Birmingham Nursing And Rehabilitation Center East

Penalty

Inspection fine: $24,83454 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility's Quality Assurance Performance Improvement (QAPI) committee failed to address all causal factors related to four staff members providing Cardiopulmonary Resuscitation (CPR) to a resident with an Advanced Directive for Do Not Resuscitate (DNR). The QAPI committee also failed to notify the Governing Body of the adverse event. The incident involved a resident whose end-of-life wishes were not honored, as licensed staff did not review the resident's chart for code status prior to initiating CPR. Additionally, the resident's nurse was not in the facility at the time of the code and could not immediately locate the appropriate paperwork to identify the resident's DNR status when she returned. All licensed staff performing CPR on the resident did not have current CPR certification at the time of the incident. The facility did not develop or implement an action plan to prevent recurrence of such events. The incident occurred when a Certified Nursing Assistant (CNA) noticed the resident's breathing was shallow and their color had changed. The CNA called for help, and a Registered Nurse (RN) and a CPR Instructor responded. The RN began chest compressions, and the CPR Instructor called a Code Blue. The resident's nurse returned to the facility during the code but was unable to verify the resident's DNR status. The resident expired after CPR was performed. The QAPI committee's documentation did not include a performance improvement plan or any corrective actions to address the incident. Interviews with staff revealed that the nurses involved in the incident assumed the code status had been checked and proceeded with CPR. The Director of Nursing (DON) confirmed that the facility's policy on CPR and Advance Directives was not followed. The Administrator acknowledged that the incident was discussed in a QAPI meeting, but no performance improvement plan was developed. The Regional President of the facility's management company was not notified of the adverse event until much later and expressed concern that the facility did not honor the resident's end-of-life wishes. The incident was not reported to the State Agency as required.

Removal Plan

• Clinical operations (Clin-Ops) nurse will in-service the Executive Director (ED), Director of Nursing (DNS) and Quality Assurance and Performance Improvement (QAPI) committee on new policy A.3a. titled, Accident/Incident & Adverse Events.
• ED and DNS will in-service 100% of licensed staff on Accident/Incident & Adverse Event Documentation and Investigation. No licensed staff member will be allowed to work until completion of in-service.
• System to be followed per policy, Notification and Documentation in the Resident's Medical Record: a. The Licensed Nurse shall place the resident on the 24-Hour Report, document the incident, and notify the supervisor and Director of Nursing for follow through prior to the end of shift in which the accident/incident or adverse event occurs.
• The Licensed Nurse may complete a Nurses' Note and update the Resident Care Plan.
• The Nurse's Notes could contain the following documentation.
• The Executive Director/Director of Nursing will notify the State Department of Health in accordance with reporting guidelines in the event the accident/incident is reportable.
• The Executive Director/Director of Nursing will monitor, track, and trend the accident/incident and adverse event through utilization of the electronic medical record quality assurance reports. These reports will be reviewed through the weekly Risk Review Meeting attended by the Interdisciplinary team (IDT). The event log will be reviewed in the Quality Assurance Performance Improvement (QAPI) meeting.
• Through investigation and root cause analysis, performance improvement plans will be implemented to correct all causal factors of the adverse event.

Penalty

Inspection fine: $24,83454 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to honor a resident's Advanced Directive for end-of-life wishes. The resident, identified as RI #159, had an Advanced Directive and an active physician's order for Do Not Resuscitate (DNR) status. On the evening shift, the resident was found unresponsive by a Certified Nursing Assistant (CNA). The first licensed responder, a Registered Nurse (RN), initiated CPR without checking the resident's code status, which was against the facility's protocol. Other staff members, including a CPR Instructor, a Licensed Practical Nurse (LPN), and another RN, also participated in the resuscitation efforts without verifying the resident's medical record for an Advance Directive. The resuscitation efforts continued until another LPN identified the DNR order, but by then, the resident had been subjected to various invasive procedures and expired shortly after. Interviews with the staff revealed that none of the involved personnel checked the resident's code status before initiating CPR. The RN who first responded admitted to not verifying the code status and assumed the resident was a full code. The CPR Instructor and other nurses also did not check the resident's medical record for the DNR order. The facility's policy required that the code status be verified before initiating CPR, but this was not followed. The failure to honor the resident's end-of-life wishes was likely to cause serious harm or impairment, placing the resident in immediate jeopardy. The deficiency was identified through a complaint received by the Alabama Department of Public Health. The facility's policies on Resident Bill of Rights, Advance Directives, and CPR were reviewed, and it was found that the staff did not adhere to these policies. The incident was corroborated by medical records, staff interviews, and the facility's own documentation. The failure to follow the resident's Advanced Directive and the facility's protocols led to the resident being subjected to unwanted resuscitative measures, which was against their documented end-of-life wishes.

