cms_WY: 46
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 46 | GRANITE REHABILITATION AND WELLNESS | 535013 | 3128 BOXELDER DRIVE | CHEYENNE | WY | 82001 | 2019-10-25 | 678 | K | 1 | 0 | GM1D11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, staff interview, review of policy and procedures, facility incident report review, review of the facility's Standards for Code Blue and review of professional standards, the facility failed to ensure basic life support was administered to 1 of 1 sample resident (#2) who required emergency life support, and failed to ensure staff were familiar with facility policies related to CPR. The facility failed to implement the advance directive for 1 of 1 sample resident (#2) that expired in the facility that had elected to receive CPR in the event of cardiopulmonary arrest. At the time of the survey 53 out of 117 residents had elected to receive CPR in the event of cardiopulmonary arrest. This resulted in a determination of an immediate jeopardy situation and substandard quality of care for these residents. 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 was reviewed with the resident on [DATE], [DATE], [DATE], and [DATE] and the resident elected to maintain a full code status. Review of an unsigned and undated Standards for Code Blue provided by the facility on [DATE] at 9:40 AM showed Any person who discovers that a resident is unresponsive should immediately notify the employee in charge. Steps to take immediately: 1. Activate the Code Blue a. To activate the Code Blue in your Center: i. Announce Code Blue and the location of the unresponsive resident by shouting or paging overhead (#39) at least three times .ii. Establish the Resident's Code status . Interview with the administrator on [DATE] at 1:15 PM revealed the Standards for Code Blue was a process the facility had been using forever. 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 had 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 incident report submitted to the State Survey Agency on [DATE] showed the incident type was documented as Failure to provide Services and stated the resident was a Full Code, and confirmed the facility staff failed to initiate CPR. The documentation further showed RN #1 was immediately educated regarding Wyoming POLST and full code. The facility developed a plan of action and as part of the action plan had started educating all licensed nurses and implemented random daily nurse interviews regarding the POLST and full code status. h. 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. However, the action plan failed to address the unavailability of the nurse and the CNA's failure to activate a Code Blue to obtain assistance. i. 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. j. 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; however she had realized in the last week CNAs also needed to be educated. This education was to include the corporation's policy of only licensed nurses being allowed to perform CPR; and if a resident was found unresponsive they were to find a nurse, call code blue, retrieve the resident's chart, and return to the resident's room. The intercom system was activated by dialing #39 on the telephone. Further, she had begun the process to educate the CNAs individually and planned to finish at the all-staff in-service which was to be held on [DATE]. k. Review of an undated Inservice Education Summary form provided by the SDC showed the topic was CPR, codes, POLST. Further review showed 15 CNAs and 2 HSAs had completed the education. Review of the facility's personnel roster (updated on [DATE]) showed the facility employed 50 CNAs (31 full-time, 3 part-time, 13 PRN, 1 unspecified, 2 restorative aides) and 13 hospitality aides. l. Interviews with 9 CNAs on [DATE] between 1:20 PM and 4:08 PM revealed how they would respond if they found an unresponsive resident. Seven of the 9 CNAs described a response that was inconsistent with the facility's Standards for Code Blue, as evidenced by the following: i. CNA #2 stated she would yell for help, try CPR, and if no one came would run out of the room to get help. ii. CNA #3 stated she would check on the resident and then go get a nurse. iii. CNA #4 stated she would yell code and then find a nurse. iv. CNA #5 stated she would yell code blue and find a nurse. In addition, if she was unable to find a nurse she would call 911 and start CPR. v. CNA #7 stated she would notify the nurse, call a different floor if a nurse was not available, and check the resident's code status in their chart. vi. CNA #9 stated she would push the call light, find a nurse, and start compressions. In addition, if she could not find a nurse she would ask another CNA for assistance. vii. CNA #10 stated she would look for signs of life, call for a nurse, stay in the resident's room, and start CPR. In addition, she thought #39 was used to activate the intercom, however she was not sure. m. 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 . n. Interview with the administrator on [DATE] at 4:52 PM revealed the facility did not have a policy in regard to the procedure to follow if a resident, visitor, or staff member was found unresponsive. In addition, the administrator stated the Advance Directive policy and the CPR policy were sufficient and a policy that outlined the steps to take when a resident was found unresponsive was not necessary because it was a standard of care. o. Review of the POLST/Code Status/Full Code audit sheets updated on [DATE] showed 53 of the 117 residents had a code status of Full Code. This number was confirmed on [DATE] at 5:30 PM by the district DON 2. 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)). 3. 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. 4. On [DATE] at 6 PM, the administrator was notified of the immediate jeopardy related to the facility's failure to initiate CPR for resident #2, and failure to ensure facility staff were familiar with facility policies or standards of care related to CPR. The facility's removal plan included the following corrective actions: a. Education will be provided to all staff including nursing, dietary, activities, and housekeeping in regard to the WyoPOLST form, verification of code status before initiation of interventions if a resident was unresponsive, Full Code versus DNR status, announcement of the standards for code blue, and CPR initiated by a licensed nurse only. The education was to begin on [DATE] at 6 PM and continue until all staff had been educated prior to work. b. An audit was conducted on [DATE] of all current residents to verify their code status and physician signature. c. An audit was conducted on [DATE] on all current employees to verify current CPR/BLS certification. d. A Mock Code Blue Drill was conducted on [DATE] at 7 AM and would continue every shift for the next 24 hours and then one time per week for 4 weeks, monthly for two months, and once per quarter. e. A monitoring system was put into practice to ensure staff were able to identify code status and initiate a code. In addition, audits would be conducted to ensure current residents' POLST forms were complete; licensed staff had current CPR/BLS certification, and a CPR-certified nurse was on duty at all times. The removal plan was accepted on [DATE] at 1:44 PM, and the immediate jeopardy was removed on [DATE] at 2:40 PM. However, deficient practice remained at a scope and severity of G (Actual harm that is not immediate jeopardy). | 2020-09-01 |