| 4 |
SANTA FE CARE CENTER |
325030 |
635 HARKLE ROAD |
SANTA FE |
NM |
87505 |
2020-01-16 |
678 |
J |
1 |
0 |
WQZY11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > On [DATE] R #9 was found unresponsive (not responding to stimuli such as calling of her name and shaking her body) in the facility dining hall. She was taken from the dining area to her room prior to initiation of CPR (techniques to manually provide for blood circulation and oxygenation in an emergency) delaying this potentially life saving measure. During interviews with multiple staff in the facility, the staff could not immediately and accurately identify residents' code status. Some staff indicated they would start CPR on any resident found unresponsive until code status could be verified by looking in the Electronic Health Record (EHR) or a binder located at the Nurses Station, and then stop CPR if resident had elected to be Do Not Resuscitate (DNR) (Do not provide CPR services). Record review for CPR Certification status of staff revealed that the two certified Nursing Assistant's (CNA's) and the nurse involved in provision of CPR during the event on [DATE] with R #9 did not have up to date certification. This resulted in an immediate jeopardy (IJ) at a scope and severity of J (isolated jeopardy to resident health and safety) being identified on [DATE] at 2:15 pm. A Plan of Removal was approved and verified on [DATE] at 1:40 pm. Based on the Plan of Removal, the interventions included: 1. Completed audit of all residents' code status. 2. All clinical staff to have a list of residents' code status provided to them each shift that is updated daily. 3. All clinical nurses and Certified Nursing Assistants (CNA) were educated to begin CPR immediately for any resident who has elected it and found requiring it at the place at which they are found according to Basic Life Support (BLS) guidelines. 4. All nursing clinical staff to have current certification in BLS/CPR as of [DATE]. Based on the Plan of Removal, the Scope and Severity was reduced from the level J to a level [NAME] Based on record review and interview, the facility failed to: 1. Initiate CPR immediately for 1 (R #9) of 1 (R #9) residents reviewed for prompt provision of CPR when required. 2. Ensure there was a system in place for all clinical staff to immediately determine the code status (level of medical interventions a patient wishes to have if their heart or breathing stops). 3. Educate all clinical staff to provide care if a resident is discovered without breathing and/or heart beat that reflected residents wishes in accordance with their Advanced Directives. 4. Ensure clinical staff with current CPR certification are available to provide CPR if needed, at all times in the facility. These deficient practices have the potential to result in a resident not receiving immediate/effective basic Life Support/CPR if they have elected that or receiving CPR if not elected for any of the 94 residents identified as living in the facility on [DATE] by the administrator in the, Patients Census And Conditions Of Residents, (CMS-672). Findings related to R #9: [NAME] Record review of census and [DIAGNOSES REDACTED].#9 revealed, she was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. B. Record review of nursing progress note on [DATE] at 5:54 am, (a late entry regarding the event [DATE]) revealed, At about 8 AM Pt. (patient/resident) non-responsive heart rate (beats per minute) and respirations diminished (less than her normal) Pt. is full code CPR started. 911 EMT's(Emergency Medical Technicians) notified. CPR was stopped when told by EMT's to stop when they took over. Pt. with V/S (vital signs, generally meant to be heart rate, respirations, blood pressure) and transported by EMT's to ER (emergency room ). C. On [DATE] at 8:35 am, during interview, the Director Of Nursing (DON) revealed regarding the event on [DATE] when R #9 became non-responsive in the dining room, That was a scary one .we came up (back to the facility) and watched the video, she (R #9) is sitting at the dining room table she reaches for her hot chocolate and takes a drink - puts it back and takes another drink and then all of a sudden she drops her cocoa and has shaking (demonstrates her arms mild shaking) then she dropped her head. Then (first name of CNA #5) came and sat in front of her and kind of looked closely and called for the nurse (LPN #1) they took her back to her room (There is a camera in the dining area and hall but not resident room) (Do you have the video still?) oh no, they only last about 7 days (Do you have a record of the code event?) No, (first name of LPN #1) did not complete one .