Capitol Care Center
Facility I.D. Number :0045666
Date of Survey: 06/10/03
Every facility shall respect the residents right to make decisions relating to their own medical treatment, including the right to accept, reject, or limit life-sustaining treatment. Every facility shall establish a policy concerning the implementation of such rights. Included within this policy shall be:
THE IMPLEMENTATION OF PHYSICIAN ORDERS LIMITING RESUSCITATION SUCH AS THOSE COMMONLY REFERRED TO AS DO-NOT-RESUSCITATE ORDERS. THIS POLICY MAY ONLY PRESCRIBE THE FORMAT, METHOD OF DOCUMENTATION AND DURATION OF ANY PHYSICIAN ORDERS LIMITING RESUSCITATION. ANY ORDERS UNDER THIS POLICY SHALL BE HONORED BY THE FACILITY;
Procedures for providing life-sustaining treatments available to residents at the facility.
The facility shall honor all decisions made by a resident, an agent, or a surrogate pursuant to subsection (c) above and may not discriminate in the provision of health care on the basis of such decision or will transfer care in accordance with the Living Will Act, the Powers of Attorney for Health Care Law, the Health Care Surrogate Act or the Right of Conscience Act.
ALL MEDICAL TREATMENT AND PROCEDURES SHALL BE ADMINISTERED AS ORDERED BY A PHYSICIAN. ALL NEW PHYSICIAN ORDERS SHALL BE REVIEWED BY THE FACILITYS DIRECTOR OF NURSING OR CHARGE NURSE DESIGNEE WITHIN 24 HOURS AFTER SUCH ORDERS HAVE BEEN ISSUED TO ASSURE FACILITY COMPLIANCE WITH SUCH ORDERS.
AN OWNER, LICENSEE, ADMINISTRATOR, EMPLOYEE OR AGENT OFA FACILITY SHALL NOT ABUSE OR NEGLECT A RESIDENT.
These regulations are not met as evidenced by:
Based on interviews and record review the facility failed to have in place a system that readily identified residents that were to receive Cardiopulmonary Resuscitation (CPR), and to have staff trained to immediately implement emergency procedures for those requiring CPR. These failures resulted in a delay of more than five minutes prior to CPR being implemented for R1. In addition, the facility failed to have consistent documentation of code status in one (R2) of three sampled residents.
1) Review of R1's record indicates that R1 had a diagnoses, in part, End Stage Renal Disease on Dialysis; Chronic Ischemic Heart Disease; Hypertension; Congestive Heart Failure; Hypothyroidism; Peripheral Vascular Disease with right above the knee amputation; Pulmonary Hypertension and Diabetes Mellitus. Review of R1's "Admission Information on Advance Directives" indicates that R1's power of attorney chose "No, I do not at this time have an existing Advance Directive." Review of R1's "Physician's Order Sheet" Identifies R1's Code Status as a "Full Code".
Review of R1's "Nurses Notes" at 0130 (1:30 a.m.) on 5/26/03, "(R1) complains of shortness of breath. Put on 2 liters of oxygen. SPO2=98%, lungs clear, bowel sounds active, skin cool, dry to the touch, eyes Pearla, oriented times three. No other complaints offered, will continue to monitor." Vitals not taken at this time.
At 0215 (2:15 a.m.) on 5/26/03, "(R1) still complaining of shortness of breath, SPO2 - 98%, Oxygen on at 2 liters. Accucheck (blood sugar monitoring) 132. (R1) stated she doesn't feel well, lungs clear, will continue to monitor." Vitals not taken at this time.
At 0235 (2:35 a.m.) on 5/26/03, "(R1) found face down on bedside table, unresponsive to stimuli, tried to revive (R1) by shaking, calling name, no response, no pulse felt, no heartbeat heard,( Z2) (physician) notified. (R1) is a full code, code called. Worked on (R1) from 0240 (2:40 a.m.) to 0300 (3:00 a.m.), ambulance and fire truck arrived at 0300 (3:00 a.m.)."
Interview with E3 (licensed practical nurse - LPN) at 2:50 p.m. on 6/3/03 and 9:45 a.m. on 6/10/03, E3 stated that it was her first code and she wasn't sure what to do. E3 called Z2 (physician) through the answering service system and was connected to the physician on call who said to find out what the family wants. E3 called E11 supervisor on call at home and asked for assistance. E11 instructed E3 to call E9 the house supervisor. E3 called E9 (house supervisor) to tell him the situation and E9 instructed E3 to look up R1's code status in R1's chart. E3 was having difficulty finding R1's code status in the chart.
Interview with E14 (certified nursing assistant - CNA) at 1:10 p.m. on 6/10/03, E14 indicated that E3 (LPN) came to the nurses desk stating "I think (R1) is dead". E3, E14 and E15 (CNA) all went to R1's room. E3 listened to the heart while E14 and E15 checked for a pulse. E14 indicated that R1 was blue in color. E3 left the room after instructing E14 and E15 to stay with R1. E14 held R1's head up in an upright position for approximately 10 minutes before anyone came back in the room.
Interview with E9 (LPN - house supervisor) at 11:35 a.m. on 6/5/03 indicated that E3 was having difficulty finding R1's code status. E9 told E3 he would be right down. E9 said he went to second floor immediately. E9 arrived on second floor and helped E3 look for R1's code status and found in the physicians order sheet that R1 was a full code. E9 said he then called a code over the intercom, then called 911 and took the crash cart down to R1's room along with E3. E9 indicated that R1 was still sitting up in the wheelchair and E3 and two certified nursing assistants (CNA's) transferred R1 from wheelchair to bed and backboard was placed behind R1.
E3 started mechanical respirations on R1 with the Ambubag and E10 (certified nursing assistant - CNA) started compressions on R1. E9 said he then went back out to the desk to make copies of the record for the ambulance. The fire department arrived and took over on the code. The ambulance arrived and the fire department and ambulance asked how long had it been since R1 was seen alive. They ran a strip indicating that R1 was in asystole and R1's pupils were fixed and dilated. The paramedics called the physician and the code was called off.
Review of R1's nurses notes indicate a five (5) minute delay between R1 being found unresponsive and CPR being initiated.
Interview with E3, at 9:45 a.m. on 6/10/03, indicates that it was probably seven minutes between when R1 was found unresponsive and CPR was initiated.
2) Review of R2's record indicates R2 was admitted 3/21/03 with a diagnoses, in part, Respiratory Failure; Chronic Airway Obstruction; Asthma; Diabetes Mellitus; Hypertension and fracture of left femur. Review of R2's 1 "Advance Directive" indicates that R2's power of attorney (POA) signed the "Do Not Resuscitate (DNR) Order" form on 3/24/03 and the physician signed this form on 3/31/03. Review of R2's "physician's order sheet" identifies R2 as a "Full Code".
At 10:05 on 5/21/03, R2 was found without breath sounds and no pulse present, R2 was not resuscitated per review of R2's nurses notes. R2's physician was notified and attempts to reach R2's POA were unsuccessful. According to the nurses notes a physician's order was not obtained prior to the facility electing not to resuscitate.