Victorian Manor Healthcare and Rehabilitation
Facility I.D. Number: 0044982
Date of Survey: 07/08/2003
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, cardiac emergencies, traumatic injuries, toxicologic emergencies and other medical emergencies.
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.
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 resident's 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 observations, interviews, and record review, the facility failed to assess and evaluate the emergency medical needs for one resident (R7) on 04/30/03. R7 was noted on 04/30/2003, by staff to be without pulse oximetry readings and unresponsive. The facility licensed staff failed to stay with R7, who was a full code, and they failed to initiate CPR (cardiopulmonary resuscitation) procedures. Paramedics were called on 04/30/03, to the facility, they initiated CPR procedures and transported R7 to a hospital where R7 was pronounced dead after suffering cardiopulmonary arrest.
The failure of staff to accurately assess R7's condition and start CPR resulted in the death of R7 and placed other residents in the facility at risk.
R7 was a 50-year-old female with diagnosis of Hypoglycemia, insulin dependent diabetes, seizure, Coronary Artery Disease, Dementia with mood disorder, Hypertension, Anxiety disorder (unspecified). R7's current Physicians order was for full code status.
The following is documented in R7's chart:
On 04/30/03, at 1:30 a.m "Called to room by certified nurses aide. Resident is pale, not responding quickly to name or question. Accucheck taken and 420. Pulse 58 weak. Temperature 97. Coverage of insulin given accucheck sliding scale."
On 04/30/2003, at 1:55 a.m. "Respiratory therapist called to room to assist in evaluating. Unable to get pulse oximetry reading, resident nonresponsive."
On 04/30/2003, at 2:05 a.m. "Call placed to paramedics. Respiratory at bedside oxygen administered via mask." This entry made by E9 (11-7 nurse).
During interview with E9 on 05/14/2003 per phone, E9 told surveyor facility staff did not start CPR before calling the paramedics.
Interview with E10, respiratory therapist, per phone on 05/29/2003, E10 told surveyor no CPR was started by facility staff. Written statements from E10 on 04/30/2003, document that E10 was unable to get pulse oximetry reading and the resident was unresponsive. E10 clearly documents that at 1:55a.m., R7 "Resident found to be cool and clammy. Respirations of 8 but slow and shallow with periods of apnea. Pupils were dilated and fixed, pulse 58 and weak, unable to get pulse oximetry reading, resident unresponsive." E10 then left the room after assessing this condition and didn't start emergency CPR procedures. E9 went to fill out forms and did not continue to assess the resident or start emergency care, and E10 went to make copies of physician order sheet and advance directives for the paramedics, leaving the resident after documenting that the resident was now unresponsive and in arrest.
E6, certified nurses aide (CNA), was left in room with R7. E6 also left the room to go down and open the door for the paramedics at 2:12 a.m. E5 (CNA) stayed in the room with R7.
E10's written statement of licensed staff leaving R7 with only a CNA staff in the room with R7 was confirmed by interviews with E5 and E6 per phone conversations of 05/14/03 and 05/15/03. E6 also had a written statement of 04/30/2003, stating she, E6, was left with R7. When she left the room, she asked E5 to stay with R7.
E9 and E10 both left the room of the resident after assessing R7 who was without a pulse and slowly rapidly decreasing respirations.
Review of the CPR certification forms sent by the facility revealed that E9, E10, and E7 (RN 11-7 supervisor) were all certified to perform life saving resuscitation.
Paramedic records of 04/30/2003, responding to the facility document "found the resident lying in bed and was unresponsive, apneic, pulseless." Staff were not performing CPR upon their arrival. Paramedics initial assessment shows they were the ones to initiate CPR and ventilate the resident.
Hospital emergency room documents state: Chief complaint: "Asystole/full arrest in nursing home."
Modifying factors: "Found by nursing home staff in full arrest. Paramedics noted asystole and intubated patient in the field administered life saving protocol."