Failure to Provide Timely Medical Intervention and Emergency Response
Penalty
Summary
The facility failed to accurately assess and provide timely and necessary medical intervention for residents experiencing acute changes in condition. In multiple instances, staff did not notify physicians or provide adequate interventions when residents exhibited significant symptoms such as low oxygen saturation, shortness of breath, hypotension, and altered mental status. For example, one resident with a history of diabetes, COPD, heart disease, and dependence on supplemental oxygen was found with an oxygen saturation as low as 71%, but the nurse on duty did not notify the physician or escalate care. The resident's condition did not improve after initial interventions, and there was no evidence of further medical action before the resident was later found unresponsive. The facility also failed to provide basic life support (BLS) and cardiopulmonary resuscitation (CPR) in accordance with standards of practice. In several cases, staff initiated CPR without first checking for a pulse, did not use a backboard to ensure effective compressions, and delayed calling emergency medical services (EMS). In one incident, a nurse took over 30 minutes to call 911 after a resident was found unresponsive, and in another, a nurse left an unresponsive resident alone to seek help from another floor, further delaying emergency response. Staff interviews revealed a lack of knowledge regarding code team assignments, CPR protocols, and the use of emergency equipment such as crash carts and AEDs. Additionally, the facility did not maintain adequate staffing or effective systems for emergency response. There was no staffing plan for a newly opened unit, and staff had to physically leave the unit to obtain assistance during emergencies due to the absence of a communication system. Observations confirmed that at times, no staff were present on certain units, and some staff were not CPR certified. These failures resulted in actual harm and subsequent deaths for multiple residents who experienced acute changes in condition.
Removal Plan
- Educated the Administrator, DON, RDCS, and RDO on the facility CPR policy, emergency response processes, and code blue flow sheets related to how to respond to emergency situations and to notify others for help by use of walkie-talkie or overhead paging system.
- Provided education to department heads (Activities Director, Housekeeping Services Director, Assistant Director of Nursing, Medical Records Director, Maintenance Director, Director of Social Services, Minimum Data Set Director, Dietary Manager, Human Resources Director, Wound Care Nurse) on the CPR policy, emergency response processes, and code blue flow sheets.
- Educated all staff (CNAs, LPNs, RNs, housekeeping, receptionists, therapists, activities staff) on the facility CPR policy, emergency response processes, and code blue flow sheets.
- Assessed all residents for any acute changes in condition.
- Provided CPR recertification to nurses; removed nurses from the schedule until they received updated CPR recertification.
- Audited crash carts to ensure they were stocked and readily available for an emergency situation.
- Educated all clinical staff and validated that code statuses were updated; updated code status orders for three residents.
- Met to discuss future staffing for when closed units opened.
- Initiated education to all clinical staff, scheduler/HR, DON, and Administrator to ensure there was always a minimum of one staff member on the first floor.
- Implemented mock code blues on alternating shifts; audits to be documented on the code blue flow sheet and reviewed during QAPI.
- Added CPR policy training to new hire orientation and with staff; DON responsible for ensuring all new hires received the information and monitoring education.
- Added education topics to all new hire orientation training; ensured employees oriented at sister facilities completed all education topics prior to starting on the floor.
- Reviewed all resident care plans for accuracy.
- Ran audit report on all residents to assess for change of condition that was not addressed; DON/designee to audit reports.
- Completed a mock code blue drill to identify areas of struggle.
- Administered a hands-on and written post-test for all nurses working; demonstrated use of overhead page, locating code status in the electronic medical record, and use of walkie talkies; staff performed return demonstration.
- Initiated audit of the bed board code status to be reviewed and updated by the DON; results reviewed through QAPI.
- DON or designee to audit reports from the electronic medical record system to audit for any resident changes in condition; results reviewed through QAPI.
- Conducted interview questionnaires with first floor staff on how to obtain help during emergency situations; results reviewed through QAPI.
- Audited crash cart by the DON or designee to ensure all needed supplies are contained; results reviewed through QAPI.
- Audited first-floor staffing to ensure scheduled staff members are present as scheduled; results reviewed through QAPI.
- Provided additional one-on-one education to LPN #521 regarding what the Code Blue form was and when to utilize it.