Failure to Verify Code Status in Emergency
Penalty
Summary
The deficiency involved a failure by licensed nurses to follow the facility's policy and procedure regarding the verification of a resident's code status in an emergency situation. A resident, who was receiving hospice care, was found unresponsive in her bed by RN A. Despite the resident's documented status as a Full Code, RN A did not verify this information and failed to initiate life-saving measures. Instead, RN A assumed the resident was a Do Not Resuscitate (DNR) due to her hospice care status and proceeded with postmortem care without calling Emergency Medical Services or a Code Blue. The resident's medical records clearly indicated her Full Code status, which had been confirmed in discussions with her husband and documented in her care plan and physician orders. However, RN A, along with RN C and RN Supervisor B, did not verify the resident's code status as per the facility's procedure. This oversight led to the resident not receiving the resuscitative measures she had requested, as her wishes were not honored due to the staff's failure to check her chart and confirm her code status. The incident placed all residents receiving hospice care at risk of not having their wishes honored, resulting in Immediate Jeopardy. The facility's policy required staff to provide basic life support in accordance with the resident's advance directives, but this was not followed. The deficiency was identified as having the potential for more than minimal harm, although it was not considered Immediate Jeopardy after the initial finding.
Plan Of Correction
Preparation and execution of this plan of correction does not constitute admission or agreement of the facts alleged or conclusion set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by both federal and State laws. 1. Resident #1 expired on Nurse A and Nurse B were suspended immediately. 2. Residents who, in house in the past 3 months were reviewed to ensure all advanced directives were followed. This was completed by and no discrepancies were noted. All Code statuses were followed as ordered. Social services validated all current residents' code status and validated the status is correct according to their individual wishes on Nurse A is no longer employed at the facility and the results of the investigation were reported to the board of nursing. Education was provided to Nurse B prior to returning to work. 3. Facility completed code blue drills each shift 72 hours post incident and re-educated staff on our code blue policies. Completed by Staff received an electronic communication with immediate education on resident rights, advanced directives, and validating residents' code status in their chart prior to calling a code blue on. The nursing supervisors were re-educated by the ADON and/or designee regarding verifying code status on any resident found without vital signs or unresponsive prior to having contact with residents. Licensed nurses have been in-serviced by the ADON and/or designee that residents receiving hospice service does not equate to the resident being a full code and staff must check all residents' code status when they are found unresponsive. This was completed prior to having contact with residents. A new process was put into place where the Facility will add residents' full code status order to the MAR to be signed off every shift by the nurse if the patient is on hospice and is a full code to increase visibility to nursing staff. Written Code blue competency tests were administered to the licensed staff and CNAs and validated by the DON/Designee. Regularly scheduled staff completed by and PRN staff will complete testing prior to having contact with residents. Any new staff members will receive code blue education and competency testing during their orientation days before working the floor alone ongoing. Facility staff were re-educated by the ADON and/or designee of the advance directive processes; neglect and; resident's rights regarding treatment and advance directives; communication of code status; and physician notification of changes. Regularly scheduled staff completed by and PRN staff will complete education prior to having contact with residents. 4. Facility completed ad hoc QAPI on and continued with ad hoc QAPI for the following three weeks on and Code blue drills varying day/shift will continue weekly for one month, followed by three drills a month varying day/shift monthly thereafter to be completed by DON/designee. Random weekly checks will be completed by DON and/or designee for three months to ensure the nurses & CNAs are competent with checking the residents' code status when a resident is found unresponsive, regardless of status, i.e., Hospice, STR, etc. ADON and/or designee will complete weekly audits of current hospice residents to ensure there is a separate order being signed off stating the resident's full code status if appropriate. Audits will be completed weekly for one month, followed by monthly for two months. DON and/or Designee will audit any new hires to ensure a code blue competency test has been satisfactorily completed monthly x3 months. Incident was reviewed during QAPI meeting on and the committee agrees with this corrective action. Results of the previously mentioned audits including checking the code status, code blue drills, auditing of hospice resident orders, physician notification of change of condition for full code hospice residents, and new hire competencies will be submitted to the Administrator and brought to QAPI for review and evaluation monthly. Audits will continue for a minimum of 3 months or until significant compliance has been met as deemed by the QAPI committee.