Facility I.D. Number145874
Date of Survey:01/15/02
The facility shall have written policies and procedures, governing all services provided by the facility which shall be formulated by a Resident Care Policy Committee consisting of at least the administrator, the advisory physician or the medical advisory committee and representatives of nursing and other services in the facility. These policies shall be in compliance with the Act and all rules promulgated thereunder. These written policies shall be followed in operating the facility and shall be reviewed at least annually by this committee, as evidenced by written, signed and dated minutes of such a meeting.
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, untoward drug reactions and overdoses).
4) Toxicologic emergencies (for example, untoward drug reactions and overdoses).
5) Other medical emergencies (for example, convulsions and shock).
AN OWNER, LICENSEE, ADMINISTRATOR, EMPLOYEE OR AGENT OF A FACILITY SHALL NOT ABUSE OR NEGLECT A RESIDENT.
The facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of the resident, in accordance with each residents comprehensive assessment and plan of care. Adequate and properly supervised nursing care and personal care shall be provided to each resident to meet the total nursing and personal care needs of the resident.
These REQUIREMENTS are not met as evidenced by:
Based on record reviews and interviews, the facility failed to:
a.) Initiate immediate Cardio Pulmonary Resuscitation (CPR).
b.) Use acceptable techniques/methods while performing CPR .
c.) Continue CPR until the arrival of the paramedics.
This was for 1 resident (R1) in the sample who was noted by a staff member to be unresponsive. R1 was pronounced dead at the facility on 12/13/01.
1) R1 was a 79 year old female admitted to the facility on 7/27/01 with diagnoses including Coronary Artery Disease (CAD), Hypertension, Senile Dementia and Alzheimer's disease. R1 was a full code (CPR) per physician's order upon admission. Social service notes dated 12/13/01 indicate that E4 called Z4 on this same date to verify R1's code status. Z4 stated that he still wanted R1 to be a full code. During interview on 12/27/01 at 10:30 AM in the conference room, E4 stated that on 12/13/01 she told E5 the family requested R1 remain a full code.
A. Per interview on 12/27/01 with E7, the Certified Nursing Assistant (CNA), at 3:50 PM in room 331, E7 stated that she checked R1 sometime between 7:30 and 8:30 PM on 12/13/01 and found her not breathing. R1 was in front of the nurses station sitting in a wheelchair. She told E5 that R1 was dead. According to E7, E5 stated, "she can't be dead, put her back to bed." E7 stated that she called for another CNA, E9, to assist her in putting R1 back to bed. E7 stated that she was with R1 from the time she found her unresponsive in the wheelchair until the time she put her to bed and that no CPR was initiated. E7 stated that after she put R1 back to bed she changed R1's clothing because R1 was soiled with stool and urine. E7 stated that she left the room when E5 came in and therefore does not know whether or not E5 initiated CPR. CPR was not initiated immediately after R1 was found unresponsive by the nurses station.
B. Per the facility's final investigation report (Report) dated 12/19/01 E5 stated, "I started CPR, compressions only." The Report also noted that E5 was told to initiate CPR by her supervisor, E6. E6 stated that when she arrived on the third floor from the first floor, E5 was still not doing CPR and had no equipment available. Per the Naperville police department audio dispatcher tape, E5 stated that she did CPR for about 5 minutes but then stopped and was no longer continuing because the resident had no vital signs.
According to the American Heart Association Basic Cardiac Life Support instruction material, "IF YOU DO BEGIN CPR, YOU MUST ALSO REALIZE YOUR OBLIGATIONS. THE DECISION TO ABANDON CPR EFFORTS CAN ONLY BE MADE BY A PHYSICIAN. Once you begin CPR you are obligated to continue..." During review of personnel files and by confirmation of E1, E5 was not currently CPR certified.
Per the facility's Report dated 12/19/01and interviews with CNA's on 12/27/01 no overhead page code signal was announced (code blue). Per the facility's Report, interviews with E5, E6, E8, E10 and E11 were conducted and revealed that no code blue was announced. Per interviews on 12/27/01 with E7 and E9 it was confirmed that no overhead emergency code signal (code blue) was announced after finding R1 unresponsive on 12/13/01.
Per the facility report dated 12/19/01, E5 did not call 911 until after being told to do so by a supervisor. Per facility policy on CPR someone is to notify the rescue squad (911). At 10:30 AM in the conference room on 12/27/01 E1 confirmed that the CPR policy was in effect several years prior to the incident which occurred on 12/13/01. The Naperville police dispatch audio tape verifies that E5 waited at least 5 minutes before calling 911.
C) Per the facility's policy on CPR staff is to continue CPR until paramedics arrive and take over resuscitation. Nursing notes of E5 dated 12/13/01 state "CPR done for 5 minutes."
Per interview with E12 on 12/27/01 in the conference room it was verified that only one inservice had been given for the prior year in emergency response care (Preparation for airway suctioning). Review of the facility's inservices prior to 12/13/01 revealed that none of the nursing staff who attended to R1 on 12/13/01 had attended any inservice training regarding emergency care or CPR.
E5 and E6 were unable to be contacted and are no longer employed at the facility.