Removal Plan

• Emergency Quality Assurance committee meeting held to review and approve deficiency action plan for F 578 and the dot sticker system to identify code status.
• Medical Director notified of IJ deficiency: F 578.
• All residents with Do Not Resuscitate (DNR) orders have the potential to be affected, the facility completed 100% code status audit to ensure each resident's code status verified.
• The chart spine will have an orange sticker placed stating DNR and an orange dot on the name tag on the resident's door to indicate DNR status; also, a green sticker stating FULL CODE will be placed on the spine of the chart and a green dot on the name tag of the resident's door to indicate FULL CODE status.
• This will allow for easy verification of residents who have chosen DNR status. DNR wishes will be easily recognized by any staff member without having to go to the medical record or the resident's care plan.
• ED, DNS and Clin-ops will in-service 100% of staff on the dot/sticker system. No staff member will be allowed to return to work until in-service complete.
• ED, DNS and Clin-ops completed 100% audit of care plans to verify code status is care planned.
• Development and implementation of a new policy titled Accident/Incident & Adverse Events to include feedback, documentation, and investigation of all resident accidents and adverse events.

Penalty

Inspection fine: $24,83454 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that CPR was not initiated for a resident with a Do Not Resuscitate (DNR) order. The incident involved Resident Identifier (RI) #159, who had an Advanced Directive directing staff to withhold lifesaving measures, including CPR. On the date of the incident, RI #159 was found by a Certified Nursing Assistant (CNA) in respiratory distress and unresponsive. Despite the resident's DNR status, a Registered Nurse (RN) initiated CPR and called for additional assistance without verifying the resident's code status. Multiple staff members, including another RN, a Licensed Practical Nurse (LPN), and a CPR Instructor, assisted in the resuscitation efforts without checking the resident's DNR order. CPR was performed for approximately 10 minutes until Emergency Medical Services (EMS) arrived and continued advanced cardiac life support until they were informed of the DNR status by another LPN. RI #159 expired shortly after the resuscitation efforts were terminated by EMS. The facility's policy on Cardio Pulmonary Resuscitation (CPR) was not followed, as staff failed to verify the resident's code status before initiating CPR. Interviews with the involved staff revealed that none of them checked the resident's chart for the DNR order before starting resuscitation efforts. The Director of Nursing (DON) confirmed that the policy required staff to check the resident's code status and follow the resident's wishes as documented in their Advanced Directives. The failure to adhere to this policy resulted in the initiation of unwanted lifesaving measures on a resident who had explicitly chosen to forgo such interventions. Additionally, the facility did not ensure that all pertinent information related to the resuscitation efforts was documented in the medical record. The DON acknowledged that the required documentation, including the time CPR was initiated and other critical details, was not recorded. Furthermore, it was discovered that one of the staff members who provided CPR did not have a current CPR certification at the time of the incident. These deficiencies were identified during the investigation of a complaint received by the Alabama Department of Public Health, which highlighted the facility's non-compliance with state regulations and the potential for serious harm to residents.

