Failure to Provide Timely Emergency Care Due to Inadequate Staff Training
Penalty
Summary
Forest Park Nursing and Rehabilitation was found to be non-compliant with federal and state regulations due to a failure to protect residents from neglect. The facility did not provide adequate orientation and training to agency staff, which resulted in a delay in emergency services for a resident who became unresponsive. The resident, who had a history of alcoholic cirrhosis, congestive heart failure, Type 2 Diabetes Mellitus, and pneumonia, was found unresponsive and without a pulse. Despite having a POLST form indicating a full code status, there was confusion among staff due to the presence of a DNR bracelet and conflicting information in the resident's electronic record. The incident involved multiple staff members, including an LPN and an RN, who were agency staff. The LPN assessed the resident and informed the RN supervisor of the resident's condition, but there was a lack of follow-up and coordination in responding to the emergency. The RN supervisor, upon finding the resident unresponsive, did not immediately initiate CPR and instead left the room to obtain a crash cart. This delay, coupled with the absence of staff in the resident's room when EMS arrived, contributed to the failure to provide timely emergency care. Interviews with staff revealed that agency personnel were not familiar with the facility's emergency procedures, including the location of crash carts and oxygen supplies. Additionally, there was no system in place to ensure that agency staff were oriented to the facility's policies and procedures. This lack of training and orientation placed 48 other residents at risk, as they would require emergency intervention if found unresponsive.
Plan Of Correction
1. Facility is unable to retroactively correct issue for Resident #1. 2. DON/Designee audited current resident code status to ensure the order and POLST match on 2/13/25. There are no residents with hospital wrist bands and no special instructions in PCC regarding code status. DON/Designee provided immediate orientation/education to licensed agency and facility staff currently working in the facility on 2/13/25 regarding facility policies on resident code status, copy of floor plan including location of crash carts, oxygen, and other emergency supplies as well as how to meet EMS at the front door after calling 911 if receptionist is not on duty. Education included the following information: if a resident has change in condition, the nurse refers to the order and the POLST. If there is no order and no POLST, resident is automatic full code. If resident is a full code and CPR is to be initiated, code is called immediately. All available licensed staff are to be present and CPR initiated and not stopped until EMS arrives and instructed to do so. Do not freely type a special instruction in PCC regarding code status. When a resident is admitted or readmitted to facility from the hospital, all hospital bracelets are to be removed. This education/orientation was forwarded to agencies 2/14/25 for signatures prior to start of shift. DON/Designee will provide orientation/education to any additional licensed agency and facility staff prior to the start of their shift to include facility policies on resident code status, copy of floor plan including location of crash carts, oxygen, and other emergency supplies as well as how to meet EMS at the front door after calling 911 if receptionist is not on duty. Education will include the following information: if a resident has change in condition, the nurse refers to the order and the POLST. If there is no order and no POLST, resident is automatic full code. If resident is a full code and CPR is to be initiated, code is called immediately. All available licensed staff are to be present and CPR initiated and not stopped until EMS arrives and instructed to do so. Do not freely type a special instruction in PCC regarding code status. When a resident is admitted or readmitted to facility from the hospital, all hospital bracelets are to be removed. Directed in-service was conducted by approved company for F-tag 600 Freedom from Abuse, Neglect, and Exploitation will be conducted on 2/27/25 for licensed nursing staff. Staff will show evidence of understanding by completion of quiz. Staff that cannot attend directed in-service will be provided with education and test to complete prior to working on next scheduled shift. 3. HR Director/Designee will review schedule daily to ensure licensed agency and staff scheduled have completed the orientation or will complete prior to start of shift for new agency staff. As part of new admission process, licensed nurse will review code status documentation to ensure facility code status policy is followed. As part of the post admission record review for new admissions, the IDT will review new admission records to ensure code status documentation reflects resident's correct code status and the facility code status/POLST process was appropriately followed. 4. DON/Designee will audit 10 resident charts weekly for 2 months, then monthly for 3 months to ensure residents have code status in order and if there is a POLST that it matches the order. NHA/Designee will audit licensed agency staff for completed orientation weekly for 2 months, then monthly for 2 months. Results of audit will be reviewed by QAPI committee for any recommendations. DON/Designee will provide orientation/education to any additional licensed agency and facility staff prior to the start of their shift to include facility policies on resident code status, copy of floor plan including location of crash carts, oxygen, and other emergency supplies as well as how to meet EMS at the front door after calling 911 if receptionist is not on duty. Education will include the following information: if a resident has change in condition, the nurse refers to the order and the POLST. If there is no order and no POLST, resident is automatic full code. If resident is a full code and CPR is to be initiated, code is called immediately. All available licensed staff are to be present and CPR initiated and not stopped until EMS arrives and instructed to do so. Do not freely type a special instruction in PCC regarding code status. When a resident is admitted or readmitted to facility from the hospital, all hospital bracelets are to be removed.
Removal Plan
- DON/Designee will provide orientation/education to licensed agency and facility staff to include facility policies on resident code status, copy of floor plan including location of crash carts, oxygen, and other emergency supplies as well as how to meet EMS at the front door after calling 911 if receptionist is not on duty.
- Education will include information: if a resident has change in condition, the nurse refers to the order and the POLST. If there is no order and no POLST, resident is automatic full code. If resident is a full code and CPR is to be initiated, code is called immediately, all available licensed staff are to be present and CPR initiated and not stopped until EMS arrives and instructed to do so.
- Do not freely type a special instruction in PCC regarding code status.
- When a resident is admitted or readmitted to facility from the hospital, all hospital bracelets are to be removed.
- Human Resources Director/Designee will review schedule to ensure licensed agency and staff scheduled have completed the orientation or will complete prior to start of shift for new agency staff.
- This education/orientation will be forwarded to agencies for signatures prior to start of shift.
- DON/Designee will audit current resident code status to ensure the order and POLST match, there are no residents with hospital wrist bands and no special instructions in PCC regarding code status.
- DON/Designee will audit resident charts to ensure resident have code status in order and if there is a POLST that it matches the order.
- NHA/Designee will audit licensed agency staff for completed orientation.
- Results of audit will be reviewed by QAPI committee for any recommendations.