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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]. The [DATE] electronic physician order [REDACTED].#8 documented do not resuscitate/do not intubate. The order was signed by Medical Doctor #9 on [DATE]. 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 and gave them oxygen. Licensed Practical Nurse #4 came in the room and told them to keep the resident's head up. Social Worker #5 met Certified Nurse Aide #1 halfway in the hall and stated the resident was a DNR (do not resuscitate). Certified Nurse Aide #1 came into the resident's room and told Licensed Practical Nurse #4 the resident was a DNR (do not resuscitate). At that moment, Licensed Practical Nurse #4 was not doing compressions on the resident. Advance directives for residents could be found in the pink Medical Orders for Life Sustaining Treatment binder behind the nurses' station or in the electronic chart. After the [DATE] incident, they received inservices on advance directives and code blue. During an interview on [DATE] at 12:30 PM the Director of Nursing stated they believed Registered Nurse Supervisor #6 had a lapse in judgment when they resumed chest compressions on Resident #1 during the [DATE] incident. It had been identified moments earlier that the resident was a do not resuscitate status by Social Worker #5. When they interviewed Registered Nurse #6 after the incident, they had stated because they did not know if the resident was a do not intubate, that chest compressions needed to resume. It was a care plan violation. The do not intubate had nothing to do with the do not resuscitate. They were suspended during the facility investigation and eventually terminated from employment. It did not make any sense that Registered Nurse Supervisor #6 thought they had to know if the resident was a do not intubate in order to stop chest compressions. Licensed Practical Nurse #4 should not have started chest compressions before determining the resident's code status. It was probably less than two minutes when compressions first stopped when they learned the resident was a do not resuscitate. Licensed Practical Nurse #4 was re-educated in person by myself on advance directives and code blue, and also received the additional inservices. There was a full house training for staff on advance directives and code blue after that incident. They had also done some mock code blue drills and inservices prior to the [DATE] incident as a part of their regular trainings. All new hires were trained on advance directives and code blue during orientation and annual inservices. The two problems they saw with the [DATE] incident were: Licensed Practical Nurse #4 should not have started chest compressions without checking on the resident's code status first; and Registered Nurse Supervisor #6 should not have resumed chest compressions after it was clearly identified the resident was a do not resuscitate. During an interview on [DATE] at 12:50 PM, Social Worker #5 stated they were first alerted to the [DATE] incident when they were in another resident room on the unit. They heard yelling in the hall and looked out and an aide mentioned Resident #1 was gurgling and turning blue. They pulled out Resident #1's Medical Orders for Life Sustaining Treatment form from the binder at the nurses station and saw that the resident was a do not resuscitate. They went to the resident's room and Licensed Practical Nurse #4 and Certified Nurse Aide #3 were both in the room. Licensed Practical Nurse #4 was not actively performing chest compressions when they arrived. They told them the code status was do not resuscitate. They left the room to allow staff to perform post-mortem care. While at the nurses station emergency medical services arrived. Licensed Practical Nurse #4 came to the nurses station and asked if a Code Blue had been called and they said No, so Licensed Practical Nurse #4 announced on the overhead a Code Blue. Then, Registered Nurse Supervisor #6 came to the nurses station and made a comment about the emergency medical technicians resuming chest compressions. When they heard that, they reinforced the resident was a do not resuscitate and had the Medical Orders for Life Sustaining Treatment in their hand when they entered the resident's room. That evening they did in-person education for nursing staff on advance directives, Medical Orders for Life Sustaining Treatment and Code Blue. The facility had always had Medical Orders for Life Sustaining Treatment binders on all of the units. They did Medical Orders for Life Sustaining Treatment audits monthly and compared them with the physician orders [REDACTED]. Everything changed when Registered Nurse Supervisor #6 came on the scene and restarted compressions. It turned a peaceful death with dignity situation into chaos. During an interview on [DATE] at 2:00 PM Licensed Practical Nurse #4 stated they had been on their medication cart when they heard yelling coming down the hall. When they got to Resident #1's room they were in bed and their color was blue. They told the aides to get the resident's head up as they were gurgling. They could not feel a pulse. They were under the impression they should always start cardiopulmonary resuscitation until they knew the code status. Social Worker #5 came in the room shortly after they started chest compressions. They had only done 30 chest compressions (one set) when Social Worker #5 stated the resident was a do not resuscitate. They were not doing compressions at the time the social worker entered the room with that determination. They could tell the resident was already deceased at that point. Moments later, Registered Nurse Supervisor #6 came into the room and stated they would resume compressions and told them to get the resident's face sheet and call a Code Blue. They told them Social Worker #5 had already determined the resident was a do not resuscitate. Shortly after, Registered Nurse Supervisor #6 came to the