§483.24(a)(3) Personnel provide basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advance directives.
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Observations:
Based on review of established guidelines from the American Heart Association (AHA) for cardiopulmonary resuscitation (CPR - emergency life-saving procedure that is done when the heart stops beating and when performed immediately can double or triple chances of survival after cardiac arrest), facility policy and clinical records, and staff interviews, it was determined that the facility failed to provide CPR as required for one of one resident reviewed who had requested that CPR be administered in the event that they became unresponsive with no pulse. Resident R1 became unresponsive and pulseless, facility did not administer CPR to Resident R1 as required. This failure placed 43 of 95 residents ( R2, R3, R4 R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21 R22, R23 R24 R25, R26, R27 R28, R29, R30, R31, R32 R33, R34, R35 R36, R37, R38 R39, R40, R41, R42, R43, and R44), that had requested to have CPR administered if they became unresponsive and pulseless, at a high risk for death and resulted in an Immediate Jeopardy situation.
Findings include:
Review of guidelines from the AHA, dated 2020, revealed, the AHA urged all potential rescuers to initiate CPR unless a valid Do Not Resuscitate (DNR) order was in place; if there were obvious clinical signs of irreversible death present, including rigor mortis (stiffness of the limbs and body that develops 2 to 4 hours after death and may take up to 12 hours to fully develop), dependent lividity (reddish-blue discoloration of the skin resulting from the gravitational pooling of blood in the lower lying parts of the body in the position of death), decapitation (separation of the head from the body), transection (division by cutting across the body), or decomposition (decay); or if initiating CPR could cause injury or peril (serious or immediate danger) to the rescuer.
Review of facility policy entitled "Cardiopulmonary Resuscitation Procedure CPR For The Adult Victim" dated October 2023, indicates to: Check for response, tap the victim's shoulder and shout "are you all right". If there is no response shout/summons help; assign someone to check the code status of the victim; if victim has orders for resuscitation delegate staff to call 911, get AED, announce code, obtain emergency cart, call physician, and call family; check for pulse - if no definite pulse, start chest compressions; open airway and give two breaths; and to continue until EMS arrives.
Residents R2 through R44's clinical record review of physician's orders revealed that CPR be administered in the event that they became unresponsive with no pulse.
Resident R1's clinical record revealed an admission date of 8/18/23, with diagnoses including chronic obstructive pulmonary disease (COPD - progressive lung disease resulting in shortness of breath), dysphagia (difficulty swallowing), and high blood pressure.
A POLST (Pennsylvania Order for Life-Sustaining Treatment) dated 8/18/23, stated, "FIRST follow these orders, THEN contact physician, certified registered nurse practitioner, or physician assistant. This is an Order Sheet based on the person's medical condition and wishes at the time the orders were issued. Everyone shall be treated with dignity and respect." The POLST was signed by both the physician and Resident R1 and Section A revealed that CPR/attempt resuscitation was to occur when no pulse and no breathing were present. Physician's Order dated 8/18/23, identified Resident R1 as a FULL CODE (allows for all interventions needed to restore breathing or heart functioning). Care plan initiated on 8/21/23, indicated Resident R1 is a FULL CODE and will receive CPR in the event of cardiac and/or respiratory arrest.
Progress note completed by Registered Nurse (RN) Employee E1 dated 3/3/24, at 3:42 a.m. indicated that "Resident sends roommate down to nurses station stating she can't breathe, resident won't keep oxygen on, educated that she needs to keep oxygen face mask up on her face covering her nose and mouth, moaning, lungs with a few rales / diminished in bases. Resident can talk in complete sentences with no distress noted in speech. Reassurance that she is doing fine, continues to be nervous / anxious. Resident encouraged to close eyes and sleep, she is doing fine, she needs to relax."
Progress note completed by RN Employee E1 dated 3/3/24, at 3:51 a.m. indicated that "Resident on rounds noted to have ceased to breathe, resident cold and mottled with no heart rate or breathing noted, pronounced at 0351."
Progress note completed by Licensed Practical Nurse (LPN) Employee E2 dated 3/4/24 at 4:00 a.m. indicated that "During rounds, CNA reported that resident was not breathing, RN Supervisor notified for assessment. Mottling present with absence of breath sounds or pulse."
Progress note completed by RN Employee E1 dated 3/4/24, at 4:10 a.m. indicated that "Husband was notified that resident had ceased to breath ...."
