Nursing Investigation Results -

Pennsylvania Department of Health
BIRCHWOOD HEALTHCARE AND REHABILITATION CENTER
Patient Care Inspection Results

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BIRCHWOOD HEALTHCARE AND REHABILITATION CENTER
Inspection Results For:

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BIRCHWOOD HEALTHCARE AND REHABILITATION CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on an abbreviated complaint survey completed on January 16, 2020, it was determined that Birchwood Nursing and Rehabilitation Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.




 Plan of Correction:


483.24(a)(3) REQUIREMENT Cardio-Pulmonary Resuscitation (CPR):This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
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.
Observations:

Based on review of clinical records, employee personnel files (Cardiopulmonary resuscitation is an emergency procedure that combines chest compressions often with artificial ventilation in an effort to manually preserve intact brain function until further measures are taken to restore spontaneous blood circulation and breathing in a person who is in cardiac arrest) select facility policies and documentation and staff interviews, it was determined that the facility failed to timely contact emergency medical services for one of one resident reviewed (CR1) requiring cardiopulmonary resuscitation) and failed to ensure that staff maintain current CPR certificaiton.

The findings include:

A review of facility policy entitled "Emergency Procedure- Cardiopulmonary Resuscitation" dated April 2016, revealed that personnel have completed training on the initiation of cardiopulmonary resuscitation (CPR) and basic life support (BLS), including defibrillation, for victims of sudden cardiac arrest.

According to the facility policy, if an individual is found unresponsive, briefly assess for abnormal or absence of breathing. If sudden cardiac arrest is likely, begin CPR: A) Instruct a staff member to activate the emergency response system (code) and call 911, B) Instruct a staff member to retrieve the automatic external defibrillator (AED), C) verify or instruct a staff member to verify the DNR (do not resuscitate) or code status of the individual, D) Initiate the basic life support (BLS) sequence of events.

A review of CR1's clinical record revealed that the resident was admitted to the facility on December 9, 2019, with diagnoses to include encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition i.e.: viral infection or toxins in the blood), enterocolitis due to clostridium difficile (infection of the colon by the bacteria clostridium difficile), dementia and hypertension (high blood pressure).

A review of Resident CR1's POLST (Pennsylvania Orders for Life-Sustaining Treatment) form dated December 9, 2019, and signed the resident's representative revealed that the resident was to receive CPR if he had no pulse or was not breathing. The POLST form noted that the resident was to receive limited additional interventions, noting that the resident did not want intubation (placement of a flexible plastic tube into the windpipe to maintain an open airway), advanced airway interventions or mechanical ventilation.

A review of documentation in Resident CR1's clinical record completed by Employee 1, Registered Nurse, revealed that on December 16, 2019, at 7:07 p.m., the resident was found in bed unresponsive to both verbal or painful stimuli. No spontaneous breathing or a heart rate were detected.

According to the nursing documentation, CPR was initiated and EMS (emergency medical services) was notified at approximately 7:20 p.m. approximately 13 minutes after the resident was found unresponsive and CPR was initiated.

Nursing documentation in the clinical record further revealed that EMS arrived at the facility 7:27 p.m., (20 minutes after CPR was initiated) and at 7:59 p.m. "rescue efforts were unsuccessful in obtaining sustainable spontaneous heart rate or respiration", the resident expired at the facility.

A review of the facility's "New Hire Checklist" provided by the facility revealed that upon hire, a copy CPR \ is required if applicable.

Interview with the Director of Nursing on January 16, 2020, at 10:55 a.m. revealed that a copy of CPR certification is required for both licensed practical nurses and registered nurses that work in the facility.

Interview with Employee 7, Human Resources, on January 16, 2020, at 2:15 p.m. revealed that 6 out of 7 licensed staff scheduled on the evening shift of December 16, 2019, did not have CPR certifications in their employee files.

Employee 1, Registered Nurse, was scheduled to work December 16, 2019, at 3:00 p.m. to 11:30 p.m. A review of the employee's personnel file revealed no CPR certification available at the time of the survey ending January 16, 2020.

Employee 2, Licensed Practical Nurse, was scheduled to work December 16, 2019, at 3:00 p.m. to 11:30 p.m. and had an expired CPR certification as of October 2019.

Employee 3, Licensed Practical Nurse, was scheduled to work December 16, 2019, at 5:15 p.m. to 9:45 p.m. and did not have a CPR certification on file at the time of the survey ending January 16, 2020.

Employee 4, Licensed Practical Nurse, was scheduled to work December 16, 2019, at 3:00 p.m. to 11:30 p.m. and did not have a CPR certification on file at the time of the survey ending January 16, 2020.

Employee 5, Licensed Practical Nurse, was scheduled to work December 16, 2019, at 3:00 p.m. to 11:15 p.m. and did not have a CPR certification on file at the time of the survey ending January 16, 2020..

Employee 6, Licensed Practical Nurse, was scheduled to work December 16, 2019, at 3:00 p.m. to 11:30 p.m. and did not have a CPR certification on file at the time of the survey ending January 16, 2020.

Interview with the Director of Nursing on January 16, 2020, at approximately 3:30 p.m. confirmed that the facility
failed to demonstrate a functioning system to ensure there are an adequate number of staff present at all times who were properly trained and/or certified in CPR for Healthcare Providers to be able to provide CPR until emergency medical services arrives and failed to to ensure that staff maintain current CPR certification for Healthcare Providers.

The DON also verified that the staff failed to promptly summon EMS on December 16, 2019, when the resident was found without respirations and heart rate.



28 Pa. Code 201.19 Personnel policies and procedures

28 Pa. Code 201.18(e)(1)(2) Management

28 Pa. Code 211.10(a)(b)(d) Resident care policies

28 Pa. Code 211.12 (a)(c)(d)(1)(5) Nursing services
Previously cited 5/22/19, 4/12/19, 6/29/18



 Plan of Correction - To be completed: 02/12/2020


1. Human Resources has completed audit of licensed staff and obtained documentation of employees CPR completion. HR will review licensed clinical employ files twice a year and upon hire to ensure nursing staff are current with CPR/AED certification.
2. The center will provide CPR training for any licensed staff that requires recertification. Mock code drills will conducted monthly on alternating shifts.
3. Education will be provided to licensed staff encompassing the assessment of a cardiac event, timely notification of EMS and documentation requirements. Scheduled licensed staff are required to CPR certified.
4. Audits of CPR card documentation and Mock drill results will be completed. Results of the audits will be forwarded to QAPI committee for review.


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