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Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 2, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during the abbreviated survey (NY 213), the facility failed to honor advance directive wishes for 1 of 3 residents (Resident #1) reviewed. Specifically, cardiopulmonary resuscitation (attempt to restart the heart) was implemented on Resident #1 when it was established they were unresponsive and without a pulse before their advance directive wishes were determined; once their advance directives were determined to be do not resuscitate (withhold cardiopulmonary resuscitation and allow a natural death) based on their Medical Orders for Life Sustaining Treatment, cardiopulmonary resuscitation ceased, only to be resumed due to staff appearing on scene and misunderstanding the resident's advance directives. Subsequently, once emergency medical services arrived on scene, cardiopulmonary resuscitation ceased once again due to clarification of the resident's advance directives (do not resuscitate), and the resident expired. Findings include: The facility policy Advance Directives, revised (MONTH) 2022, documented a resident's advance directives were to be honored in accordance with state law and facility policy. Advance directives, including the Medical Orders for Life Sustaining Treatment form, would be maintained in a designated, clearly marked, and readily accessible area at the nursing station to ensure immediate availability in emergency situations. Advance directives orders were documented within the resident's profile in the electronic Medication Administration Record [REDACTED]. Resident #1 had [DIAGNOSES REDACTED]. The [DATE] Minimum Data Set assessment documented the resident was cognitively intact and their advance directives were do not resuscitate and do not intubate. The Medical Orders for Life Sustaining Treatment form, signed by the resident (verbal consent) on [DATE] at 12:30 PM, (during their hospitalization and prior to their admission to the facility), documented the resident wished for a do not resuscitate/do not intubate order. The form was witnessed by two registered nurses and signed by a hospital medical doctor on ,[DATE]/ 2024. The [DATE] electronic physician order [REDACTED].#8 documented do not resuscitate/do not intubate. The order was signed by Medical Doctor #9 on ,[DATE]/ 2024. The comprehensive care plan, initiated on [DATE], documented the resident's advance directives were do not resuscitate/do not intubate, the goal was their wishes were to be honored, and the intervention was to ensure all necessary paperwork went with them upon transfer to the hospital or home. The [DATE] facility incident report documented: - At 4:40 PM Resident #1 was being transferred to bed (via mechanical lift), and their face turned purple. - The certified nurse aides immediately moved the resident back onto the bed, applied oxygen and called out for further assistance. - Licensed Practical Nurse #4 administered 5 liters of oxygen via face mask, identified there was no pulse, and initiated chest compressions until the resident's code status was determined. - Social Worker #5 retrieved the resident's Medical Orders for Life Sustaining Treatment form which confirmed the resident was a do not resuscitate/do not intubate. - Licensed Practical Nurse #4 immediately ceased chest compressions upon that confirmation. - Registered Nurse Supervisor #6 arrived on scene and was made aware of the code status by Licensed Practical Nurse # 4. However, they directed that cardiopulmonary resuscitation resumed. - Licensed Practical Nurse #7 then took over chest compressions at the direction of Registered Nurse Supervisor #6, and 911 was called. - An automated external defibrillator (AED) from within the facility was placed on the resident by staff. Emergency medical services arrived and took over compressions. The automated external defibrillator determined the resident was not shockable. - At that time, Social Worker #5 returned to the resident's room with the Medical Orders for Life Sustaining Treatment form in hand to reinforce the resident's do not resuscitate/do not intubate status. - All life-saving measures were immediately ceased and the resident was pronounced deceased at 4:52 PM. Staff statements from the [DATE] facility incident report included: - Licensed Practical Nurse #4 acknowledged their error in initiating chest compressions prior to verification of the Medical Orders for Life Sustaining Treatment, as they were aware of the policy and reacted too