Nursing Investigation Results -

Pennsylvania Department of Health
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
Inspection Results For:

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YORKVIEW NURSING AND REHABILITATION - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an Abbreviated Survey in response to one complaint, completed on June 29, 2022, it was determined that Yorkview Nursing and Rehabilitation 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 related to the health portion of the survey process.

 Plan of Correction:

483.24(a)(3) REQUIREMENT Cardio-Pulmonary Resuscitation (CPR):This is the most serious deficiency although it is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one which places the resident in immediate jeopardy as it has caused (or is likely to cause) serious injury, harm, impairment, or death to a resident receiving care in the facility. Immediate corrective action is necessary when this deficiency is identified.
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.

Based on review of established guidelines for cardiopulmonary resuscitation (CPR), the facility's policies, review of residents' clinical records, as well as staff interviews, it was determined that the facility displayed past non-compliance in its failure to ensure that CPR was provided in accordance with physician's orders and the resident's CPR declaration resulting in death for one of eight residents reviewed (Resident 1), creating an Immediate Jeopardy related to the lack of CPR.

Findings Include:

Review of the facility's policy titled "Emergency Procedure-Cardiopulmonary Resuscitation," recently revised January 2019, reads "If an individual is found unresponsive, briefly assess for abnormal or absence of breathing. If sudden cardiac arrest is likely, begin CPR."

The policy continues "Instruct a staff member to call 911 and also notify the Supervisor who will then call/direct the 'code.'" "Instruct a staff member to retrieve emergency equipment." " Verify or instruct a staff member to verify...the code status of the individual." " Initiate the basic life support (BLS) sequence of events."

Cardiopulmonary Resuscitation (CPR) is defined as "an emergency lifesaving procedure performed when the heart stops beating." Also, "CPR incudes the manual application of chest compressions and ventilations to patients in cardiac arrest, done in an effort to maintain viability until advanced help arrives."

The American Heart Association (AHA) has established evidenced-based decision-making guidelines for initiating CPR when cardiac or respiratory arrest occurs. The AHA urges all potential rescuers to initiate CPR unless a valid Do Not Resuscitate (DNR) order is in place; obvious clinical signs of irreversible death (e.g., rigor mortis, dependent lividity, decapitation, transection, or decomposition) are present; or initiating CPR could cause injury or peril to the rescuer.
If a resident experiences a cardiac or respiratory arrest and the resident does not show obvious clinical signs of irreversible death (e.g. rigor mortis, dependent lividity, decapitation, transection, or decomposition), facility staff must provide basic life support, including CPR, prior to the arrival of emergency medical services, in accordance with the resident's advance directives and any related physician order, such as code status, or in the absence of advance directives or a DNR order.

Review of Resident 1's clinical record revealed diagnoses including hypertensive heart disease with heart failure (heart disease that occurs due to high blood pressure) and ischemic cardiomyopathy (the heart's inability to pump blood properly due to damage to the heart muscle).

Review of Resident 1's physician orders revealed CPR-Full Code status dated October 29, 2020.

Full Code is defined "if a person's heart stops beating and/or they stopped breathing , all resuscitation procedures will be provided to keep them alive. The process can include chest compressions, intubation and defibrillation and is referred to as CPR."

Continued review of Resident 1's clinical record revealed a document titled "Decision of Agent or Representative Regarding CPR Status of Incompetent Resident," dated August 8, 2012. Review of the document revealed an electronic signature dated October 29, 2020, whereby Resident 1's Healthcare Agent marked the area reading "I authorize [Resident 1] to have CPR."

