| 12691 |
WEST HILLS HEALTH AND REHAB |
445501 |
6801 MIDDLEBROOK PIKE |
KNOXVILLE |
TN |
37919 |
2012-05-18 |
155 |
J |
1 |
0 |
LG2N11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, facility policy review, and interviews, the facility failed to follow advance directives to provide emergency resuscitation for one resident (#1) of twenty residents reviewed. The facility's failure resulted in Cardio-Pulmonary Resuscitation (CPR) not being initiated for at least five minutes after the resident was found without respirations, CPR being unsuccessful, and the resident was pronounced (officially diagnosed and declared) dead at 8:05 p.m. on [DATE]. The facility's failure resulted in an Immediate Jeopardy. The Administrator, the Corporate Nurse, and the Director of Nursing were informed of the Immediate Jeopardy in the Administrator's office, on [DATE], at 11:00 a.m. The findings included: Medical record review revealed Resident #1 was initially admitted to the facility on [DATE]. Review of a history and physical dated [DATE] revealed the resident had [DIAGNOSES REDACTED]. Further review of this history and physical revealed Resident #1 was a "full code" (has advance directives for resuscitation measures, if found without breath or pulse, which may include providing respirations, chest compressions, electrical shock, and medications). Review of Departmental Notes (computerized multi-disciplinary notes), dated [DATE], revealed the resident fell out of the bed, at approximately 11:50 p.m., and was transferred to the hospital. Further record review revealed the resident was readmitted to the facility on [DATE], following hospitalization for surgical repair of a left [MEDICAL CONDITION]. Review of the resident's Re-admission orders [REDACTED]. Review of physician's orders [REDACTED]. Review of the resident's Care Plan, dated [DATE], revealed, "Advance Directive...Full Code...Resuscitate". Review of facility Departmental Notes dated [DATE], at 7:35 p.m. revealed, "...resident did not have signs of respirations or was a pulse palpated..." Further review of the Departmental Notes revealed, "7:40 p.m. Code was called and CPR was intiated...7:50 p.m. EMS (Emergency Medical Services) arrived...8:05 p.m. EMS called (discontinued resuscitation efforts) the code, and resident was pronounced at the facility." Review of undated policy titled, "Code Arrest - Procedure and Protocol", revealed, "General Guidelines...First person on the scene will begin CPR and call for help. Continue until otherwise directed by physician or relieved." Interview with Certified Nursing Assistant (CNA) #1, on [DATE], at 1:40 p.m., in the Director of Nurses (DON) office, revealed CNA #1 walked by the first floor dining room at approximately 7:30 p.m. and observed Resident #1 sitting alone in a geri chair. Further interview revealed CNA #1 observed Resident #1's "color looked bad" and the resident was unresponsive when spoken to. CNA #1 stated...went to get a nurse and found Licensed Practical Nurse (LPN) #2 passing medication in the hallway. CNA #1 stated LPN #2 went to the resident, and sent CNA #1 to find another nurse (LPN #1). CNA #1 stated she was unable to find LPN #1, and returned to the dining room where LPN #2 was with the resident. CNA #1 stated the resident was still in the geri chair and no resuscitation was started. CNA #1 stated LPN #2 told...to take the resident to the resident's room. CNA #1 stated...took the resident to...room on the 200 hall, while LPN #2 went to find LPN #1. CNA #1 stated...did not know if the resident was breathing or not, but stated, "it was the first time I found someone like that...I covered...face up with a blanket..." CNA #1 stated the resident still remained in the geri chair and no resuscitation was started. CNA #1 stated she went out into the hall when LPN #1 and LPN #2 arrived. CNA #1 stated...waited in the hall for approximately 5 minutes (does not know exact time) when one of the nurses (does not remember which) came out of the resident's room and went to find Registered Nurse (RN) #1. CNA #1 stated the LPN returned with RN #1, there was no crash cart or resuscitation equipment taken into the room. CNA #1 stated ...then returned to the second floor and then clocked out at 7:42 p.m. Interview with RN #1, on [DATE], at 2:07 p.m., in the DON's office revealed RN #1 was working in the treatment nurse's office on the evening of [DATE]. RN#1 stated LPN #2 came to office at approximately 7:30 p.m. (does not know exact time). RN#1 stated LPN #2, "told me that I needed to pronounce (Resident #1)...was not breathing". RN #1 stated...went to the resident's room and found the resident in a geri-chair with LPN #1 in the room. RN #1 stated there were no efforts being made to resuscitate the resident. RN #1 stated the resident did not have any respirations or pulse, and the resident's pupils were fixed (unmoving and un-reactive to light). RN #1 stated, "I was under the assumption she was a DNR (advance directive to not attempt resuscitation)". RN #1 stated...went to the nurse's station and called the resident's family, does not know the time this occurred. RN #1 stated...told the son the resident had expired. RN #1 stated LPN #1 interrupted the phone conversation, and RN #1 handed the telephone to LPN #1, and looked at the resident's medical record with LPN #2. RN #1 