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Scope: Isolated
Severity: Immediate jeopardy to resident health or safety
Citation date: May 9, 2022
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews and record review during an abbreviated survey (NY 474), the facility failed to accurately identify the resident's advance directive status and did not initiate Cardiopulmonary Resuscitation (CPR) when a resident was found unresponsive and with no pulse. This was evident for 1 (Resident #1) of 4 residents reviewed for Advance Directives. Specifically, Resident #1 who had a Full Code status as documented in the Social Work notes, Physician notes and the Comprehensive Care Plan was not provided with life- saving CPR when found unresponsive and with no pulse. Licensed Practical Nurse (LPN) #1 and Registered Nurse Supervisor (RNS) #1 did not verify the resident's code status after noting a discrepancy and did not initiate CPR. This resulted in actual harm to Resident #1 with the potential for serious harm for 291 Residents with full code status that is immediate jeopardy and substandard quality of care. The findings are: The facility's policy titled Do Not Resuscitate (DNR) dated [DATE] documented all residents admitted to the facility shall be presumed to consent to the administration of cardiopulmonary resuscitation in the event of cardiac or respiratory arrest unless there is a consent for issuance of an order for [REDACTED]. DNR orders must be reviewed and renewed by the attending physician each time the resident is required to be seen, but not less than once every 30 days and must indicate that the order was reviewed in the resident's chart. Residents with DNR orders will be identified in the following ways: 1) an alert will be initiated in sigma (symbol of orange circle); 2) an orange label on the spine of the resident's medical record; 3) an orange identification on the resident's bracelet indicating DNR. The armband shall be worn always. A list of DNR's will be distributed by the social worker department to each unit as they are updated as needed. The facility's policy titled Cardiopulmonary resuscitation (CPR) dated [DATE] documented it is the policy of the facility that when cardiac/respiratory arrest occurs, prior to arrival of EMS, at a minimum basic life support must be provided via chest compression, artificial ventilation and use of AED as indicated. The initiation of CPR to a resident who experiences cardiac/respiratory arrest will be in accordance with the resident's advance directive. CPR-certified staff will be available at all times to provide CPR when needed. Brain death begins ,[DATE] minutes following a [MEDICAL CONDITION] if CPR is not initiated. CPR will be immediately initiated in the case of [MEDICAL CONDITION] unless: resident has an advanced directive declining CPR with a valid DNR order by the physician in place; there are obvious clinical signs of irreversible death (e.g., rigor mortis, dependent lividity, decapitation, transection, decomposition). Resident's code status of DNR order will be in the Electronic Medical Record (EMR) on the horizontal tab next to the patient's name. The facility's policy titled Resident identification bracelets revised on [DATE] documented all residents will always have an identifying wristband in place to allow for proper resident identification. The admitting nurse or unit clerk will verify if any additional tabs need to be placed on the resident's ID wristband, including but not limited to allergy (red), aspiration precaution (blue), elopement risk (green), or DNR (orange), and place them on ID wristband. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS-an assessment tool) dated [DATE] documented the resident with Brief Interview for Mental Status (BIMS) score of 14 indicating cognitively intact. The Advance Directives documented resident had no advance directives. The Comprehensive Care Plan (CCP) dated [DATE] documented the Resident had advance directives of healthcare proxy. The CCP lacked documented evidence of resuscitation instructions. Interventions included assist Resident responsible party to enact advanced directives and review advanced directives quarterly and as needed with resident and responsible party. On [DATE], the Social Worker (SW #1) documented the Resident did not wish to initiate MOLST at this time. The physician's orders [REDACTED]. An advance directive order for HCP was written on [DATE] and [DATE]. The Nurse Practitioner's (NP#1 and NP #2) notes dated [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] documented Resident was a full code. The Nurse's Progress notes (NPN) dated [DATE] at 7:30 AM by Registered Nurse Supervisor (RNS #1) documented a pronouncement of death note at 6:55 AM. Clinical signs and symptoms of death: unconscious and unarousable (yes), absence of respiration (yes), palpable pulse (no), absence of heartbeat (yes), no audible or palpable blood pressure (yes), pupils fixed and dilated-non-reactive (yes), body shows signs of rigidity (rigor mortis) (no), signs of lividity (cyanosis/blood pooling) (yes). An additional note documented Writer was called to the unit to see the resident who was reported to be unresponsive. When seen Resident presented with no signs of life. Resident is DNR. This was respected and resident was determined expired at 6:55 AM. The NPN dated [DATE] at 10:34 AM by Licensed Practical Nurse (LPN#1) documented at 6:55AM during morning meds, I was called by the CNA that the resident is not responsive. I observed resident lying in bed with no pulse, full vitals taken immediately. RNS#1 notified; MD made aware. The NP #2 note dated [DATE] at 1:41 PM documented time of death 6:55 AM, cause of death [MEDICAL CONDITION], cardiac arrhythmia and End Stage [MEDICAL CONDITIONS]. Resident#1's