Review of Resident 1's interdisciplinary progress notes revealed documentation by the Licensed Practical Nurse (Employee 8), on June 24, 2022, that reads "At 0400 [ 4 o'clock AM] nursing assistant notified writer of pt [patient] not looking like himself. Writer assessed pt, upon assessment pt with a faint pulse and Cheyne stokes respirations [atypical pattern of breathing involving deep breathing followed by shallow breathing]. Nurse supervisor called and made aware of pt change in condition, code status of being a full code , and to report to the floor immediately. Pt still had pulse at the time of the RN [Registered Nurse Supervisor- Employee 1] arrival. RN supervisor took over assessment. Gave instructions to call MD [Medical Doctor] . Did not indicate CPR at that time. While on phone with MD [on call Certified Registered Nurse Practioner-CRNP] RN informed me pt had lost pulse. MD [CRNP] update of RN findings at the time. RN to assess of no apical pulse follow death process and facility policy. 0415 RN supervisor pronounced pt at 0415."

Review of Employee 1's witness statement, dated June 24, 2022 revealed "When the LPN [Employee 8] relayed the message from the doctor I understood that to mean-no CPR."

Review of Employee 8's witness statement, dated June 28, 2022 continued to describe the incident "As I was still on the phone [Employee 1] looked at her watch and said he's gone and pronounced him at 4:15 AM saying she doesn't feel a pulse anymore. Then I asked the on call doctor what should we do he is a full code. On call said there isn't much we can do. You can call the family and treat it like a normal death."

Review of the witness statement provided to the Director of Nursing (DON), by the Certified Registered Nurse Practioner (CRNP), dated June 24, 2022 revealed "I was told that resident was dead with no pulse. I asked if recently sick at all. LPN stated no he was found to be dead, but earlier in the shift he was walking around wandering the unit and was restless at the beginning of the night. Staff placed him into a broda chair around 2 AM. I told the LPN have the RN assess him to make sure he had no apical pulse. If no apical pulse, proceed with the death and follow facility protocol."

Interviews with the Nursing Home Administrator (NHA) and the DON, on June 29, 2022 at 2:18 PM, revealed Employees 1 and 8 did not follow facility policy by neglecting to provide CPR to Resident 1 per physician order and Resident/Representative direction at the time of Resident 1's change in condition. The interviews also revealed Employees 1 and 8 did not call a code blue in order for additional facility personnel to respond for assistance, and also failed to contact 911 for advanced emergency services per facility policy.

The interviews also revealed Employees 1 and 8 were educated and disciplined on June 24, 2022 and Employee 1's employment with the facility has been terminated. Employee 8 has not returned to employment with the facility at the time of the survey and remains under suspended status.

Prior to the onsite investigation, the facility failed to provide emergency cardiopulmonary resuscitation to Resident 1 with a full code status, which resulted in harm to the Resident.

The NHA and DON were notified of the Immediate Jeopardy on June 29, 2022, at 3:50 PM. An Immediate Plan of Correction was requested. The Immediate Plan of Correction was immediately provided by the NHA, which was accepted.

Review of documents and actions provided by the facility and reviewed onsite to address the Immediate Jeopardy include: a facility wide sweep conducted by DON/designee for all residents' verification of accurate code status and orders on June 24, 2022. All licensed nursing staff were educated on the facility CPR policy by Assitant Director of Nursing /Staff development RN on June 24, 2022. Education will continue prior to start of each shift for licensed nursing staff as follows: DON/Designee will conduct code blue drills each shift x 1 week. 3x a week for 1 month and month x 3 months for the facility's Quality Assurance and Performance Improvement Committee to address any trends or patterns.

The facility's education and audits were reviewed during the onsite survey.

Licensed staff performing duties on each resident hall were interviewed during the onsite survey regarding the facility's CPR policy/procedure and demonstrated knowledge and understanding.

The Immediate Jeopardy was lifted on June 29, 2022 at 4:46 PM and the deficient practice was found to be past non-compliance.

28 Pa. Code 201.14(a) Responsibility of licensee
28 Pa. Code 201.18(a)(b)(1)(2)(3)(e)(1) Management
28 Pa. Code 201.29(j) Resident rights
28 Pa. Code 211.10(c)(d) Resident care policies
28 Pa. Code 211.12(c)(d)(1)(5) Nursing services

 Plan of Correction - To be completed: 07/19/2022

Past noncompliance: no plan of correction required.

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