence of respirations and a heart rate. LPN E indicated that if the resident was a full code, even if they were cold and blue LPN E would initiate CPR. LPN E received CPR training on [DATE] from the NE Safety Council. Interview with NA (Nurse Aide) F on [DATE] at 3:50 PM indicated that if NA F found a resident unresponsive, NA F would call for the charge nurse. NA F was unable to identify the significance of yellow dots found on the name plates of rooms. Observation of yellow dots indicating full code status held on [DATE] at 3:40 PM to 3:44 PM revealed yellow dots on the nameplates of the following rooms: room [ROOM NUMBER] 212, 217, 101, 108, and 117. Observation of yellow dots on charts indicating full code status held on [DATE] at 3:45 PM indicated yellow dots were present on charts 101A,107A, 108A,117A, 118A, 203B, 204B, 212B, 217A and 217B. The dots on the charts do no correspond with the dots on the door nameplates. Interview with RN H held on [DATE] at 3:45 PM indicated if RN H would enter a resident room and observed an unresponsive resident with the absence of heart rate and respirations, RN H would attempt to arouse the resident and check the chart to see if the resident is DNR( do not resuscitate) status. If the resident were a full code, RN H would attempt CPR. When questioned when CPR would not be initiated, RN H responded if a do not resuscitate order is present or unless the color has already changed and there are no signs of hope. Interview on [DATE] at 3:55 pm with NA I revealed NA I would get the charge nurse if she found a resident unresponsive and wait for them to tell her what to do. Interview with the DON held on [DATE] at 4:10 PM revealed the facility did not have a policy on how to identify DNR residents as opposed to full code written up on the yellow dot system but DON said I can type something up. Interview held with the DON on [DATE] at 4:45 PM confirmed 2 nameplates by resident rooms did not have yellow dots, Residents 31 and 51. Residents 31 and 51 were determined to be full code status. The DON indicated (gender) had typed up dot guide today.Interview with the DON indicated nurses are informed of the yellow dot system during initial orientation. The following interventions were implemented by the facility on [DATE], [DATE] and [DATE] to abate the immediacy of the situation and protect residents who wanted to have CPR. An action plan was created listing CPR as the area of concern with a goal of residents receiving CPR according to current CPR guidelines. Approaches included: Audit placement of round yellow stickers daily times 1 month, then weekly times one month, then monthly times 3 months, then reassess and schedule audits on a prn random basis. Tentative schedule developed with a completion date of [DATE]; Assess monthly with QA(Quality Assurance). The outcome was all round yellow stickers were in place on the charts and beside name on door after replacing needed stickers. Move stickers under plastic on the resident name plate by their room door with a completion date of [DATE]. The outcome was all round yellow stickers are under plastic on the resident name plates by their door. Re-educate staff concerning CPR guidelines and protocols on all 3 shifts before they work with a completion date of [DATE] and [DATE] and current staff by [DATE]. The outcome was re-education completed on all three shifts and will continue until all staff reeducated before they work. Random questioning of staff concerning CPR policies and procedures weekly times one month, monthly times 1 month, then reassess and scheduel random questioning on a prn basis. Tentative schedule developed. The completion date was [DATE] and assess monthly with QA. The outcome indicated staff questioned gave correct answers to questions asked. Code Blue drills weekly times 1 month alternating shifts and assess then continue on a quarterly basis. Completion date was [DATE]. The first drill is scheduled for [DATE] quarterly schedule completed. Room changes or code status change with completion date of [DATE] Outcome will be social worker will give notice to DON with reminder to move round yellow stickers with move, and give copy of all code status changes to DON, audit weekly. On admission, admission nurse will put round yellow stickers on chart and by door under plastic on name plate and document on admission check list. Completion date of [DATE] with outcome to audit of all admissions upon admit. The final approach is to report findings to QA meeting monthly with the next QA meeting being [DATE]. The outcome will be to address all findings. All facility nursing staff who were scheduled to work were re-educated on the CPR policy on [DATE] and [DATE]. Based on the facilities actions, the IJ status was abated on [DATE]. |
2017-03-01 |