HEARTLAND OF PIQUA
275 KIENLE DRIVE, PIQUA, OH 45356
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 BASIC LIFE SUPPORT, INCLUDING CPR, PRIOR TO THE ARRIVAL OF EMERGENCY MEDICAL PERSONNEL, SUBJECT TO PHYSICIAN ORDERS AND THE RESIDENT’S ADVANCE DIRECTIVES.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on review of closed and current medical records, review of an Emergency Medical Squad (EMS) report, review of a facility Self-Reported Incident (SRI), review of a facility investigation, interviews with staff and the physician, review of the facility Emergency Management Policy Guidelines, the facility failed to timely initiate Cardiopulmonary Resuscitation (CPR) and timely contact Emergency Medical Services (EMS) for one resident (#5) who was a Full Code and was found unresponsive and without vital signs. Life threatening harm and death occurred when Resident #5 did not receive timely CPR or EMS and expired at the facility. This resulted in Immediate Jeopardy for one (#5) of four residents reviewed for change in condition and death in the facility.
On [DATE] at 2:35 P.M., the Administrator, Director of Nursing (DON) and Regional Nurse #325 were notified Immediate Jeopardy began on [DATE] at 5:30 P.M., when Resident #5 was found unresponsive. Licensed Practical Nurse (LPN) #360 was informed by State tested Nursing Assistant (STNA) #350 that Resident #5 was unresponsive, and LPN #360 subsequently checked Resident #5 and found the resident to be without a pulse and other vital signs. STNA #350 requested LPN #380 respond to Resident #5’s room and LPN #380 confirmed the resident was without vital signs as well; however, neither LPN #360 nor LPN #380 began CPR. STNA #350 provided post mortem care to Resident #5. Hospice Provider #450 was notified of Resident #5’s death. The medical record was not reviewed to confirm the resident’s code status. Registered Nurse (RN)# 390 was in the facility and upon hearing of Resident #5’s death, instructed the LPNs to check the resident medical record to verify the resident’s code status. When LPN #360 checked the chart, the resident was discovered to be a Full Code. LPN #360 obtained
the crash cart and proceeded to Resident #5’s room to initiate CPR and 911 was called. Upon the EMS arrival at the facility, CPR was being performed on Resident #5. Resident #5 was noted by EMS services to be cold to touch, dependent lividity and rigor mortis was beginning to set in. EMS did not initiate care due to obvious signs of death. Resident #5 expired in the facility.
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.
You can make a difference. If you have a loved one living in this nursing home or any other nursing home where you suspect any form of abuse or neglect, contact us immediately.
We have helped many already and we can help you and your loved one as wellby filing a state complaint, hiring a specialized nursing home attorney or helping you find a more suitable location for your loved one.
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