MOTHER THERESA HOME I.D. Number 0035881 1270 FRANCISCAN DRIVE LEMONT, ILLINOIS 60439 As result of a complaint investigation conducted on February 3, 1999, by representatives of the Department, it has been determined the following violations occurred. "A" VIOLATION(S) The advisory physician or medical advisory committee shall develop policies and procedures to be followed during the various medical emergencies that may occur from time to time in long-term care facilities. These medical emergencies include, but are not limited to, such things as: Pulmonary emergencies (for example, airway obstruction, foreign body aspiration, and acute respiratory distress, failure, or arrest). Cardiac emergencies (for example, ischemic pain, cardiac failure, or cardiac arrest). Traumatic injuries (for example, fractures, burns, and lacerations). Toxicologic emergencies (for example, untoward drug reactions and overdoses). Other medical emergencies (for example, convulsions and shock). There shall be at least one staff person on duty at all times who has been properly trained to handle the medical emergencies listed in subsection (a) of this Section. This staff person may also be counted in fulfilling the requirement of subsection (d) of this Section, if the staff person meets the specified certification requirements. Adequate and properly supervised nursing care shall be provided to each resident to meet the total nursing care needs of the resident. General nursing care shall include at a minimum the following and shall be practiced on a 24-hour, seven day a week basis: Objective observations of changes in a resident's condition, including mental and emotional changes, as a means for analyzing and determining care required and the need for further medical evaluation and treatment shall be made by nursing staff. Treatments and procedures, including, but not limited to, enemas, irrigations, catheterizations, applications of dressings or bandages, and supervision of special diets shall be properly carried out. The facility failed: 1. To initiate cardiopulmonary resuscitation (CPR) on R3 who was found 1-18-99, 11:10am, in room without pulses or respirations with no Do Not Resuscitate order. The resident was pronounced dead at 12:20pm by Z2. 2. To have written Policies and Procedures to initiate when medical emergencies are determined. The findings include: R3 was found 1-18-99, 11:10am, by staff, "something wrong with R3", charting continues per E6-- Res found slumped to L side of wheelchair, unresponsive and flaccid--res. immediately transferred to bed; lips cyanotic with circumoral pallor and cyanotic mottling to face--unable to obtain heart sounds, breath sounds, radial pulse or BP (blood pressure)--res. remained unresponsive during assessment-no palpable carotid pulse. Call placed to Z1 at 11:22am--absence of VS (vital signs) continued; Z1 returned call 11:25am, status report given--Z1 states,"call family and see what their wishes are" Z1 informed that Z2 in the building--Z1 asked if Z2 could assess resident. Z2 notified of resident status and will assess. Per MD order sheet dated 1-18-99, 12:20pm. Pt. with pupils fixed & dilated No heart tones Imp/Deceased Per E2, E3, and E4, no CPR was began nor was 911 called. E2 stated there is no facility policy for Medical Emergencies but they follow the AHA (American Heart Association Guidelines) for Medical Emergencies. In fact, the facility did not follow these guidelines in the incident involving R3. For R3, who had no MD ordered DNR, the responder should have established unresponsiveness, which is documented, and then activate the EMS (Emergency Medical Services) System. The next step, per Guidelines for CPR, AHA, 4th edition, after activating EMS, is to assess for breathlessness and if no breathing give 2 slow breaths. If no pulse, begin chest compressions. "Most of the time, however, you are not certain exactly when breathing failed or the heart stopped. This may occur sometime later than the injury or problem which caused the initial unconsciousness. UNDER CERTAIN CONDITIONS PERMANENT BRAIN DAMAGE MAY NOT OCCUR FOR A PROLONGED PERIOD. ---Therefore, give the victim the benefit of the doubt whenever possible and begin CPR. (page 9)."