Scotchwood Health Care Center
Facility I.D. Number: 0043661
Date of Survey: 11/12/03
Incident Report Investigation of 10/20/03
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.
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 subsection (d) of this Section, if the staff person meets the specified certification requirements.
When two or more staff are on duty in the facility, at least two staff people on duty in the facility shall have current certification in the provision of basic life support by an American Heart Association or American Red Cross certified training program. When there is only one person on duty in the facility, that person needs to be certified. Any facility employee who is on duty in the facility may be utilized to meet this requirement.
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 observation, record review and interview, it was determined that the facility staff failed to follow their Cardiopulmonary Rususcitation (CPR) policy, failed to provide emergency medical attention by not initiating CPR according to the R1's code status after discovering R1 unresponsive and without a pulse. This lack of emergency medical attention failed to provide R1 with a chance of being revived.
The facility also failed to ensure that at least two staff on duty have current Cardiopulmonary Resuscitation (CPR)certification for 20 of 42 shifts in a 2 week period (48%) (10/21/03 through 11/03/03).
R1's medical record shows diagnoses of Obesity, Bipolar, Schizophrenia, Insulin Dependent Diabetes Mellitus, Hypertension, Coronary Artery Disease, Chronic Obstructive Pulmonary Disease, and Asthma. R1's Resident Assessment Instrument (RAI) dated 08/12/03 indicates that R1 was 52 years old, responsible for herself, and independent with her physical functioning. R1's current physician's order sheet dated 10/16/03 to 11/15/03 shows an order for a "Full Code"(providing life saving techniques such as CPR) signed by her attending physician, Z2. On the spine of R1's chart is a green dot indicating that R1 was a "Full Code". On the inside cover of the chart is a green sticker that reads: "Full Code". During interview with E2, Director of Nursing (DON), on 11/04/03, at 2:25p.m., she confirmed that the green dot was for a resident who was a "Full Code" status. And, that R1 was in fact a "Full Code".
Facility document titled, REPORT OF ALLEGED RESIDENT ABUSE and dated 10/22/03, shows that on 10/20/03, R1 was observed at 7:30a.m. lying across her bed with no pulse or respirations, that she was a "Full Code", and that E3, Licensed Practical Nurse (LPN), failed to follow facility policy and perform CPR and call 911. The document indicates that the type of occurrence was neglect and the type of abuse was, also, neglect. This document was prepared and signed by E1, Administrator (ADM). The investigation concluded that E3 made a nursing judgement and chose not to do CPR on R1. E3 failed to follow facility policy and was terminated.
Review of E19's employee statement shows that on 10/20/03, at 6:50a.m., she saw R1 sitting on the side of the bed.
On 10/20/03 at 7:20a.m., E3, Licensed Practical Nurse, (LPN), was called to R1's room where E6, Certified Nurse Aide (CNA) had found R1 without a pulse and unresponsive. Neither staff attempted to initiate CPR. E3, LPN failed to call 911 or to immediately notify the physician as per the facility policy.
Review of employee statements shows that on 10/20/03, at 7:20a.m., E6, Certified Nurse Aide (CNA), saw R1 lying on the bed. Her face, lips and other parts of her body were purple. During interview with E6, CNA, on 11/04/03, at 2:07p.m., she stated: "7:20a.m. was the first time I saw (R1). I checked her wrist and her neck for a pulse. and laid my hand on her chest to check for respirations. She had no pulse or any respirations. She was cold and really limp. She was blotchy. I left the room and went to the hall phone and paged (E3,LPN). I ran back to the room and waited for the nurse. When (E3) came in she checked (R1's) pulse and respirations. There were none. (E3) said, 'She's gone' and told me to find someone to help get her into bed. I did not start CPR. I did not know she was a "Full Code". I was not aware that anyone called 911."
Review of E3's statement shows that on 10/20/03, at approximately 7:20a.m., she was called to R1's room and found R1 lying on her back across the bed. Her face was mottled purple and cold to the touch. During interview with E3, LPN, on 11/04/03, at 3:45p.m., she stated: "I was at the nurses station with Z4, physician, when I was called to (R1's) room. (R1) had no pulse or respirations. Her whole body was purple and cold. I went to the front nurses station and was looking for another CNA to help get (R1) onto the bed. I asked the maintenance man to help move (R1). I did not know she was a "Full Code". I tried to call the Director of Nurses and the Administrator but got no answer. I returned to the room. I did not call 911 because I did not know she was a "Full Code". I had been employed at the facility since April 2001 and had never had an orientation. Nobody told me about the color coding on the charts. I assumed the red dots were for DNR (do not resuscitate). There was nothing in the room to indicate "Full Code" on (R1) or any rooms."
During interview with E1, ADM, on 11/04/03, at 11:32a.m., she stated: "Everyone knew (R1) was a "Full Code". There is a "Full Code" sticker on the chart."
During interview with E2, DON, on 11/04/03, at 1:45p.m., she stated: "We certify the employees in CPR and needed refreshers for recertification. We had a June inservice and reviewed CPR and the Advance Directive policy. There was no reason why (E3) did not initiate CPR. She was the head nurse. I don't know why (E3) didn't jump on (R1) and start CPR." During second interview with E2, DON, on 11/04/03, at 2:25p.m., she verified that R1 was a "Full Code". And, stated: "I was not aware if (E3) called 911 or not. (E3) handled nothing."
During interview with E5, Social Service Designee (SSD), on 11/04/03, at 2:00p.m., she stated that R1 has always been a "Full Code" and that she reviewed this with R1 on January 15, 2003 and R1 had decided to remain a "Full Code". E5 confirmed that the red and green dots started in February of 2003.
During interview with E1, ADM, on 11/04/03, at 2:22p.m. she confirmed that there is nothing on the doors or in the rooms to indicate whether or not residents are "Full Codes or DNR". It is just on the charts." At 3:10p.m., on 11/04/03, E1 stated that she called the company that handles the 911 calls and the company spokesperson stated that no 911 calls had been received between 7:00a.m. and 8:00a.m. on 10/20/03.
The facility's CARDIOPULMONARY RESUSCITATION (CPR) FOR ADULTS policy states: "Rule: Begin immediately. Begin (CPR) immediately if the resident has no pulse, no respiration, unresponsiveness. Rule: First responsibility is to resuscitate the resident. The person in charge will delegate the task of calling for emergency assistance in a timely manner. Under the detailed procedure section for CPR: #2. Call for help if the resident shows no response and you are alone. Have other staff summon emergency medical aid and call physician immediately." Review of the nurses notes dated 10/20/03, shows that at 7:45a.m., E3, LPN called to notify Z2, attending physician, of resident passing. Paged. At 7:50a.m., Z2 called back and agreed to sign the death certificate.
On 11/05/03, review of nursing employees CPR certification status, revealed that 4 of 9 nurses CPR cards were expired and 2 of 19 CNAs CPR cards were expired. Only 5 of the 19 CNAs cards were current. 12 of the 19 had no evidence of being certified in CPR. The DON verified these findings. On 11/07/03, review of the nursing schedule for the period of 10/21/03 through 11/03/03, showed that there was either only one staff on duty per shift with a current CPR certification or no staff on duty with a current CPR certification for 20 of the 42 shifts in that 2 week time period.