stated the medical record stated the resident was a full code. RN #1 stated the DON was called, and staff took the crash cart (wheeled cart with resuscitation equipment) to the resident's room, and began Cardio-Pulmonary Resuscitation (CPR). RN #1 stated residents that are full code status are to have CPR immediately when found in Cardio-Pulmonary arrest (no pulse or respirations). RN #1 stated CPR was continued by EMS until the resident was pronounced dead by EMS (time unknown by RN #1). Interview with LPN #2, on [DATE], at 11:25 a.m., in the DON's office revealed LPN #2 was working on the first floor on [DATE]. LPN #2 stated...was at the end of 400 hall when CNA #1 called Resident #1's name. LPN #2 stated...recognized something was wrong by the sound of CNA #1's voice. LPN #2 stated...did not know what time this occurred. LPN #2 stated "I secured my medicine cart and started walking that way". LPN #2 stated CNA #1 called out that LPN #2 needed to "come in here". LPN #2 stated the resident was sitting in geri-chair in dining room. LPN #2 stated, "...was not breathing. I thought...had passed away...eyes were fixed...skin was cool to touch..." LPN #2 stated...told CNA #1 to take the resident to...room and remove the room-mate. LPN #2 stated...went to find LPN #1, who was on the 300 hall. LPN #2 stated, "I told...was not looking good". LPN #2 stated they assessed Resident #1 in the resident's room and found no breath or pulse. LPN #2 stated no resuscitation efforts were made. LPN #2 stated...left LPN #1 with the resident and went to find RN #1. LPN #2 stated...notified RN #1 and they headed back to the resident's room. LPN #2 stated "I found out...was a full code...(from LPN #1 at the nurse's station)...and RN #1 took the crash cart to the resident's room and began CPR and attached the Automatic External Defibrillator (AED, a device that delivers a stimulating shock to the patient's heart)." Interview with LPN #1, on [DATE], at 12:49 p.m., in the DON's office revealed LPN #1 was the nurse assigned to Resident #1 on [DATE]. LPN #1 stated...was passing medications on the 300 hall, at approximately 7:35 p.m. (does not know exact time), when LPN #2 stated, "come check...something is wrong...". LPN #1 stated they went to the resident's room, where the resident was in a geri-chair. LPN #1 stated, "...color was grey, not good ...did not appear that...was breathing..." LPN #1 also stated, "my assessment was that...had no pulse or respirations...had expired". LPN #1 stated LPN #2 went to get RN #1 to "assess" the resident. LPN #1 stated, "I thought...was a DNR". LPN #1 stated...went to check the chart, at the nurse's station, and found the resident was a "full code". LPN #1 stated RN#1 and LPN #2 had just arrived at the nurses station, and...told RN #1 that the resident was a full code. LPN #1 stated RN #1 and LPN #2 took the crash cart to the resident's room to begin CPR. LPN #1 stated...stayed at the nurse's station. Interview with the DON, on [DATE], at 5:00 p.m., in the DON's office, confirmed residents with advance directives for a full code, are to have CPR intiated immediately when found without breath or pulse. In summary, the facility failed to immediately provide CPR for Resident #1, when the resident was found without breath or pulse on [DATE]. The facility failed to honor the resident's advance directive for a full code, and CPR was not initiated for at least five minutes. The CPR was unsuccessful and the resident expired at 8:05 p.m., on [DATE]. The Immediate Jeopardy was effective from [DATE] to [DATE]. An Acceptable Allegation of Compliance, which removed the immediacy of the jeopardy, was received and corrective actions were validated by the surveyor through review of documents, staff interviews, and observations conducted onsite on [DATE]. The surveyor verified the allegation of compliance by: 1. Reviewing the Inservices on resuscitation policy and procedures titled "Code Arrest" provided to staff from [DATE] to [DATE]. 2. Verified that 100% of the current medical records had been audited and reorganized to place the advance directives document (POST form) immediately inside the front cover of the record. 3. Conducted interviews with all nurses present in the facility to verify 100% had been inserviced and were oriented to the Code Arrest policy and procedure. All nurses knew where to find the resident's advance directives. 4. Interviewed the DON and the Staff Development Coordinator to verify the content of the Inservices and that 100% of staff had been inserviced on the Code Arrest policy and procedure. 5. Interviewed 100% of Certified Nursing Assistants (CNA) working and verified all had been inserviced and knew how to respond to a resident found without breath or pulse. 6. Interviewed the Medical Records Supervisor and confirmed 100% of records had been audited and the advance directives/POST form was correct and on the front of the record. Also confirmed the Medical Records Supervisor will continue to audit the records for three months to confirm compliance. 7. Interview with the Social Worker verified each resident's advance directives will be audited at least quarterly to ensure the document is accurate. Non-compliance continues at a "D" level for monitoring of corrective actions. The facility is required to submit a plan of correction. |
2015-08-01 |