Challenge Scenario. Featured TAG TOPIC SCENARIO NOTES F155

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1 TAG TOPIC Let the resident refuse treatment or refuse to take part in an experiment and formulate advance directives SCENARIO In this scenario, the facility failed to ensure all residents received resuscitation (CPR) and Basic Life Support (BLS) as requested and failed to have a selected procedure manual in the facility for staff to follow. Could this happen at your facility? For additional details related to this scenario, see page 2 What actions would you and your staff members take to prevent this from occurring in your facility? NOTES

2 Based on record review, observations, and staff interviews, the facility failed to ensure all residents received resuscitation (CPR) and Basic Life Support (BLS) as requested and as care planned for 1 of 14 former residents (Resident #18) and 2 of 19 current residents reviewed for advanced directives (Residents #33 and #34) and failed to have a selected procedure manual in the facility for staff to follow. The facility identified a census of 96 residents. Resident #18 requested to have CPR in the event of an emergency resuscitation. At 3:10 a.m., staff found the resident with no signs of life. The staff did not perform CPR as the resident had wished. Findings include: A hospital transfer form indicated the resident transferred from the hospital and medically stable. The transfer form identified the resident as a code (CPR to be given). The Initial Care Plan revealed the resident requested a full code (wanted CPR). The review of the Nursing Documentation dated 5/10 indicated that at 3:10 a.m. a Certified Nursing Assistant (CNA) walked past the resident s room and discovered the resident had stopped breathing. The CNA called for the nurse and upon assessment the resident had no signs of life. The CNA had cracked the resident s window upon the resident s request at 2:00 a.m. The nurse confirmed the resident had no vital signs at 3:15 a.m. The nurse notified the daughter and son-in-law to come to the facility at 3:15 a.m. The physician on call gave the nurse the approval to release the body at 3:30 a.m. to funeral home. On 6/2 at 9:00 a.m. Staff Q, Registered Nurse was interviewed and stated at 3:10 a.m. the CNA called for her to go to the resident s room. The CNA had told her that she did not think the resident had been breathing. Staff Q stated she went into the resident s room and noted his/her position and he/she had a yellow tint to his/her skin, no pulse or respirations noted. The resident s jaw opened and staff could not close the mouth. The resident had no reaction. Staff Q stated she left the room to look at the chart and called Staff R, Licensed Practical Nurse, to go to the resident s room. Staff Q stated it took approximately two minutes to find his/her code status and she had the CNA obtain the vitals. The nurse stated she found the resident s advance directives under the admission records. Staff Q also stated the resident s code status had not been displayed in any other place. Staff Q stated she had not performed CPR on the resident and she honestly did not think of CPR at the time. Staff Q stated the resident had no signs of life, no vital signs, no response to pain and the resident appeared to have been deceased for a period of time based on the resident s color and loss of body heat. The nurse stated she did not know the facility s policy on CPR. The resident s primary physician stated on 6/2 at approximately 11:30 a.m. that he could not comment on whether the nurse should have started CPR due to the resident s appearance but the bottom line was the resident wanted CPR and did not receive it. Upon review of the facility policy/procedures, it was found the facility had multiple CPR policies and procedures for staff to follow. The facility s policy on Cardiopulmonary Resuscitation (CPR) and Basic Life Support (BLS), revised in December 2006 (sent to the Department of Inspections & Appeals), directed the facility to: a. Provide periodic Mock Codes (simulations of an actual arrest) for training purposes. b. Select and identify a CPR team for each shift in the case of an actual arrest. c. The facility needed to maintain equipment and supplies necessary for CPR/BLS in the facility at all times.

3 The review of the General Guidelines of the facility s policy on Cardiopulmonary Resuscitation (CPR) and Basic Life Support (BLS) revealed the guidelines directed: a. Depending on the underlying cause, the chances of surviving SCA may be increased if CPR is initiated immediately upon collapse. b. In potentially reversible situations, early delivery of a shock with a defibrillator plus CPR within minutes of collapse can further chances of survival. c. The goal of early delivery of CPR is to try to maintain life until the emergency medical response team arrives to deliver Advanced Life Support (ALS). The Director of Nursing was interviewed on 6/2 at 9:00 a.m. and stated the facility did not have a defibrillator in the facility nor did they do mock codes for training. The Director of Nursing was interviewed again on 6/2 at 11:40 a.m. and stated the correct CPR policy could be located in the Med Pass policy book. The facility s procedure for administering CPR shall incorporate the steps covered in the American Heart Association 2005 Guidelines for Cardiopulmonary Resuscitation and Emergency Care or facility BLS training material. The steps included the following areas: 1. Check victim for pulse and respirations: a. If they are absent, attempt to arouse the individual (for example, by shaking them or by a sternal rub. b. If the victim responds but is injured, follow facility protocol for first aid or call 911. c. If the victim is unresponsive (no movement, or response to stimuli, and no return of pulse and /or respirations), follow steps 2 through Activate the emergency response team and initiate CPR: a. Call a code as designated by facility protocol. b. Designate a staff person to call 911 and then contact the resident s Attending Physician and the resident s family. 3. Open the airway. 4. Check breathing. 5. Administer rescue breaths. 6. Check for pulse. 7. Give chest compressions. Staff K (Licensed Practical Nurse) stated on 6/2 at 2:00 p.m. that the procedure for CPR was in the Med Pass Policy book on the west side of the building and provided the policy book and the CPR policy. The review of the Emergency Procedure Cardiopulmonary Resuscitation of the revised 2010 version revealed the policy directed the staff: 1. The facility s procedure for administering CPR shall incorporate the steps covered in the 2010 American Heart As sociation Guidelines for Cardiopulmonary Resuscitation and Emergency Care or facility BLS training material.