identification (ID) wrist band given to the surveyor by the Director of Nursing (DON) had a DNR orange tab alert and [MEDICAL TREATMENT] purple tab alert. Review of Resident #1's Electronic Medical Record (EMR) under alerts lacked an alert for DNR, a symbol of orange circle. The facility's investigative summary completed on [DATE] documented on [DATE] a discrepancy was identified regarding Resident's expiration which facilitated an immediate investigation. Interviews were performed and statements obtained. On [DATE] at 6:45 AM CNA #1 and CNA #2 reported they observed Resident#1 looked dead and RNS #1 came to the room. LPN#1 stated at 6:55 AM they were alerted by CNA#1 that the Resident is unresponsive with no pulse, no respiration and could not obtain vital signs LPN#1 notified RNS #1. LPN#1 noted Resident#1 had ID band on with orange tab indicating resident is a DNR. The Resident's EMR lacked the orange symbol indicating DNR. LPN#1 alerted RNS #1 about the band and EMR discrepancy and LPN#1 stated they were instructed by RNS #1 to follow the wishes of Resident#1 as DNR. RNS #1 statement documented they responded to the Resident's room at approximately 6:55 AM and the Resident showed no signs of life. RNS #1 reported they checked the Resident's ID band and observed an orange dot listing patient as DNR and respected their wishes and did not initiate CPR. RNS #1 stated that on review of the Resident data on the unit they were unable to locate any advance directive information and utilized the Resident clinical presentation and ID band to make their decision. The facility's investigative summary also documented that based on information, the facility reviewed the incident as part of their Quality Assurance Program Initiative (QAPI). A review of policy and procedure and appropriate actions were not taken by staff and additional measures could have been utilized to identify patient advance directives. The findings revealed RNS #1 relied on Resident's clinical presentation and overt signs of death as well as the orange tab ID band indicating resident was a DNR. RNS #1 did not follow policy and procedures or adhere to professional standards of practice of verifying the resident's advance directives and code status after noting a discrepancy as the patient EMR. During an interview on [DATE] at 10:55 AM the night shift CNA#1 stated on [DATE] at approximately 6:45 AM, while doing rounds they noted Resident#1 did not respond to their name. CNA #1 turned on the light and the resident appeared unresponsive. Resident was pale, mouth was open, and resident was not breathing. CNA #1 called LPN #1; LPN #1 checked the resident's ID band which had a DNR alert. LPN #1 called RNS #1, they came and observed the resident is DNR, as per the wristband. During an interview on [DATE] at 12:31 PM the night shift LPN #1 they stated on [DATE] while they were giving medications, CNA #1 told them that Resident#1 was unresponsive. They went to the room and took the vital signs and noted an absence of pulse. The Resident's body was warm, not breathing and not responding to sternal rub. LPN #1 checked the armband and found the armband indicated DNR. They told CNA #1 to stay with the resident and they went to check the EMR. The EMR indicated Resident had no DNR order. They informed RNS #1 regarding the discrepancy and waited for further instructions. LPN #1 stated if the Resident was not a DNR the protocol was to call a code blue and start CPR. LPN #1 told RNS #1 they would get the crash cart and RNS #1 stated no. LPN #1 stated they told RNS #1 several times that the Resident #1 was a full code. RNS #1 instructed them to do their work and notify the family and doctor of Resident's expiration. During a phone interview on [DATE] at 2:37 PM the night shift RNS #1 stated on [DATE] they received a call from LPN #1 at approximately 6 or 7AM that they found the resident dead. RNS #1 stated they took their penlight and checked the Resident's pupils and noted pupils were fixed and dilated. They checked the carotid pulse and noted an absence of pulse, resident's skin was cold, and mottling started to take place. RNS #1 stated the Resident had an armband that indicated DNR status. RNS #1 stated they checked the Medical Doctor (MD) orders and did not find any documentation regarding advance directives. There was no documentation of DNR in the EMR. RNS #1 stated they followed Resident's ID band and clinical presentation of the Resident not to do CPR. RNS #1 stated if Resident did not have ID band, they would have called a Code Blue. RNS #1 stated usually there is a list at the nursing station on a green paper from SW with all Residents on floor and their DNR status. During an interview on [DATE] at 5:30 PM with the Director of Nursing (DON) they stated they were made aware of the incident during morning meeting on [DATE]. The DON stated the RN Risk Manager (RNRM) initiated the investigation and identified an issue that the EMR had no orange alert and CPR was not performed for Resident #1, who was a full code. Both nurses were removed from the schedule the morning of incident. They were both terminated as of [DATE] and they were reported to the Office of Professions. The facility immediately in-serviced all licensed staff on [DATE] on emergency response, CPR, documentation on codes and ID band accuracy. The DON stated as of [DATE] they have in-serviced 221 staff out of 350 staff and as of [DATE] 299 staff received in-service which is about 85% of the total licensed staff. The 15% of staff who did not receive in-service were not scheduled to work and will be given in-service before returning to work. The facility changed the ID band policy that the admission nurse will apply Resident's arm band and the SW will double check to make sure the armbands