ATTALLA HEALTH AND REHAB
LOCATED: 915 STEWART AVENUE SOUTHEAST, ATTALLA, AL 35954
ATTALLA HEALTH AND REHAB was cited by the DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES for the following deficiencies:
PLEASE NOTE: The following highlighted quoted text is only a portion of the full report/survey submitted by DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES. The full report/survey can be found here.
FACILITY FAILED TO PROVIDE NECESSARY CARE AND SERVICES TO MAINTAIN THE HIGHEST WELL BEING OF EACH RESIDENT
LEVEL OF HARM –IMMEDIATE JEOPARDY
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interviews, review of Resident Identifier (RI) #1’s medical record, the facility’s policy titled Cardiopulmonary Resuscitation (CPR) and Basic Life Support and the 2010 American Heart Association (AHA) Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, the facility failed to ensure Employee Identifier (EI) #2, a Licensed Practical Nurse (LPN) assessed the condition of RI #1 after a CNA (Certified Nursing Assistant) was reported to her that RI #1, a resident with Full Code status, did not have a pulse.
On [DATE], the State Agency received a complaint regarding the care RI #1 received on [DATE]. According to the complainant, she received an anonymous call on [DATE] that stated RI #1 died in the facility as the result of staff negligence.
On [DATE] at 9:22 a.m., an interview was conducted with EI #2, the LPN assigned to care for RI #1 during the 7a – 7p shift on [DATE]. According to EI #2, around 3:45 p.m./4:00 p.m., she was at the nurses’ station when a CNA came and informed her that RI #1 did not have a pulse. Instead of going into RI #1’s room, EI #2 acknowledged she stood in the resident’s doorway and noticed RI #1 was pale in color. EI #2 did not assess RI #1’s condition or check the resident’s vital signs after EI #1 reported to her that RI #1 did not have a pulse. EI #2 left RI #1’s doorway and proceeded to the nurses’ station to call the nursing supervisor, EI #3. EI #2 paged overhead for the supervisor, EI #3, to come to the hall where RI #1 resided. EI #2 did not call code blue, as indicated in the facility’s policy. As EI #2 was walking back to RI #1’s room, she observed EI #3 walking from the other hall. According to EI #2, she told EI #3 that she needed her to come to RI #1’s room. EI #2 said when she and EI #3 entered RI #1’s room they assessed the resident’s vitals. EI #3 assessed RI #1’s pulse and told EI #2 to go and find out what RI #1’s code status was. When asked, what RI #1’s code status was, EI #2 said RI #1 was a Full Code. When asked, who initiated CPR, EI #2 stated she did not know as she was at the nurses’ station making copies. EI #2 was asked, why she did not enter RI #1’s room to assess the resident. EI #2 said she felt like RI #1’s color was pale and she needed to get another nurse to help her. EI #2 was asked, what did the AHA CPR guidelines state should be done when a person is found unresponsive. EI #2 said, she thought the guidelines said to call for help. When asked, what could have been done differently for RI #1, EI #2 said she did not know what she could have done differently. According to EI #2, she has been a licensed nurse for [AGE] years. EI #2’s personnel file revealed she was certified in Basic Life Support for Healthcare Providers/CPR and AED Program on [DATE], with an expiration date of [DATE].
In a follow-up interview on [DATE] at 10:44 a.m., EI #2 said what she could have done differently, was to ring RI #1’s call light for help in the resident’s room.
On [DATE] at 3:21 p.m., the surveyor conducted an interview with EI #3, the RN Supervisor on [DATE]. The surveyor asked EI #3 can an unresponsive resident be assessed from the doorway of a room. EI #3 said, no. According to EI #3, when the CAN (EI #1) informed EI #2 (the LPN) that RI #1 was pale and without a pulse, EI #2 should have gone into RI #1’s room to assess the resident. EI #3 was asked, what the AHA CPR guidelines instructed a staff to do when they find a resident unresponsive. EI #3 said if the person is a Full Code you should start CPR. When asked if EI #2 initiated CPR, EI #3 replied, No. EI #3 said CPR was initiated after she assessed RI #1 and found the resident without breath sounds, a heartbeat or a pulse. EI #3 explained how she started chest compressions and told EI #2 to go to the desk and call all available nurses and 911.
In a follow-up telephone interview on [DATE] at 1:58 p.m., EI #3 acknowledged that when EI #2 (the LPN) met her in the hallway, EI #2 told her that she did not think RI #1 was breathing. EI #3 further acknowledged that EI #2 had not called a code blue. When asked, if she asked the LPN (EI #2), why a code was not called. EI #3 said, no. EI #3 said she did not think to ask EI #2 why she had not called a code when she found RI #1 unresponsive. When asked, what should have been done, EI #3 replied, she (EI #2) should have gone in the room, checked for a pulse and then called a code.
Personal Note from NHA-Advocates: NHAA shares with all the families of loved ones who are confined to nursing homes the pain and anguish of putting them in the care of someone else. We expect our loved ones to be treated with dignity and honor in the homes we place them. We cannot emphasize enough to family members of nursing home residents; frequent visits are essential to our loved ones’ well-being and safety. This nursing home and many others across the country are cited for abuse and neglect.
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