Pennsylvania Department of Health
LINDEN HALL
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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LINDEN HALL - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on an Abbreviated survey in response to of information submitted by the facility completed on September 19, 2025, it was determined that Linden Hall was not in compliance with the following requirements the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations as they relate to the Health portion of the survey.

Plan of Correction:

483.24(a)(3) REQUIREMENT Cardio-Pulmonary Resuscitation (CPR):

§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 a review of established guidelines for cardiopulmonary resuscitation (CPR), review of facility policies, review of residents' clinical records, review of facility documentation and staff interviews, it was determined that the facility failed to ensure that CPR was provided in accordance with established facility policy and procedure for one of three residents reviewed(Resident 1). This was identified as a past non-compliance situation.

Findings include:

Review of guidelines from the American Heart Association (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 to the rescuer.

Review of the facility policy, "Cardiopulmonary Resuscitation", undated, revealed that CPR will be attempted for any resident who is found to have no palpable pulse and/or no discernible respirations, unless there is a written physician order to the contrary and/or written advance directives (documentary evidence recognized by the courts of Pennsylvania).

Additionally, the policy revealed that all licensed nurses must have a current CPR certificate. Staff members are trained on the code status of each resident and the code status is maintained in each individual medical record and also on the nurses report sheet that is reviewed each shift. For residents who have requested CPR, they are considered a "full code".

Review of Resident 1's clinical record revealed a Pennsylvania Orders for Life-Sustaining Treatment (POLST) dated March 26, 2024, indicated Resident 1's intention to have CPR. Review of Resident 1's physician's orders signed August 1, 2025, indicated resident's code status was full code.

Review of Resident 1's clinical record revealed a progress note by licensed staff, Employee E3, dated September 11, 2025, at 3:45 a.m. indicating that "Paperwork for transfer to hospital initiated by this writer in preparation to send him to hospital for evaluation if necessary. Observed pt [patient] @ approximately 0300, pt observed lying still. Upon entering room no movement of chest was detected. Resident does not respond to touch or movement by this writer. Request to obtain Dyna Map [vital signs monitor] be returned to room for assessment. No pulses or heartbeat noted. Dyna Map does not register any vital signs, on auscultations [technique using a stethoscope to listen to the heart and lungs] no air exchange could be heard nor heartbeat. Pupils are fixed and do not respond to light. Resident pronounced @ 0315 by this writer".

Review of facility documentation including a statement from Employee E4 obtained via telephone on September 11, 2025, at 9:00 a.m. indicated that he/she went into the resident's room at 1:30 a.m. and resident was having difficulty breathing and was not able to communicate his needs which was not unusual. Employee E4 fed resident pudding and gave sips of water, which is the resident's usual request. Employee E4 then voiced concern to Employee E3 about resident's condition as resident was coughing. Employee E4 indicated that Employee E3 assessed the resident, felt resident was anxious and stated that medicine would be given. Employee E4 stayed with the resident until Employee E3 returned to take vital signs. Employee E3 then left to prepare paperwork and to call EMS (emergency medical services). Employee E4 left room to assist other residents until called back by Employee E3 at which time he/she was informed that resident had passed. Employee E3 began postmortem care as instructed by Employee E3. Employee E4 revealed that he/she was not asked to do CPR or call EMS at any time.

Review of facility documentation including a statement from Employee E5 obtained via telephone on September 11, 2025, at 9:15 a.m. indicated that he/she knew the resident was not feeling well, but was not asked to assist in any capacity. Employee E5 indicated that Employee E3 was preparing paperwork to send the resident to the hospital and then went to check on the resident. Employee E3 called Employee E5 to the resident's room and was informed that the resident took his last breath. Employee E5 was instructed to do postmortem care. Employee E5 revealed that he/she was not asked to do CPR or call EMS at any time.

Review of facility documentation including a statement from EmployeeE3 obtained via telephone on September 11, 2025, revealed that Employee E4 informed Employee E3 that resident needed to be seen. Employee E3 stated resident's arms were shaking and he/she was not concerned initially because these behaviors were considered to be normal. Employee E3 indicated that this was around 3:00 a.m. Employee E3 was unable to obtain vital signs including oxygen saturation and blood pressure due to how cold resident's hands were and how much resident was shaking. Employee E3 stated that a moist cough and gurgling were heard, but lung sounds were not ascultated. Employee E3 felt that resident was having some anxiety and applied oxygen at 2L (liters) per minute. Employee E3 stated upon returning later, resident's condition was the same and Xanax (anti-anxiety medication) was administered. Employee E3 then left the room to prepare paperwork to send resident to the hospital. Upon returning to the room, resident was not breathing. Employee E3 stated resident's eyes were fixed, chest was not rising, and NA (nurse aide) was called to bring the dynamap to check for vital signs. Employee E3 could not obtain vital signs, did not hear air exchange, and pronounced the resident deceased at 3:15 a.m. Employee E3 revealed that he/she did not realize resident was a full code until approximately 7:00 a.m. when oncoming nurse questioned. Employee E3 stated he/she "did not think about checking the resident's code status or initiating CPR". Employee E3 also stated that he/she did not check the front of the resident's chart where code status was located when preparing paperwork to send the resident to the hospital.

Interview conducted with the Nursing Home Administrator on September 19, 2025, at 10:30 a.m. revealed the administration was aware staff did not perform Cardiopulmonary Resuscitation to Resident 1 in accordance with resident's identified interventions as indicated on the POLST and CPR should have been provided in accordance with the facility's policy.

The facility self identified the deficient practice at the time of the incident, September 11, 2025. The facility implemented a corrective action of education, whole house assessments, and monitoring audits.

The facily's immediate action plan included the following:

A chart audit was done to determine that accurate code status was reflected in each individual resident record and on the 24 hour report, nurse report sheet and CNA (certified nursing assistant) assignment sheet.

Nursing staff was in-serviced on code status, initiating CPR procedures and expectations. Mock codes were done as competencies for use of an AED (Automated External Defibrillator - portable devide that can be used to treat a person whose heart has suddenly stopped working) and initiating CPR.

Code status for each resident will continue to be maintained on the 24 hour report and will continue to be reviewed each shift. Mock codes will be done quarterly to maintain competency. Monthly audits will be done to ensure code status for each resident is accurately reflected in the medical record and 24 hour report.

Results of the audits and mock codes will be reported to the Quality Assurance Performance Improvement Committee quarterly meetings by the Director of Nursing/designee for 4 quarters for review and recommendation.

On September 19, 2025, after review of audits and documentation of completed employee education revealed the facility had completed the interventions developed for the action plan on September 11, 2025 on September 16, 2025.

28 Pa. Code 201.14(a) Responsibility of licensee

28 Pa. Code 201.18(e)(3) Management

28 Pa. Code 211.12(c)(d)(1)(5) Nursing services

Plan of Correction - To be completed: 09/29/2025

Past noncompliance: no plan of correction required.

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