Glenwood Healthcare and Rehabilitation
Facility I.D. Number: 0032839
Date of Survey: 01/16/2003
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.
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.
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.
Objective observations of changes in a resident's condition, including mental and emotional changes, as a means for analyzing and determining care required and the need for further medical evaluation and treatment shall be made by nursing staff and recorded in the resident's medical record.
Each resident's medical record shall contain an ongoing record of notations describing significant observations or developments regarding each resident's condition and response to treatments and programs.
These requirements are not met as evidenced by:
Based on review of clinical records and facility policy and procedure and staff and other interviews, the facility failed to determine a new resident's DNR status, failed to assess a change in one residents condition (R3), failed to follow the facility policy on initiation of CPR, failed to properly document emergency measures taken during attempted CPR, and terminated CPR before calling the attending physician and emergency service. The lack of properly assessing a resident and performing CPR placed R3 and other residents in the facility at risk.
Review of the closed record of R3 shows R3 resided at another facility for five years. R3 was hospitalized for 15 days for pneumonia, post respiratory failure and gastrostomy tube insertion prior to admission to facility. R3 was admitted to the facility on November 22, 2002. Review of pictures dated November 22, 2002, and found in R3's closed record revealed R3 to be very emaciated with multiple sores over the entire body. R3 was transported to the facility via ambulance in full leather restraints. R3 had multiple diagnoses including schizophrenia and history of agitation and combative behavior. The facility had to administer Haldol twice during R3's nursing home stay which lasted from November 22, 2002, to November 24, 2002, when he expired. Review of nurse's notes dated November 24, 2002 indicated that nursing staff had to call previous nursing home to find out about R3's previous medical and behavior history.
Review of R3's entire closed record, and interviews with E4, E5 and E11 revealed that staff were unaware of R3's advanced directives.
During interview on January 15, 2003, at 3:40P.M. via telephone, E8 (CNA) stated, "R3 looked weak and not that responsive at 7P.M.. I saw R3 again about 8 or 8:30 P.M.. R3 looked drowsy. I always reported to my nurse (E11), at least 4-5 times that day."
Review of the nurse's notes dated November 24, 2002 did not show any documentation on R3's change in condition. There was no evidence of a nursing assessment being done on R3 after E8 reported R3's change in condition. Review of the nurse's notes dated November 24, 2002, 10:30P.M. show upon making rounds, R3 appeared not to be breathing no pulse. Attempted to resuscitate. Resuscitation ended at 10:45P.M.. The clinical record did not show if R3 was a DNR (do not resuscitate). The clinical record also did not show that 911 was called.
During interview on January 13, 2003, at 9:30A.M. in the conference room, E4 (nurse manager) stated, "R3 came here in very poor condition. From day one, we knew he was in the process of dying. During rounds, the CNA (certified nurse's aide) noticed R3 wasn't as responsive. We assessed R3 had no respirations and no heart rate so we started CPR to no avail. R3 was presumed dead. We usually call 911 if a resident is not a DNR or not on hospice. 911 wasn't called and R3 was presumed dead." During interview on January 15, 2003, at 12:00 P.M., E4 further stated, "I initiated the CPR. I checked for a carotid pulse, there wasn't one. I started 2 breaths. I put the mask on his face with the ambu bag. I did the chest compressions. We tried to do the CPR for about 15 minutes more of less. I stopped the chest compressions because his bones were crackling. He wasn't responding at all during the CPR. 911 wasn't called to my knowledge."
During interview on January 15, 2003, at 10:25A.M. over the telephone, E 11 (Licensed Practical Nurse) stated, "I went down to the room to connect R3's G-tube. I, another LPN and the CNA were on 10P.M. rounds. When I went in, R3's skin was blue and R3's eyes were open. R3 was mottled. The nail beds were blue. The nurse (LPN) stayed in the room and I got the crash cart. I overhead paged the nurse manager for that shift. E4 (nurse manager) started the chest compressions. I put the mask with the ambu bag on R3. E4 thought it was cruel to do the chest compressions because R3 was so skinny and fragile. E4 stated she was afraid of breaking R3's ribs. E4 stopped the CPR. We did CPR for about 5 minutes. I called the doctor, but E4 was the one who spoke with the doctor. No paramedics were called. I'm not sure if R3 was a DNR or not. This was my first time taking care of R3. E4 told me to chart. E4 told me exactly what to put in the chart."
