MOUNT VERNON, TX – MISSION MANOR HEALTHCARE RESIDENCE

Based on interview and record review, the facility failed to ensure the right to be free from neglect was provided for 1 of 6 residents reviewed for neglect. (Resident #1)

The facility neglected to train staff on their policy to immediately provide CPR for residents with an unknown code status (do not resuscitate or full code) for life saving measures was unknown. Resident #1 was a full code (wanted all possible life saving measures in the event her heart or breathing stopped). LVN A did not start CPR for 9 minutes from the time she determined Resident #1 did not have a pulse or respirations on [DATE]. Resident #1 was transported to the hospital via ambulance on [DATE] and was pronounced dead upon arrival. The facility did not have an effective system for identifying the code status for residents.

During an interview on [DATE] at 3:24 p.m. the DON said when a resident was found unresponsive and they had a full code status, CPR should be initiated immediately. She said the facility’s process failed and needed to be changed. The DON said the staff should be in-serviced on the proper steps to take during a code situation. The DON said according to the statements from staff present when Resident #1 coded, there were nine minutes between the time the code was called, and the time CPR was initiated. She said the AED should be kept by the crash cart and brought to the room for use during a code.

During an interview on [DATE] at 2:27 p.m., LVN B said she did not know the facility policy regarding the code status for the residents. She said today was her second day working alone and she was training a newly hired nurse.

During an interview on [DATE] at 2:28 p.m., RN F said she did not know the facility policy regarding obtaining the code status for residents. She said the nurse should start CPR then send someone to check the code status, and if they were a do not resuscitate (DNR), staff could discontinue performing CPR.

During an interview on [DATE] at 2:33 p.m., CNA C said she did not know where to look for the resident’s code status. She said she would have to ask the charge nurse.

During an interview on [DATE] at 2:35 p.m., CNA G said she was not sure how to check the code status of a resident. She said she would ask the charge nurse.

During an interview on [DATE] at 2:37 p.m., CNA D said she worked as both a CNA and transportation aide. She said she was CPR certified and did not know where to look for a resident’s code status. CNA D said she transported residents to and from appointments and would not know the code status if something happened during transport.

During an interview on [DATE] at 3:31 p.m., LVN E said she was not aware of a system for determining a resident’s code status. She said she would check the chart for the code status before starting CPR. LVN E said she would only trust what was on the chart. She said it would take her about two minutes to check a resident code status on the chart.

During an interview on [DATE] at 3:44 p.m., the administrator said she did not know CPR was not administered immediately for Resident #1 when she coded on [DATE]. She said the code status should not be checked prior to administering CPR, she said that should be delegated.