Glenwood Care Center
Facility I.d. Number: 0040394
Date of Survey: 02/07/03
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.
Objective observations of changes in a residents 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.
AN OWNER, LICENSEE, ADMINISTRATOR, EMPLOYEE OR AGENT OF A FACILITY SHALL NOT NEGLECT A RESIDENT.
These regulations are not met as evidenced by:
Based on review of clinical records, paramedics emergency medical service (EMS) report and facility's policy and procedures and staff and other interviews, the facility failed to initiate Cardio Pulmonary Resuscitation (CPR) in a timely manner, failed to properly administer CPR, and failed to call 911, and delayed obtaining emergency medical services over 36 minutes after assessing one resident (R1) unresponsive, and without any pulse, blood pressure or respirations (in a full arrest).
Review of R1's closed record and 01/27/03 EMS report shows that on 01/27/03, R1 was found in bed unresponsive, without a pulse, blood pressure or respirations at 11:20PM. 01/31/03 interview of E3 (nurse) and 02/5/03 interviews of E5 (nurse aide), E8 (nurse aide) and Z3 (Paramedic) also showed that R1 was found in a full arrest on 01/27/03 at 11:20PM. Record review indicated that R1 was a full code. E3 stated that it was 20 minutes after finding R1 in this condition before a private ambulance service, not 911, was called. E3 said the delay in calling the ambulance was due to E3 being so busy doing other things and E3 stated that she told E7 (nurse), to call the private ambulance instead of telling E7 to call 911. E7 told surveyor during 2/5/03 interview , that she called the private ambulance, not 911, sometime after 11:30 or after 11:45PM. R1's 01/27/03 EMS report stated that facility called at 11:56PM. Z3 told surveyor that it was just luck that their ambulance just happened to be in close proximity to the facility, when the call came in to the dispatcher. Z3 also stated that he asked the staff why they delayed calling for EMS and why the staff did not call 911 instead of the private ambulance and that the staff responded to these questions by telling Z3 that they were told to call the private ambulance and that the nurses are not supposed to call for EMS until they have contacted the Administrator and Director of Nurses (DON), first. The EMS report states that the ambulance arrived at the facility at 11:58PM. E5, E8 and E9 (nurse aide) all stated to surveyor that the resident did not appear ice cold, had some pink still in the face and was only slightly pale in the face. Z3 interview and the EMS report showed that at 11:58PM R1 had a "fine V - Fib" cardiac rhythm on the monitor.
E3 and E5 both told surveyor that after finding R1 in a full arrest at 11:20PM, they both left R1 alone in the room to do other things. E3, E5, E8 and E9 all stated during individual interviews, that E9 was the staff person that initiated CPR on R1. E8 and E9 stated that E9 was the only staff member performing CPR on R1 until the paramedics arrived at 11:58PM at which time E8 joined in and ambu bagged R1 for the paramedics. E9 stated that she only performed chest compressions on R1 and that no artificial ventilation was performed on R1 until the paramedics arrived. E9 also stated that the paramedics arrived a few minutes after E9 initiated CPR on R1. "When I arrived to the 2nd floor, (E7) was at the nurses station asking for the phone number to the ambulance company, which I gave her, (E3) was in the hallway walking toward the nurses station and (R1) was alone in her room. (E5) entered (R1's) room shortly after I and helped me transfer (R1) off her bed and onto the floor. I then started doing chest compressions on (R1) and had only completed about 25 - 30 compressions before the paramedics arrived." Z3 told surveyor that he wrote on the EMS report that staff were doing CPR when the paramedics arrived on the scene, because he saw them doing chest compressions, so he assumed they were doing CPR.
R1 was transferred to the hospital 01/28/03 at 12:11AM and was pronounced dead in the Emergency Room at 12:29AM. Z4 (R1's Physician) stated during 02/06/03 interview , that he was notified of R1's decline in status until 1/28/03 at about 4AM. Z4 was told that R1 was found without a heart rate and expired. Z4 also stated that he was shocked to hear R1 had expired because Z4 had visited R1 on 1/27/03 and R1 appeared stable, in no acute distress and with normal vital signs.