Progress note completed by RN Employee E1 dated 3/4/24, at 7:16 a.m. indicated "(name mentioned) CRNP (Certified Registered Nurse Practitioner) notified of resident CTB at 0351."
During interview on 3/5/24, at 9:20 a.m. Director of Nursing (DON) provided the following information: RN Employee E1 was working the night Resident R1 passed way. RN Employee E1 did call the DON to inform her of Resident R1 passing away and informed the DON that he/she did not provide CPR as ordered as he/she felt Resident R1 had been gone for a while and it would have been abuse of a corpse. DON was not in the facility at the time and was unable to assess Resident R1 herself having to go solely on what RN Employee E1 reported to her via telephone.
During a telephone interview on 3/5/24, at 9:27 a.m. RN Employee E1, provided the following information: Certified Nurse Aides (CNA) completed rounds around 2:00 a.m. to 2:30 a.m. and there was no indication of any changes with Resident R1. Around 3:51 a.m. RN Employee E1 was starting to do his/her routine rounds, when the CNA's informed him/her that they thought Resident R1 was gone. RN Employee E1 went to assess Resident R1 and found him/her to be in bed with eyes open, and pupils fixed and dilated, mouth open, cool to touch, mottled (red or purple blotches or streaks caused by lowered blood flow to the skin) to his/her upper chest, and with no respirations or heart rate. RN Employee E1 stated he/she attempted to call the physician, but it was not going through, and he/she notified the CRNP at 7:15 a.m. RN Employee E1 stated he/she notified Resident R1's husband at 4:15 a.m. and the husband did ask if Resident R1 was revivable, and he/she informed the husband that Resident R1 was not. RN Employee E1 stated that he/she did not perform CPR as Resident R1 wished, as he/she felt Resident R1 had been gone for a while and it would have been abuse of a corpse.
During interview on 3/5/24, at 10:45 a.m. Nursing Home Administrator (NHA) and DON provided the following information: Licensed Practical Nurse (LPN) Employee E2 was outside on break at the time of the incident and did not see Resident R1. LPN Employee E2 did complete a progress note based on what he/she was told by staff who were present.
During a telephone interview on 3/5/24, at 12:28 p.m. CNA Employee E3 provided the following information: Resident R1 was last checked on between 1:30 a.m. and 2:00 a.m. At that time, he/she was in bed with his/her oxygen on and was responding to staff. At 3:40 a.m. CNA Employee E3 went into Resident R1's room and found him/her with dried blood all over his/her face and arm was cold. CNA Employee E3 left Resident R1's room and tried to call LPN Employee E2 who was on break. LPN Employee E2 did not pick up her phone, so CNA Employee E3 found RN Employee E1 and told him/her who then went to Resident R1's room.
The facility failed to promptly initiate CPR in accordance with the resident's wishes and professional standards of nursing to a resident who had requested CPR upon admission, had a physician's order for CPR and had been identified as a FULL CODE, when finding the resident unresponsive, without a pulse or breathing and without clear clinical signs of death placing 43 other residents who had requested that CPR be administered in the event that they were to suddenly become unresponsive and pulseless in Immediate Jeopardy.
The NHA was notified of the Immediate Jeopardy (IJ) situation and IJ template was provided to the NHA on 3/5/24, at 12:21 p.m. An Immediate Action Plan was requested.
The Immediate Action Plan was provided by the NHA, DON, and Corporate Quality Assurance (QA) Director on 3/5/24, at 2:13 p.m. which was accepted at 2:32 p.m.
The plan include:
The facility Corporate QA RN reviewed the facilities CPR policy and worked with the facility Administrator and DON to develop the facilities IJ Abatement plan.
All facility Licensed nurses will be immediately re-educated on the facilities CPR policy and Emergency procedures policy. The Emergency procedures policy was reviewed and revised to clearly guide the facility license nursing staff on emergency measures including CPR. The education was started 3/4/24 and will be completed today. If the nurses are not working today and have not yet been re-educated on the policies they will be reached via phone and re-educated. The licensed nurses will not be allowed to work until re-education completed. This education will be done by the facility Clinical Director RN and the facility RN Staff Developer.
The facility nurse infection preventionist will also review all current resident's advanced directive / POLST forms to be sure that current advance directive / code status orders are currently and clearly noted on the medical record and that the resident care plan clearly reflects the residents current code status. These reviews have started and will be completed today.
The facility contacted the facility Medical Director and as part of the facilities QAPI committee reviewed with the Medical Director the facilities action plan to address the IJ at F678.