quickly. They completed approximately 30 chest compressions when Social Worker #5 arrived with the Medical Orders for Life Sustaining Treatment form, confirming do not resuscitate/do not intubate status, and immediately stopped. When Registered Nurse Supervisor #6 arrived on scene, they instructed Licensed Practical Nurse #4 to resume chest compressions, despite Licensed Practical Nurse #4 stating the resident was do not resuscitate/do not intubate. Registered Nurse Supervisor #6 stated they were going to take over chest compressions and instructed Licensed Practical Nurse #4 to call a Code Blue (a medical emergency usually involving respiratory or [MEDICAL CONDITION]). - Licensed Practical Nurse #7 arrived on scene and Registered Nurse Supervisor #6 instructed them to take over chest compressions. Shortly thereafter, emergency medical services arrived on scene and took over. Social Worker #5 provided the Medical Orders for Life Sustaining Treatment form once again, which was given to Registered Nurse Supervisor #19 (who arrived on scene due to the Code Blue announcement), who then told everyone to cease chest compressions. - Registered Nurse Supervisor #6 noted that when they arrived on scene and Licensed Practical Nurse #4 stated the resident was do not resuscitate, they thought if a resident was do not resuscitate, they had to do cardiopulmonary resuscitation if they did not know whether the resident was do not intubate, until they spoke to a medical provider. Registered Nurse Supervisor #6 was aware the facility utilized Medical Orders for Life Sustaining Treatment forms and the electronic record for code status verification. The [DATE] at 4:33 PM facility investigative summary by the Director of Nursing included: - During a mechanical transfer lift on [DATE], Resident #1 experienced [MEDICAL CONDITION]. - Certified Nurse Aides #1, #2 and #3 acted swiftly to recognize the emergency and repositioned and applied oxygen to Resident # 1. - Licensed Practical Nurse #4 initiated cardiopulmonary resuscitation while awaiting the resident's code status. - The Medical Orders for Life Sustaining Treatment form was retrieved and confirmed by Social Worker #5 that Resident #1 was do not resuscitate/do not intubate, and resuscitative measures were ceased. - When Registered Nurse Supervisor #6 came on scene, they acted on a misunderstanding of the resident's code status and instructed compressions to resume. - The [DATE] incident was thoroughly investigated. A care plan violation occurred regarding Resident #1's documented do not resuscitate/do not intubate order status. The temporary miscommunication of the resident's do not resuscitate/do not intubate status highlighted the need for improved clarity and adherence to advance directives. The New York State Department of Health Certificate of Death documented the resident was pronounced deceased on [DATE] at 4:52 PM of natural causes, with immediate cause documented as cardiopulmonary arrest due to coronary artery arrest. During an interview on [DATE] at 10:55 AM Certified Nurse Aide #3 stated they were one of three aides in Resident #1's room on [DATE] when the resident's face turned a blue color while they were in the mechanical lift. They put the resident in bed and Certified Nurse Aide #2 ran to get the nurse. They held the resident's head upright | Plan of Correction: ApprovedJanuary 10, 2025 FoltsBrook Center for Nursing and Rehabilitation is committed to ensuring that advance directive wishes are honored. 1. Resident #1 was discharged from the facility. The RN Supervisor was terminated. 2. All residents are at risk of this deficient practice. An audit was conducted on all residents Advance Directives. No further issues were identified. 3. The facilitys Advance Directives Policy and Procedure was reviewed. An audit will be conducted to ensure residents code status is accurate across the indicators (Order and MOLST). This audit will be conducted monthly xs 3 months. The audit results will be reviewed during the facilitys monthly QA meeting. The frequency and duration of the audit will be re-evaluated at the end of the 3-month period. Also, Code Blue drills will be implemented monthly xs 3 months. Those drills will be reviewed during the facilitys monthly QA meeting. The frequency and duration of the drills will be re-evaluated at the end of the 3-month period. - 4. All nursing staff will be educated on the Advanced Directives Policy and Procedure including the difference between CPR and DNR; and indicators for residents code status (Order and MOLST). 5. Director of Nursing |