4 2. The basic life support (BLS) sequence of events is referred to as C-A-B (chest compressions, airway and breathing). This had been revised from the previous sequence of A-B-C (airway, breathing, chest compressions). 3. Begin CPR if the adult victim is unresponsive and not breathing normally (ignoring occasional gasps) without assessing the victim s pulse. 4. Following initial assessment, begin CPR, with chest compressions rather than opening the airway and delivering rescue breathing. 5. All rescuers, trained or not, should provide chest compressions to victims of SCA. 6. Delivering high-quality chest compressions is essential. 7. Trained rescuers should also provide ventilation with a compression-ventilation ratio of 30:2. The review of the CPR/DNR Status policy dated 2010 found in the Policy Book on the south wing revealed the policy titled CPR/ DNR Status directed staff that the facility allowed each resident/family/representative the choice of determining their individual code status. The review of the Procedure section of the policy directed the staff: 1. Resident request for CPR/No code status will be signed upon admission by resident and/or family/representative. It will be reviewed with each MDS assessment review. 2. If the decision of code stratus is not readily made upon admission, the resident will be considered a Full Code until resident/family member or physician has made the decision and signed the acknowledgement form. 3. The CPR/No code status report form will be kept in the resident s chart. This will be the definitive location of the acknowledgement request of code status. 4. At any time, when a question arises about the resident s code status, the staff will be expected to review the chart for the resident s decision. 5. A full code resident listing will be maintained at the Nurses Station (NS) for reference. 6. As changes are made re: a resident s code status, the listing at NS will be updated. The facility protocol for when a resident is found to be unresponsive revealed the following guidelines to be used: Upon entering resident s room and determining resident is unresponsive: 1. Assess resident: Airway, Breathing, Circulation (ABCs). (At this time, a staff member will be sent to Nurses Station to obtain chart for verification of code status). 2. For verification of code status: View CPR/DNR status form in chart (verification of code status from chart is expected prior to initiating CPR).

5 3. After determining resident s physical condition and code status, a. Full Code: Call 911, contact other staff members on duty and initiate CPR. b. If DNR: Call family, attending physician and mortician. 4. After EMS arrives, they assume care of the resident for emergency services and transport. 5. The attending physician and family will then be notified. The review of the residents with advance directives revealed two residents doors or name plates did not contain the correct coding to help ensure the staff followed the residents advance directives. (Resident #33 and Resident #34). The facility provided a list of residents who requested CPR. The review of the CPR Directive identified Resident #34 requested CPR. The observation of the resident s door and name plate on 6/2 at approximately 5:30 p.m. revealed the door nor the name plate had a blue sticker on it to alert the staff that the resident requested CPR. The review of Resident #33 s Resident CPR Directive revealed the resident did not want CPR administered. The observation of the resident s name plate by the resident s room on 6/2 at approximately 5:45 p.m. revealed the resident s name plate contained a blue dot erroneously indicating the resident wanted CPR. The review of the facility s sheet of residents who wanted CPR revealed 41 of the 96 residents in the facility wanted CPR. Note: At the time of the complaint and survey investigation, the violation was coded at J, immediate and serious jeopardy. By 6/5, the facility had implemented measures that adequately addressed the jeopardy by training staff of the CPR/DNR policy/procedure and identify residents requesting CPR (full code) by placing a blue dot on the spine of each resident s chart and on resident room doors. During observation of the medication pass on Unit 3, licensed practical nurse (LPN) #3 was observed to perform a glucose finger stick with the facility s glucose meter on resident #193. The LPN did not clean the glucose meter prior to placing it back in the drawer of the medication cart. During observation of the medication pass, LPN # 4 was observed to have performed a glucose fingerstick on residents 144, 142 and 131 using the same glucose meter. The glucose meter was not cleaned after use or before it was used for each resident. During an interview, LPN #4 stated he did not clean the glucose meter after each resident s use and he was not aware of any policy or procedure for cleaning the glucose meter. During an interview, the DON stated that the glucose meters should be cleaned and disinfected between each resident s use and also should be cleaned after each use before placing the glucose meter on the medication cart and/or in the drawer of the medication cart.