ST JOSEPH HOME OF CHICAGO I.D. NUMBER 0013847 2650 N. RIDGEWAY AVE. CHICAGO, IL 60647 As a result of a survey conducted by representative(s) 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: 1. Pulmonary emergencies (for example, airway obstruction, foreign body aspiration, and acute respiratory distress, failure, or arrest). 2. Cardiac emergencies (for example, ischemic pain, cardiac failure, or cardiac arrest). 3. Traumatic injuries (for example, fractures, burns, and lacerations). This regulation is not met as evidenced by: Based on incident/accident review, record review, staff interview, and policy/procedure review it was determined that the facility failed to continue cardiopulmonary resuscitation (CPR) to 1 of 1 residents who was found unresponsive following a fall from the 2nd floor stairwell that resulted in his death. Review of R2's medical record denotes, that on 3/13/99 at approximately 11:30 a.m. R2 was found by E5 on the south stairwell landing between the 1st and the 2nd floor. Resident2 was unresponsive. CPR was started immediately by E6. While E6 was engaged in resuscitating R2, E8 informed E6 that R2 was a DNR (do not resuscitate) and the CPR was discontinued. There was no M.D. present to pronounce R2 dead when the CPR was discontinued. The 3/13/99 Incident Report documents at approximately 11:40 a.m., R2 was found in the 2 South stairwell on the landing between the second and first floors in his wheelchair with his wheelchair belt on. R2 was unresponsive and without vital signs. R2 had a laceration on the left side of his face 10 cm in length and one on the forehead 3 « cm by 3 « cm. R2 expired. The facility's policy/procedure clearly states "when the paramedics arrive, they will take over CPR and transfer the resident to an acute hospital." The facility inserviced the nursing staff on 3/16/99 regarding CPR guidelines. The staff was inserviced never to stop CPR unless instructed by an M.D. or a paramedic. Based on record review and staff interview it was determined that the facility failed to develop a policy/procedure for moving/transferring an injured resident. Review of R2's medical record denotes that on 3/13/99 at approximately 11:30 pm R2 fell from the 2nd floor down eight steps to the 1st floor landing. Resident 2 was unresponsive. R2 was wearing waist belt restraint that was attached to R2's wheelchair. Employee's 5 and 6 removed R2 from the wheelchair and positioned R2 flat on the floor. CPR was started. Interview with E2, who stated the facility does not have an established policy/procedure for moving injured residents. The facility had no knowledge as to if R2's neck or any other bones had been broken as a result of the fall.