cms_WY: 45
Data source: Big Local News · About: big-local-datasette
| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 45 | GRANITE REHABILITATION AND WELLNESS | 535013 | 3128 BOXELDER DRIVE | CHEYENNE | WY | 82001 | 2019-10-25 | 600 | G | 1 | 0 | GM1D11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, staff interview, facility investigation review, facility incident report review, review of policy and procedures, and review of professional standards, the facility failed to provide services to a resident that were necessary to avoid physical harm. Specifically, the facility failed to implement advance directives for 1 of 1 sample residents (#2) who experienced cardiopulmonary arrest in the facility and had elected to receive CPR in such an event. This failure resulted in harm to resident #2 who was found unresponsive, staff failed to initiate CPR, and the resident expired. Corrective measures were implemented by the facility, and compliance was determined to be met on [DATE]. The findings were: 1. Review of the WyoPOLST (Wyoming Providers Orders for Life Sustaining Treatment) form dated [DATE] (and signed by the physician on what appeared to be [DATE]) revealed resident #2 requested to be resuscitated in the event of no pulse and is not breathing. Further review showed the POLST form was reviewed with the resident on [DATE], [DATE], [DATE], and [DATE] and the resident elected to maintain a full code status. The following concerns were identified: a. Review of a progress note created by RN #1 dated [DATE] at 2:18 AM showed At 0110 (1:10 AM) this morning Resident was found not breathing, unresponsive, no pulse and no heartbeat with auscultation. Pupils nonreactive (physician name) notified and Resident pronounced dead at 0120 (1:20 AM). There was no evidence staff initiated CPR. b. Review of an Investigator's Interview Statement of Event, signed by the DON and dated [DATE], showed CNA #1 was interviewed by the facility, and described the event. The CNA told the facility she had answered the resident's call light and had started to help him/her when she was called to assist another CN[NAME] Upon returning to the resident's room ,[DATE] minutes later she found the resident unresponsive and attempted to rouse (him/her) with no response. The CNA then ran out of the room to go find the nurse. Ran up and down halls calling out for nurse and couldn't find her. Finally found her in the bathroom. Nurse finished up going to the bathroom and than (sic) went down to (the resident's) room. (The resident) was unresponsive when CNA found (him/her) + 15 min/20 min later the nurse went to the room (By the time CNA tried to arouse (him/her) and find the nurse). c. Review of an Investigator's Interview Statement of Event signed by the DON and dated [DATE], showed RN #1 was interviewed by the facility and described the event. She told the facility the CNA looked for me and I was in the restroom. Further review showed the nurse went to the resident's room to check the resident's status and noted color changes, no heartbeat, no lung sounds, was unresponsive, and was not warm to the touch. The nurse stated she immediately called the physician. In addition, RN #1 recalled receiving POLST education, however she had misunderstood the parameters with following through with the POLST. d. Review of the medical record and the investigation documentation provided by the facility showed no evidence CNA #1 or RN #1 had used the intercom system to activate Code Blue or made an attempt to contact a nurse on a different floor on [DATE] between 12:55 AM and 1:20 AM. e. Interview with LPN #1 on [DATE] at 6:07 PM revealed she was working on the third floor the night the incident occurred and Code Blue had not been activated. Further, RN #1 had contacted her approximately 30 minutes after the resident had expired, informed her the physician had been notified, orders had been received for transport, and then requested information in regard to where to find mortuary papers. LPN #1 asked the RN about the resident's code status and was informed the resident had been a Full Code; however the resident had expired before interventions had been instigated. The LPN stated she never set eyes on the resident. f. Interview on [DATE] at 2 PM with the DON, administrator, and the corporate district DON confirmed the CNA had not called Code Blue, however the CNA had gone down every hall two times until she found the nurse in the bathroom. Further, the nurse did not check the resident's chart to establish the resident's CPR status until after she had completed her assessment. The DON revealed the investigation had determined it was definitely between 10 and 15 minutes from when the CNA found the resident unresponsive until the nurse arrived in the resident's room. g. Review of the facility's incident report submitted to the State Survey Agency on [DATE] showed the incident was documented as Failure to Provide Services. The report showed the resident had elected to receive CPR in the event of cardiopulmonary arrest, and confirmed the facility failed to initiate CPR. 2. Review of the Advance Directive policy, last updated (MONTH) (YEAR), showed a policy statement of The Center relates information regarding advance directive to each resident and honors each advance directive that is given to it. Review of the Cardiopulmonary Resuscitation policy, last updated (MONTH) (YEAR), showed .CPR is initiated for those residents who: a. Have requested, through advanced directive or POLST/POST, to have CPR initiated when cardiac or respiratory arrest occurs . 3. According to Perry, Potter, and Ostendorf in Nursing Interventions and Clinical Skills, 7th edition, 2020, page 812 .Immediate recognition of [MEDICAL CONDITION] and activation of emergency medical response are critical. Early CPR and recommended health care team-level coordination that switches the provider who performs chest compressions every 2 minutes improves the performance of high-quality CPR (AHA, (YEAR)). 4. According to the American Heart Association Emergency Cardiovascular Care website found at https://eccguidelines.heart.org; (retrieved [DATE]), Part 3: Ethical Issues, Withholding and Withdrawing CPR, Out-of-Hospital [MEDICAL CONDITION] (OHCA), Terminating Resuscitative Efforts in Adult OHCA, BLS out-of-hospital system showed Rescuers who start BLS should continue resuscitation until one of the following occurs: a. Restoration of effective, spontaneous circulation b. Care is transferred to a team providing advanced life support c. The rescuer is unable to continue because of exhaustion, the presence of dangerous environmental hazards, or because continuation of the resuscitative efforts places others in jeopardy d. Reliable and valid criteria indicating irreversible death are met, criteria of obvious death are identified, or criteria for termination of resuscitation are met. 5. Review of the facility's action plan in response to this incident showed the root cause was determined to be: Nursing staff will verbalize how a code status is verified via POLST form and procedure to carry out based upon full code or DNR status. All charts will have current and updated POLST forms in place. 1) Licensed Nurses will verbalize Advanced Directives choice and explanation of full code versus DNR details. Corrective actions taken were provide education to nursing staff in regard to the POLST form, verification of code status before initiation of interventions if resident is unresponsive, full code versus DNR status and procedure to carry out accordingly. In addition, an audit was conducted on [DATE] of current resident's charts to ensure the POLST forms were complete. Monitoring included weekly random audits for nursing staff for 4 weeks on identification of how to verify code status and initiate a code status according to the policy and procedure. a Interview on [DATE] at 3:05 PM with the staff development coordinator (SDC) revealed she had educated the licensed nurses on [DATE] following the incident. Review of an Inservice Education Summary form dated [DATE] showed 26 nurses (RNs and LPNs) had received training on the topic of POLST/CPR/Full code protocol. b. Review of the facility's audit documentation showed 26 licensed nurses responded accurately to facility interviews regarding the facility's POLST/CPR/Full Code protocol. c. Review of the facility's audit documentation showed the audit of all current resident charts for completed POLST forms was concluded on [DATE]. | 2020-09-01 |