Gold Crest Care Center
November 2, 2018 Complaint Survey

Standard Health Citations


REGULATION: §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.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 2, 2018
Corrected date: December 13, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review conducted during an abbreviated survey (NY 156), the facility failed to initiate Cardiopulmonary Resuscitation (CPR) for a resident with full code status. This was evident for 1 out of 4 residents sampled (Resident #1). Specifically, on [DATE], Resident #1 was found unresponsive and the facility staff did not initiate CPR. The findings include: The facility's policy and procedure on Basic Cardiac Life Support (BCLS) dated ,[DATE] documented that if the resident does not have a Do Not Resuscitate (DNR) order, BCLS will be initiated. A resident with a DNR order is identified by a red dot sticker on the resident's identification (ID) band, and on the spine of the resident's chart. A resident who refuses to wear an ID band, a red dot is placed at the resident's door, next to his/her name. If CPR is not initiated, documentation will indicate resident is DNR. If a resident is found with clinical signs of death (no pulse, no blood pressure, no breath sounds, pupils fixed and dilated, cyanotic, cold skin, and signs of rigor mortis), a determination of death can be made by the RN. However, if these signs are noted on a resident who is not designated as DNR, CPR must be initiated by any healthcare provider who is CPR certified and can be deactivated when an order is given by the medical provider. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set, an assessment tool, dated [DATE], documented that Resident #1 had a Brief Interview for Mental Status (BIMS, used to determine attention, orientation and ability to recall information) score ,[DATE], associated with severely impaired cognition (,[DATE] severe impairment, ,[DATE] moderate impairment and ,[DATE] cognitively intact). A Comprehensive Care Plan (CCP) dated [DATE] documented that Resident #1 had an Health Care Proxy (HCP). The updated CCP of [DATE] documented that Resident #1 was placed on Hospice for [DIAGNOSES REDACTED]. A nursing progress note dated [DATE] documented that Resident #1 was admitted to Hospice Care effective [DATE] due to [DIAGNOSES REDACTED].#1 continues to be Full Code as preferred by wife/Health Care Proxy. A Social Service evaluation note dated [DATE] documented that Resident #1 had significant change and was on Hospice Care for liver [MEDICAL CONDITION]. As of [DATE], Resident #1 had a Health Care Proxy, but no Advance Directives. A nursing progress note dated [DATE] at 4:45 AM documented that Resident #1 was asleep in bed, warm to touch, no pulse, no respiration, no blood pressure, and no Oxygen saturation. The Physician was called and pronounced Resident #1 deceased at 4:45 AM. Hospice service, Resident #1's wife and the Director of Nursing Services (DNS) were informed. Post mortem care provided. A Physician's progress note dated [DATE] at 4:35 PM documented that Resident #1 expired at 4:45 AM and the family was notified. CPR was not performed; code would have been futile. The Registered Nurse Supervisor (RNS) was interviewed on [DATE] at 11:55 AM and stated that the Licensed Practical Nurse (LPN) informed her that Resident #1 passed away. Resident #1 was cyanotic, she was unable to obtain oxygen saturation and pulse. Resident #1's wife was informed that Resident #1 expired and she said, do not do anything. The RNS further stated that Resident #1 was on Hospice and there was no red sticker (for DNR) on the chart. I did not know a resident can be on Hospice and Full Code Status at the same time. The LPN was interviewed on [DATE] at 9:50 AM and stated on [DATE] at approximately 4:45AM, a Certified Nursing Assistant (CNA) informed her that Resident #1 was unresponsive. The LPN checked Resident #1's chart and Hospice was all over the chart. She checked Resident #1 and he was unresponsive. The RNS was informed that Resident #1 expired and that he was on Hospice. The RNS came to the unit and took over. The LPN asked the RNS what needed to be done and the RNS called the Physician and Hospice representatives. Resident #1's primary Physician was interviewed on [DATE] at 11:11AM and stated that Resident #1's family wanted CPR, but that they never gotten around to it. He never discussed CPR with Resident #1's family. His documentation on [DATE], that CPR would be futile, was an opinion. The DNS was interviewed on [DATE] at 12:15PM and stated that as she was performing her daily Quality Assurance chart review, she noted that Resident #1 expired on [DATE]. Resident #1 was on Hospice and the chart documented that he was Full Code. The DON stated that the RNS did not perform CPR on Resident #1, because he was Hospice and the RNS assumed that the resident had an order for [REDACTED]. The DNS was interviewed on [DATE] at 12:00 PM and stated that when a resident is a full code, found unresponsive, CPR must be initiated immediately by any healthcare provider who is CPR certified. CPR can be deactivated when an order is given by the medical provider to stop the CPR. 415.11 (3) (i)

Plan of Correction: ApprovedNovember 20, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Gold Crest Care Center recognizes the responsibility to maintain substantial compliance with federal and State Regulations. The following Plan of Correction is submitted to ensure that resident?s advance directives are honored,
Resident?s HCP was notified by RN Supervisor who directed her not to do anything
Attending physician was notified by RN Supervisor. The 2 nurses involved were suspended and then subsequently terminated.
All residents? charts/ EMR were audited to ensure proper documentation of advance
directives/full code including identification of residents with DNR or full code including those on hospice
All charts/EMR were found to have proper documentation of advanced directives
No other resident were affected including the ones on hospice.
* Policy and procedure on Advance Directives/ CPR was reviewed and updated.
* Clinical staff were re-in-serviced regarding Advanced Directives with emphasis on
identification of residents with DNR and hospice, CPR policy and Code blue/911 activation
? List of residents with DNR were updated and distributed to all units
? CPR drill will be conducted weekly for a month, then monthly for 6 months and then twice a year.
an audit tool was created and Social workers will do a monthly audit to ensure proper documentation and identification of resident?s advance directives. Social worker will update list of residents with advance directives and distribute list on the unit on a weekly basis and as needed.
all findings will be reported to the QAPI committee during the QA Meeting

Director of Nursing [DATE]