The facility will continue to monitor through daily reviews of clinical record / EHR to ensure the facility CPR policy is followed and CPR is provided per policy if a resident is a full code. The facility will ensure that all new nursing staff to the facility have the CPR policy reviewed as part of their orientation before providing resident care. This will be monitored by the facility DON, and Clinical Director. The facility CPR policy will be part of their orientation paperwork.
On 3/6/24, during an onsite visit, the Immediate Jeopardy was lifted at 12:53 p.m. after ensuring the Immediate Action Plan had been implemented.
28 Pa. Code 201.14(a) Responsibility of licensee
28 Pa. Code 201.18(b)(1) Management
28 Pa. Code 201.18(3)(e)(1) Management
28 Pa. Code 211.10(c) Resident care policies
28 Pa. Code 211.12(c) Nursing services
28 Pa. Code 211.12(d)(1)(5) Nursing services
| | Plan of Correction - To be completed: 03/26/2024
For all facility residents, including residents R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21 R22, R23 R24, R25, R26, R27 R28, R29, R30, R31, R32, R33, R34, R35, R36, R37, R38, R39, R40, R41, R42, R43, and R44, the facility Corporate QA, RN met with the facility Administrator and DON on 3/5/24 to review the facility's Cardio Pulmonary Resuscitation (CPR) policy and action plan.
The facility's Emergency procedures policy had been reviewed and revised by the Corporate QA-RN to clearly guide the facility's licensed nursing staff on emergency measures including CPR.
All facility licensed nurse were re-educated on these policies (CPR policy and Emergency Procedures policy).
The facility Administrator, RN-DON, RN-Clinical Director, RN- Staff developer, the facility Infection-Preventionist along with the facility Corporate QA-RN conducted an ad hoc Quality Assurance Performance Improvement (QAPI) review and review of the facilities action plan and assignments for implementation of the immediate action.
The re-education of all licensed nurses on the facilities CPR Policy and Emergency Procedures policy was started 3/4/24 and was completed 3/5/24. Nurses that were not working during that time were contacted via the phone and re-educated. This re-education was done by the facility Clinical Director-RN and Facility RN-Staff development nurse after review with the Corporate RN-QA nurse.
The facility Infection Preventionist nurse also initiated a review of all current resident's advanced directive/POLST (Physician Orders for Life Sustaining Treatment) forms to be sure that current advanced directive/code status was clearly noted on the resident's medical record and that the resident's care plan clearly reflects the resident's code status.
The facility RN-Clinical Director and RN-Staff Developer assisted with this audit/review and all resident records were reviewed and the audit completed 3/5/24.
The facility LNHA, RN-DON and Corporate QA-RN called the facility Medical Director on 3/5/24 to conduct an ad hoc QAPI meeting to review the identified deficiency at F678 and the facility's immediate action plan. The facility Medical Director was in agreement with the plan and the facility's continued monitoring plan and education of new nurses to the facility.
To monitor for continued compliance ,the facility will conduct daily reviews of the clinical record/Electronic Health Record (EHR) for instances of death or cardiac arrest to ensure the facility CPR policy is followed and CPR is provided per policy if the resident is a full code.
These daily reviews will be documented. The reviews will be conducted by the RN-DON, or the RN Clinical Director. The RN Supervisor will conduct the reviews on the weekend and report any concern to the DON or ADON on call.
New nursing staff to the facility will have the CPR policy reviewed as part of their orientation before providing resident care. The CPR policy will be part of their orientation paperwork.
The facility RN-DON or RN-Clinical Director will be responsible to ensure the CPR policy is reviewed on orientation.
An education / Orientation tracking tool has been developed to ensure this process takes place and added to the employee education file by the Facility Staff Development Nurse.
The facility will review compliance plan and audits/reviews at the QAPI meetings for the next 3 months
Directed in-service training is scheduled for March 21st, 2024 for all licensed and unlicensed nursing staff to include current agency staff.
The facility has arranged for directed in-servicing to be presented by
Lewis Litigation Support and Clinical Consulting, LLC on F Tag 678 and accompanying guidelines.
A post test will be given following the in-service to ensure understanding of the material presented.
In the event of an emergency prohibiting the attendance of a nursing department employee, a video recording of the live in-service will be available and mandatory for that employee to view and the post test taken.
The contents of this in-service will be emailed to the Department Field Office Supervisor. Included in the slide presentation on slide 3 is a review of the specific deficiency.
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