Red Hills Healthcare Center
Facility I.d. Number: 0045716
Date of Survey: 12/12/02
All personnel shall have either training or experience, or both, in the job assigned to them.
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.
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.
All necessary precautions shall be taken to assure that the residents' environment remains as free of accident hazards as possible. All nursing personnel shall evaluate residents to see that each resident receives adequate supervision and assistance to prevent accidents.
These requirements were not met as evidenced by:
I. Based on record review, and interviews, the facility failed to ensure that all staff were properly trained in emergency medical situations. Facility staff failed to appropriately respond to a medical emergency requiring Cardiopulmonary Resuscitation. One resident (R12) was found in the resident's room, after having slipped down in a wheelchair with the safety device around the neck.
Cardiopulmonary Resuscitation (CPR) was initiated and discontinued after 16 minutes without authorization to do so from appropriate medical personnel. Facility staff also failed to contact any emergency medical services after initiating CPR for R12.
II. Based on record review, interviews and observation, the facility failed to ensure that one resident (R12) was appropriately supervised to ensure her safety in a self-release wheelchair seat belt. R12 was found non responsive after having slipped down in her wheelchair in her room with the safety device around her neck.
R12 was a 68 year-old resident with diagnosis of Severe Huntington's Chorea with psychiatric disturbance.
R12, per observation of her safety device 12/02/02, had a self-releasing waist-safety device with a metal-type buckle with a red square in the middle to be pushed for self release. This safety device was observed to be 2 inches wide and folded to one inch wide on the left side and the right side was observed to be twisted. A sheet of rubber type material was observed being used on R12's wheelchair to reduce R12's sliding out of her wheelchair.
According to nurse's notes dated 11/23/02 at 5 p.m., "po Ativan given as per orders. Assisted up in chair et seat belt tightened. Res had her feet up on the hand rails with the seat belt around breast area." The nurse's note at 5:30 p.m. state, "CNA went to room to get resident to come to DR for evening meal. Refused at this time to come out. Sitting in WC seat belt around waist. A late entry nurse's note dated 1/23/02, at 5:15 p.m. stated, "Resident out in hall screaming et pulling hair with her hands. Seat belt around breast area again. Assisted up in W/C seat belt retightened. Escorted to room door left open to be able to observe res." The nurse's notes at 5:45 p.m. state, "CNA went back to room. Told resident to come to DR that her supper was waiting. Resident slouched down in W/C. Refused to go to DR."
According to nurse's note 11/23/02 at 6 p.m. , "CNA went back to res room to get res for supper. Res found with seat belt around arm pits et throat. Released seat belt felt for pulse. No pulse. Called for nurse". At 6:01 p.m., "Nurse entered room res sitting on floor CNA stated not breathing. CPR initiated after res eased to lying position on floor". At 6:02 p.m., "Maintenance man appeared. Relieved CNA so she could go get chart. CPR listed on chart. CPR continued as per policy." At 6:17 p.m., "CPR stopped. No pulse no respirations for one full minute."
E11 (Registered Nurse)was interviewed on 12/3/02 at 10:25 a.m., and stated that her CPR certification expired in April, 2002. E11 further stated that she was not sure what she was to do in this emergency situation. E11 stated that CPR was stopped on R12 after 16 minutes and that no one called for emergency medical personnel.
E19 (Certified Nursing Assistant ) stated in interview on 12/3/02 at 1:10 p.m. that she is a student nurse and was CPR certified in 8/02. E19 stated she released the safety device around R12's neck and eased her to the floor, yelled for help and then initiated CPR with E11.
Z1(physician) was interviewed on 12/05/02 at 3 p.m., and stated CPR should have been continued until emergency medical personnel arrived.
Z1 (physician) was interviewed by telephone on 12/5/02 at 3 p.m. and stated that on his last visit to the facility on (10/23/02) that he had told staff that R12 needed a more appropriate device to prevent her from slipping out of her wheelchair. No evidence was found that R12 was re-evaluated for a more appropriate safety device to date. On 7/24/02, the Pre-Restraining Assessment states, "res requests a seat belt that she can fasten/unfasten at will. Hx of multiple falls. Permission given per OSG." The last summary for the evaluation of the safety device in the record was dated 9/6/02 which states, "uses seatbelt in w/c-noncompliant at times (releases per self). Has had two falls in past month."
According to interviews with E4 (CNA) at 10 a.m. on 12/5/02, and E6 (Maintenance) on at 10:55 a.m. on 12/5/02, they stated that they had both seen R12 slipped down in her wheelchair on different occasions with her safety device up under her breasts but never above her breasts.
Z2 (coroner) was interviewed on 12/03/02 at 4 p.m., and stated that an autopsy had been performed on R12 and the preliminary cause of death was "Asphyxiation".
At the time of this survey, twenty-two residents of the facility census of 51 were on "Code status" and would also be at risk due to the facility's failure to react and follow emergency procedures.