Failure to Verify Code Status Leads to Unmet Resident Wishes
Penalty
Summary
Licensed nurses at the facility failed to adhere to the policy and procedure for verifying code status in an emergency situation for a resident who was receiving hospice care. The resident, who had a history of severe cognitive impairment and was on hospice care, had a documented Full Code status, which was not honored when she was found unresponsive. The failure to verify the resident's code status led to the omission of life-saving measures, as the staff assumed she was a Do Not Resuscitate (DNR) due to her hospice status. On the evening of the incident, the resident was found unresponsive in her bed by RN A, who did not verify the resident's code status and failed to initiate cardiopulmonary resuscitation (CPR) as per the resident's wishes. RN A, along with RN C, provided postmortem care without calling a Code Blue or contacting emergency medical services. RN A later acknowledged that she was unaware of the resident's Full Code status and admitted that she did not check the resident's chart, which would have indicated the need for resuscitative measures. The RN Supervisor B, who was informed of the resident's passing, also assumed the resident was a DNR due to her hospice care and did not verify the code status. This assumption was incorrect, as the resident's husband had confirmed her desire to be a Full Code. The facility's failure to ensure staff followed procedures related to honoring an advance directive resulted in Immediate Jeopardy, as it placed all residents receiving hospice care at risk of not having their wishes honored.
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 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 by 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 by that residents receiving hospice service does not equate to the resident being a 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 on. 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, ie 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 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 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.
Removal Plan
- Administrator and DON initiated an investigation into discrepancies in resident #1's chart regarding her passing.
- The facility completed an in-house audit for code status of all residents.
- Licensed nurses were educated on the facility's policy and procedure for verifying code status prior to initiating or withholding lifesaving procedures including Code Blue drills to validate comprehension.
- Resident #1's husband was notified regarding discrepancies found and investigation.
- Law enforcement and elderly affairs were notified out of abundance of caution. An immediate report was filed with the state agency.
- A record review of resident #1 was completed by the DON.
- Social Service Director completed an audit of all current residents' code status.
- RN Supervisor B and RN A received personal training from the DON on checking residents' code status and starting Code Blue procedures. Both nurses were suspended pending investigation.
- Nursing Supervisors received individual education on checking code status when residents were unresponsive and initiating Code Blue procedures from the DON.
- A text was sent to all nursing staff containing education regarding if a resident was found unresponsive, it was the responsibility of the nurse to verify code status in the chart and initiate if Full Code.
- 64 of 81 total licensed nurses received education.
- 48 out of 81 nurses completed the education.
- An additional 10 of 81 nurses completed their education.
- An additional 6 of 81 nurses completed their education.
- Remaining licensed nurses would receive education prior to working next shift.
- New hire nurses at the facility would receive the above education during orientation and prior to working an assignment.
- Mock Code Blue drills were conducted to validate education received was retained.
- Starting weekly code blue drills to be conducted on varying shifts and days to include all shifts.
- Random weekly audits to be completed to ensure staff follow facility procedure for verifying residents' code status prior to initiating or withholding.
- New hire nurses at the facility to participate in a mock code drill during orientation and prior to working an assignment.
- Ad Hoc Quality Assurance and Performance Improvement (QAPI) held to review the recommendations made from the investigation. The QAPI committee reviewed education in progress and code blue drills.