Removal Plan

• Emergency Quality Assurance committee meeting held to review and approve deficiency action plans F867, F578, F725, and F678 and the dot sticker system to identify code status.
• Medical Director notified of IJ deficiencies: F867, F578, F726, F725 AND F678.
• All residents with Do Not Resuscitate (DNR) orders have the potential to be affected, the facility completed 100% code status audit to ensure each resident's code status verified.
• An orange sticker was placed on the spine of the resident's chart stating DNR and an orange dot on the name tag on the resident's door to indicate DNR status; also, a green sticker stating FULL CODE was placed on the spine of the chart and a green dot on the name tag of the resident's door to indicate FULL CODE status.
• The AED, DNS, and Clin-ops completed and audit of all resident's charts and doors to ensure charts and doors were properly marked with code status.
• This will allow for easy verification of residents who have chosen DNR status. DNR wishes will be easily recognized by any staff member without having to go to the medical record or the resident's care plan.
• ED, DNS, and Clin-ops will in-service 100% of staff on the dot/sticker system. No staff member will be allowed to return to work until in-service complete.
• ED, DNS, and Clin-ops completed 100% audit of care plans to verify code status is care planned.
• Development and implementation of a new policy titled Accident/Incident & Adverse Events to include feedback, documentation, and investigation of all resident accidents and adverse events.

Penalty

Inspection fine: $24,83454 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide sufficient nursing staff to consistently meet the needs of the residents, specifically affecting one resident who was found unresponsive. On the date of the incident, the South Unit was understaffed around 8:20 PM when a resident was found unresponsive by a CNA. Although two nurses were scheduled to be working on the unit, one nurse had left early after working nearly 15 hours, and the other nurse was in the parking lot. The CNA had to leave the unresponsive resident to summon nurses from another unit, who then initiated CPR without first checking the resident's medical record for the DNR order that was in effect. The resident involved had a history of Chronic Obstructive Pulmonary Disease (COPD), Type Two Diabetes Mellitus with Diabetic Neuropathy, Hepatic Failure, and Congestive Heart Failure. The resident's physician orders included a DNR status. When the CNA found the resident unresponsive, she sought help from another unit, leading to a delay in care. The nurses who responded initiated CPR without verifying the resident's DNR status, which was later discovered, resulting in the cessation of resuscitation efforts. Interviews with staff revealed that the nurse assigned to the resident had stepped out, leaving the unit without any nursing staff. The facility's staffing schedule and punch detail report confirmed that one nurse had clocked out early, and the other was outside in her car. The Director of Nursing (DON) and the Administrator acknowledged the staffing issues and the failure to honor the resident's DNR status. The incident highlighted significant lapses in staffing and communication, leading to the inappropriate administration of CPR on a resident with a DNR order.

Removal Plan

• Emergency Quality Assurance committee meeting held to review and approve deficiency action plans F 867, F 578, F 725, and F 678 and the dot sticker system to identify code status.
• Medical Director notified of IJ deficiencies: F 867, F 578, F 726, F 725 and F 678.
• All residents with Do Not Resuscitate (DNR) orders have the potential to be affected, the facility completed 100% code status audit to ensure each resident's code status verified.
• An orange sticker placed stating DNR was placed on the spine of each resident's chart and an orange dot was placed on the doorway tag of the resident's room to indicate DNR status. A green sticker will be place on the spine of each resident's chart stating, FULL CODE and on the doorway name tag of the resident's room a green dot was placed to indicate resident as a full code. This was completed by medical records. ADE, DNS, and Clin-ops completed audit on all resident's chart and doors to ensure charts and doors were properly marked with code status. This will allow for easy verification of residents who have chosen DNR. DNR wishes will be easily recognized by any staff member without having to go to the medical record or the resident's care plan.
• ED, DNS, and Clin-ops will in-service 100% of staff on the dot/sticker system. No staff member will be allowed to return to work until in-service complete.
• ED, DNS, and Clin-ops completed 100% audit of care plans to verify code status is care planned.
• DNS will validate staffing for each day and each shift prior to the beginning of shift. DNS will be notified of any nonattendance of required shifts, such as (leaving early and sickness) to ensure replacement is obtained.
• Development and implementation of a new policy titled Accident/Incident & Adverse Events to include feedback, documentation, and investigation of all resident accidents and adverse events.