(first name of LPN #1) said they did a finger sweep and could not find anything, so started CPR (how was she when she left the building?) They were bag / masking her (putting air into her lungs with a bag and mask). Then they (staff) called us and we came, the administrator and I . I went over to the hospital, she was in the ED (Emergency Department) still they were working on her .the nurse there told me it was a poker chip (a poker chip was found in her airway), she said they found it when they tried to intubate her (put a breathing tube into the airway ) .the tube wouldn't go in and that is when they got it out .She died about 11 (pm) that night .the daughter told me. D. Record review of event timeline provided on [DATE] by the DON, which she relayed was from watching the video of the event, revealed: 1. At 8:02:56 am, resident discovered in dining room by CN[NAME] 2. At 8:03:35 am, resident was back in her room. 2. At 8:05:03 the backboard was taken to the room. E. Record review of incident report dated [DATE] at 3:03 pm, written by CNA #1, We took (first name of R #9) to her room and notified the nurse on duty as we were taking (first name of R #9) down where (first name {misspelled} of CNA #2) and i checked her throat and didn't see anything. We proceeded after with the [MEDICATION NAME]. No results. We transferred her to the bed and performed CPR until Paramedics arrived and took over. F. On [DATE] at 8:55 am, during interview, LPN #1 revealed, Worked here [AGE] years. I went and got the backboard. We did a mouth sweep and one of the boys (CNA #1 or #2) gave her a [MEDICATION NAME] .My thought was she had a [MEDICAL CONDITION] .the EMT's showed up and took over, in maybe less than 15 minutes. I was on the phone with the 911 dispatcher for a few minutes. The CNA's (CNA #1 and CNA #2) were doing most of the CPR. Every time we did a compression, in between she was flat line (heart monitor showed no activity from heart). We were bagging her color was never cyanotic (bluish discoloration that can indicate lack of adequate oxygenation). [NAME] On [DATE] at 10:10 am the DON confirmed that LPN #1, CNA #1 and CNA #2 did not have current certification in BLS/CPR. Findings related to code status: H. On [DATE] at 8:55 am, during interview, LPN #1 revealed (How do you know which of your residents want CPR ?) We mostly know who is CPR or not. We do it (assess for their wishes/advanced directives (various documents that instruct/directive medical professionals and your family to the treatments you want to receive or refuse.)) mostly when a new resident comes in. (How many residents do you have today?) About 26 I think. (rooms?) Rooms 18 through 32 (Can you tell me which residents you have today who are full code (have directed that they want to receive CPR if indicated) verses DNR (have directed they do not want to receive CPR if they have lost the ability to breathe adequately or their heart rate is not adequate to sustain their life ?) Yes, I think so . He identified R # 10 and R # 11 as full code(have directed that they desire CPR if indicated) and the rest of his assigned residents no code(DNR). I. Record review of electronic health records (EHR's), for resident in rooms 18 through 32 on [DATE], revealed the following resident's had Advanced Directives indicating they desired CPR (full codes) if needed , R #'s, 10, 12, 13, 14 and 15. (This information was confirmed by the DON on [DATE] at 11:55 am). [NAME] On [DATE] at 10:45 am, during interview CNA #4 revealed, that regarding what he would do if he found a resident was non responsive, I would call for nurse .I would yell for help .I would start the CPR . I just recently got my CPR, it was last Thursday (how would you know if the resident wanted CPR or wanted to be a no code?) that information we don't have .I guess I wouldn't .if I . started it and the nurse said they were not CPR then I probably would stop. K. On [DATE] at 10:50 am, during interview, LPN #3 revealed, that regarding how she would respond on finding a non responsive resident, We would try to help her do what we know .(how would you know the residents Advanced Directive status?) I know most of them (you just remember?) yes. We used to have the charts up here (at nurses desk) and it was about a year ago (they went to the electronic health record (EHR)) I would start it (CPR) right here I wouldn't move her. Look at the EHR or the book they are making a book .it is up front there (indicates the front hall where DON and Administration offices are) Yes, that is new. If we happen to not know (if the resident wanted CPR or not) we start it (CPR) not knowing. L. On [DATE] at 11:03 am, during interview LPN #4 revealed, (if you find a resident laying in the courtyard no pulse no respirations and you do not know the code status what do you do?), you could start it and stop it (CPR). Regarding (name of R #14, what is his code status?) It is not on here (on the banner in the residents EHR) but I admitted him so I know he is a DNR. M. Record review of R #14's EHR revealed, he had an updated Advanced Directive that indicated he wanted CPR. (is a full code, not DNR). N. On [DATE] at 11:10 am, during interview, LPN #2 revealed that regarding initiation of CPR when a resident is found unresponsive, you immediately get down and assess them . you start CPR . you get somebody to check on the computer (at the nursing station) to find out (their advanced directive). (What if they didn't want CPR?) then you stop (CPR). It is true, if they are not on your floor you may not know (their advanced directive status). |
2020-09-01 |