nurses station and called 911. They had directed Licensed Practical Nurse #7 take over chest compressions. By that time everybody (facility staff) showed up on the unit due to the Code Blue being announced overhead. Everyone heard the Social Worker #5 and themself reiterate the resident was a do not resuscitate. They were shocked when Registered Nurse Supervisor #6 had stated they were resuming chest compressions. They did not know where that came from. They thought maybe something had changed with advance directives protocol. It was confusing. Looking back on the situation they should not have started chest compressions until they knew the resident's code status. They had only done one set of compressions before it was determined the resident was a do not resuscitate. The training the facility provided after the incident was do not start chest compressions until a resident's code status was known. They had in-person education from the Director of Nursing and Social Worker #5. Medical Orders for Life Sustaining Treatment binders were on all of the units at the nurses' station. Advance directives orders were also in all of the residents' electronic charts. The facility periodically did mock Code Blue drills and provided inservices on advance directives. During an interview on [DATE] at 2:05 PM Certified Nurse Aide #2 stated they had been in Resident #1's room assisting with the mechanical lift when the resident's face turned blue. They helped put the resident in bed and I ran for help to Licensed Practical Nurse #4. They were not in the room when chest compressions started. They received reeducation on Code Blue and advance directives after the incident. During an interview on [DATE] at 2:50 PM Licensed Practical Nurse #7 stated they had been on the other side of the hall when they saw Certified Nurse Aides #1, #2 and #3 grab the crash cart. They came to Resident #1's room and saw Licensed Practical Nurse #4 performing chest compressions. When Registered Nurse Supervisor #6 arrived on scene, they resumed chest compressions even though Licensed Practical Nurse #4 had stated the resident was a do not resuscitate. Licensed Practical Nurse #4 was told by Registered Nurse Supervisor #6 to call a Code Blue, then they had them take over chest compressions. They did two sets of 30 compressions, then emergency medical services showed up and took over. Social Worker #5 came into the room and again stated, with the Medical Orders for Life Sustaining Treatment in hand, that the resident was a do not resuscitate and handed the form to Registered Nurse Supervisor #19, who was standing nearby (they had arrived on the unit when the Code Blue was called). Chest compressions then stopped. They received education after the incident on Code Blue and advance directives. The Medical Orders for Life Sustaining Treatment binder was a pink binder kept at the nurses station. During a phone interview on [DATE] at 9:08 AM Registered Nurse Supervisor #6 stated they had been on another unit passing medications. An aide called them (they did not know who) hysterically and asked if they knew what Resident #1's code status was. They went down to the resident's room and there were four staff in the room at that time. Staff told them they had the resident in the mechanical lift when their face turned a purple color, so they placed them in their bed and Licensed Practical Nurse #4 had started chest compressions. They quickly assessed the resident and Licensed Practical Nurse #4 informed them it was determined Resident #1 was a do not resuscitate. They did not know who had told Licensed Practical Nurse #4 that information. They were always taught once you started chest compressions, you did not stop until the physician was called. They and Licensed Practical Nurse #7 did about three rounds of chest compressions. They called a Code Blue and called 911. The ambulance was at the facility in about two minutes. While they were filling out the paperwork for transfer out of the facility, they saw one of the resident's forms documented they were a do not resuscitate, and on another form it documented they were a do not resuscitate/do not intubate. They knew the resident was already deceased when they were at the nurses' station. The emergency medical services crew came to the nurses' station and had pronounced the resident dead. They called the resident's daughter and left a message, as they did not answer their phone. In the meantime, they had called the Director of Nursing and they were asking them about the incident. They could not remember any trainings they had on advance directives, but they must have had something at some time. They had responded to other Code Blues in the facility during their employment but had never had to look for a resident's code status before because by the time they would get to the scene the nurse on site already knew the code status. After the Director of Nursing spoke to them about the incident, they told them they would be suspended until the completion of the investigation. They were re-educated on advance directives and Code Blue due to the incident. Corporate eventually terminated their employment. Ultimately, it was their responsibility as the Registered Nurse Supervisor to know and follow what a resident's code status wishes were. 10NYCRR 415.3(e)(1)(ii) | 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?ÇÖ Advance Directives. No further issues were identified. 3. The facility?ÇÖs Advance Directives Policy and Procedure was reviewed. An audit will be conducted to ensure resident?ÇÖs code status is accurate across the indicators (Order and MOLST). This audit will be conducted monthly x?ÇÖs 3 months. The audit results will be reviewed during the facility?ÇÖs 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 x?ÇÖs 3 months. Those drills will be reviewed during the facility?ÇÖs 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 resident?ÇÖs code status (Order and MOLST). 5. Director of Nursing |