are appropriate. The DON stated an audit was conducted by unit clerks to ensure ID band alerts were correct. The facility did an audit of all MD orders to ensure accuracy. Human Resources identified 40% of staff were not up to date with their CPR certification. DON stated they have arranged for CPR classes to have the 40% get their updated CPR certification. DON stated they have staff on all shifts that are CPR certified. The SW did an audit and updated the care plan to ensure resident's wishes were communicated to licensed staff. There is an orange binder on each unit which list all residents with DNR. There was a new admission audit form to ensure all information is on the form and uploaded to the EMR. During a phone interview on [DATE] at 7:34 PM with the Administrator they stated they were informed during morning report on [DATE] at 9:30 AM that Resident expired and there is an issue with expiration. They immediately initiated the investigation and investigation revealed Resident #1 was wearing ID band with [MEDICAL TREATMENT] and DNR tab/alert on the band and based on documentation on the Resident's chart in multiple places it says the Resident is a full code. RNS #1 relied on the ID band and did not perform CPR. LPN #1 acknowledged there was discrepancy on chart on multiple documentation and ID band. LPN #1 spoke to RNS #1 and did not perform CPR or call code blue. Based on findings the facility tried to implement changes to make sure this will not occur again. RNS #1 and LPN #1 were suspended pending investigation and were terminated and reported to The Office of Professions. In the investigation, the facility did note there were areas they can put measures in place to help the staff. The SW conducted audits on all care plans to ensure advance directives were current and updated. The Unit Clerk conducted an audit of resident armbands. An emergency Quality Assurance Performance Improvement (QAPI) was held today all residents who are a full code will have a physician's orders [REDACTED]. All audits were started on [DATE]. Staff were in serviced on emergency codes, ID bands and CPR. The IJ began on [DATE]. The Administrator was informed of the Immediate Jeopardy and provided with the Immediate Jeopardy template on [DATE]. Based on the following corrective actions taken, there was sufficient evidence that the facility corrected the noncompliance and was in substantial compliance for this specific regulatory requirement prior to and during the time of this survey: The facility On [DATE] the facility conducted a facility wide audit of residents' armbands to ensure placement, alert accuracy, EMR match and DNR status. Mandatory Inservice-Emergency Response was started on [DATE] for all licensed staff. As of [DATE] they have 299 out 350 which is 85% of licensed staff received in-service. The remaining 15% percent are not on the schedule to work and will be in-serviced prior to commencing work. Interviews conducted on [DATE] at [DATE] with all staff (4 CNAs, 1 LPN, 2 RNs, and 2 RNS), RN Risk Manager, DON and Administrator to ascertain the post incident in-service training/education regarding facility's procedures on identifying resident's code status. Termination of RN Supervisor & LPN on [DATE]. Reported both nurses to The Office of Professions on [DATE]. Facility Wide Care Plan Audit-of all advanced directive care plans. Reviewed polices on advanced directives, facility codes and identifiers with revision to ID band policy to include licensed personnel to check for accuracy. Facility Wide EMR Audit-checked all residents for CPR and DNR orders for accuracy. The facility checked all the residents' physicians' orders for CPR and DNR. CPR certification- all licensed staff will have updated certification by [DATE]. 483.24(a)(3) | Plan of Correction: ApprovedJune 13, 2022 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** A plan of correction is not required for Past Non-Compliance deficiencies. The facility remains responsible to expeditiously correct all deficiencies and to ensure measures are in place to maintain compliance. Please submit this information to the Department to acknowledge this message. As indicated in the SOD, ôNo Plan of Correction is required.ö Further, the SOD states that ôBased on the following corrective actions taken, there was sufficient evidence that the facility corrected the noncompliance and was in substantial compliance for this specific regulatory requirement prior to and during the time of this survey: The facility implemented the following: -On [DATE] the facility conducted a facility wide audit of residents' armbands to ensure placement, alert accuracy, EMR match and DNR status. -Mandatory Inservice-Emergency Response was started on [DATE] for all licensed staff. As of [DATE] they have 299 out 350 which is 85% of licensed staff received in-service. The remaining 15% percent are not on the schedule to work and will be in-serviced prior to commencing work. Interviews conducted on [DATE] at [DATE] with all staff (4 CNAs, 1 LPN, 2 RNs, and 2 RNS), RN Risk Manager, DON and Administrator to ascertain the post incident in-service training/education regarding facility's procedures on identifying resident's code status. -Termination of RN Supervisor & LPN on [DATE]. Reported both nurses to Office of Professions on [DATE]. -Facility Wide Care Plan Audit-of all advanced directive care plans. -Reviewed polices on advanced directives, facility codes and identifiers with revision to ID band policy to include licensed personnel to check for accuracy. -Facility Wide EMR Audit-checked all residents for CPR and DNR orders for accuracy. The facility checked all the residents' physicians' orders for CPR and DNR. -CPR certification- all licensed staff will have updated certification by [DATE].ö |