During telephone interview on January 15, 2003, at 3:40P.M., E8 (Certified Nurse's Assistant) stated, "I made my rounds around 9P.M. or shortly after that. I had just cleaned R3 because he had a bowel movement. R3 looked at me and raised his hand. R3 wasn't as responsive as usual. R3 looked drowsy. After that, I reported this to E11. Every time I left out of R3's room, I always reported to E11. E12 (CNA from another unit) was looking for me to ask me to help her with another resident. When E12 went into R3's room to look for me, she noticed R3 was still and R3's eyes were open. E12 called me and told me R3 looked like he passed. I and E12 ran back into the R3's room. We called the code. E4 and the E11 came into the room with the crash cart and immediately started CPR. They did check R3 for breathing and a pulse. E11 started to give air with the mask and E4 did the chest compressions. They did CPR for about 13 to 15 minutes. I came out of the room after they said they had everything under control. I'm sure of the time I last saw R3. According to the interview, E8 indicated he last saw R3 approximately at 9:00P.M. and believes CPR started approximately 9:30P.M..
During telephone interview on January 16, 2003, at 10:10A.M., Z1 (attending physician) stated, "I didn't know anything about R3 or where R3 came from. I remember R3 came to the facility and was only there for a few days. I was going to see R3 that Monday, but they called me to tell me R3 died the previous night. They called me to okay some medication orders. No, they didn't ask me about any DNR orders."
Review of the facility's policy and procedure on initiation of CPR (cardiopulmonary resuscitation) shows the following:
A. a temperature of the skin. If the skin is "ice cold" and there are no signs of vitals, proceed through the checklist. If skin is warm to touch initiate CPR immediately if resident is a full code or CPR status
B. pupils are fixed and dilated (shine a flash light into the eyes of the expired resident to adequately assess for any reaction)
C. any visible spontaneous signs of respirations, pulse, movement
D. attempt to obtain blood pressure
E. check upper/lower extremities for mottling
F. assess nail beds for capillary refill and/or cyanosis
G. check around resident oral cavity for cyanosis
H. check arms, legs, jaw for rigidity.
If all of the above are present, do not initiate CPR and notify physician immediately for further instruction. If all of the above are not present, initiate CPR per facility policy. There must be a minimum of two licensed professional who are conducting the assessment together.
Based on interviews with E4 and E11, an assessment to determine death was not done according to the above policy. E4 initiated CPR independently after only assessing respirations and a pulse. There was no discussion with E11 prior to starting the CPR. E4 and E11 were not sure of when R3 was last seen alive. Neither staff were aware of R3's DNR status. E4 initiated CPR at approximately 9:30P.M..
Surveyor found in the course of investigation a discrepancy in the times that R3 was last seen alive and the time CPR actually was started. E8 said he last saw R3 at about 9:00P.M. and was sure CPR started at
9:30P.M.. The CPR lasted for 13-15 minutes. E11 said CPR was started at 10:30P.M. and lasted for only five minutes. The nurse's note was written by E11 who did not initiate the CPR.
E4 started CPR without following the facility policy and procedure. E4 also arbitrarily terminated CPR because she thought it was cruel and felt R3's ribs cracking. During the emergency procedure, the facility did not contact the attending physician nor emergency services (911). After the CPR was terminated, the attending physician was called by E11. The family was unable to be contacted. R3's body remained in the facility until November 25, 2002, awaiting disposition to a funeral home. Z1 signed the death certificate on November 27, 2002, naming cause of death as cardiorespiratory arrest.