Penalty

Inspection fine: $24,83454 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that staff were trained and verified in their competencies to respond to emergent situations according to the facility's CPR policy. On the specified date, a resident identified as RI #159 was found unresponsive by a CNA. The staff who responded initiated CPR without first verifying the resident's code status in the medical record. Four staff members, including two RNs, an LPN, and a CPR instructor, assisted during the code but did not check the resident's code status. As a result, CPR was provided for nearly an hour despite the resident having a Do Not Resuscitate (DNR) order. The facility's policy required that CPR be initiated only if there was no DNR or Advance Directive identified. However, the staff failed to follow this procedure. The incident report and interviews revealed that the staff did not verify the resident's code status before starting CPR. Additionally, one of the LPNs who performed CPR did not have a current CPR certification. The EMS report confirmed that CPR was continued until a signed DNR was produced, at which point all life-saving efforts were stopped. The deficiency affected RI #159, who had multiple diagnoses including Chronic Obstructive Pulmonary Disease (COPD), Type Two Diabetes Mellitus with Diabetic Neuropathy, Hepatic Failure, and Congestive Heart Failure. The facility's failure to verify the resident's code status and ensure that all staff were trained and certified in CPR led to the inappropriate administration of CPR, contrary to the resident's documented wishes and physician orders.

Removal Plan

• Emergency Quality Assurance committee meeting held to review and approve deficiency action plans F867, F578, F726, F725, and F678 and the new dot sticker system to identify code status.
• Medical Director notified of IJ deficiencies: F867, F578, F726, F725 AND F678.
• All residents with Do Not Resuscitate (DNR) orders have the potential to be affected, the facility completed 100% code status audit to ensure each resident's code status was verified.
• An orange sticker placed stating DNR was placed on the spine of each resident's chart and an orange dot was placed on the doorway tag of the resident's room identified as DNR. A green sticker was placed on the spine of each resident's chart and on the doorway name tag of the resident's room identified as a full code.
• This will allow for easy verification of residents who have chosen DNR. DNR wishes will be easily recognized by any staff member without having to go to the medical record or the resident's care plan.
• ED, DNS, and Clin-ops will in-service 100% of staff on the dot/sticker system. No staff member will be allowed to return to work until in-service complete.
• ED, DNS, and Clin-ops completed 100% audit of care plans to verify code status is care planned.
• The ED, DNS, and Clin-ops completed 100% audit of all licensed nurses CPR certification. No licensed nurse will be allowed to work at facility unless certified in CPR.

Penalty

Inspection fine: $24,83454 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident with moderate cognitive impairment was assessed for self-administration of medication before being given a rectal suppository to self-administer. On 12/06/2023, a Licensed Practical Nurse (LPN) handed the suppository to the resident, who had not been administering their own medications and had not received any education on administering the suppository. The resident's quarterly Minimum Data Set (MDS) assessment indicated a Brief Interview for Mental Status (BIMS) score of 12/15, showing moderate cognitive impairment. The resident had diagnoses including Schizoaffective Disorder (Bipolar Type) and Parkinson's Disease. The Director of Nursing (DON) confirmed that the facility's system for determining a resident's safety in self-administration of medications involved evaluating residents based on their BIMS scores and requiring a physician's order. The resident in question did not have a physician's order for self-administration and had not been assessed and approved for it. The DON acknowledged that leaving the suppository with the resident could lead to various issues, such as the medication being dropped, flushed, or resulting in a medication error.

Penalty

Inspection fine: $24,83454 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to report accurate staffing data to CMS for the quarter from October 1, 2023, to December 31, 2023. The Payroll Based Journal (PBJ) report for this period indicated a one-star staffing rating and excessively low weekend staffing. During an interview on May 9, 2024, the Executive Director/Administrator explained that the human resources staff transmits information from staff fingerprints as they clock in to the support office, which then submits the data to CMS. The low staffing report was attributed to ancillary staff possibly not scanning in when they worked as Certified Nursing Assistants (CNAs). Despite the one-star rating, the Executive Director/Administrator stated that the facility had enough staff to meet residents' needs, but the system did not accurately capture when staff scanned in.