OVERTON, TX- OVERTON HEALTHCARE CENTER

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50818

Based on interview and record review, the facility failed to ensure all residents were free from neglect for 1 of 5 residents (Resident #1) reviewed for neglect.

RN A did not call 911 for emergency services for Resident #1 until approximately 29 minutes after
discovering Resident #1 unresponsive on [DATE].

CPR was not initiated on Resident #1 on [DATE] until approximately 9:52 PM when Fire Department arrived and began resuscitation attempts. Resident #1 was pronounced deceased at approximately 10:27 PM after Justice of the Peace arrived.

The facility staff failed to provide life saving measures to Resident #1 who was identified as being full code after he was found unresponsive in his room.

These failures resulted in an identification of an Immediate Jeopardy (IJ) on [DATE] at 5:50 p.m.

While the IJ was removed on [DATE], the facility remained out of compliance at no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope identified as isolated due to the facility’s need to complete in-service training and evaluate the effectiveness of the corrective systems.

These failures could place residents at risk for neglect due to not receiving necessary life-saving measures, decline in health, and death.

Findings include:
1. Record review of an undated face sheet indicated Resident #1 was a [AGE] year-old male readmitted to the facility on [DATE] with diagnoses including Parkinson’s Disease (movement disorder of the nervous system that worsens over time), hypertension (elevated blood pressure), and atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow). The face sheet indicated Resident #1 was a full code (in the event of cardiac arrest, CPR will be initiated).

Record review of MDS dated [DATE] indicated Resident #1 was rarely understood by others and rarely understood others. The MDS indicated Resident #1 BIMS was not conducted due to resident being rarely/never understood. The MDS did not indicate Resident #1 had a DNR advanced directive in place.

Record review of the care plan revised on [DATE] indicated Resident #1’s code status as .[resident] is a Full Code. He wishes to be resuscitated if he should stop breathing.

Record review of physician orders reflected an order of Code Status: Full Code with starting date of [DATE] with no end date.

Record review of the nursing progress note dated [DATE] written by RN A indicated that RN A found Resident #1 unresponsive at approximately 9:00 PM on [DATE]. The progress note indicated RN A assessed Resident #1 and he was without pulse or respirations. The progress note indicated RN A called the facility ADM, DON, and ADON but did not initiate CPR or call 911. The progress note indicated RN A called NP at 9:29 and was directed to call 911 due to resident Full Code status. The progress note indicated Emergency Services arrived at 9:50 PM and initiated CPR at 9:52 PM. The progress note indicated Justice of the Peace arrived at 10:20 PM and CPR was stopped at 10:27 PM and Resident #1 was pronounced deceased .

During a telephone interview on [DATE] at 12:30 PM, RN A said on [DATE] she discovered Resident #1 lying in his bed and he did not respond to her voice. RN A said she assessed Resident #1, and he had no palpable pulse, no respirations, pupils were fixed, dilated, and nonreactive to light, and resident’s lips and fingertips were cold to the touch. RN A said she did not start CPR because Resident #1 was already deceased . RN A said she called the facility ADM, ADON, and DON for guidance on funeral home notification but only the ADON responded, and she did not know the policy. RN A said she called NP for further guidance and NP directed her to call 911 due to Resident #1 Full Code status. RN A said the 911 operator asked her to start CPR on Resident #1, but she declined to do so because he was already gone. RN A said she was familiar with Resident #1’s code status because she was responsible for updating the resident code status book nightly at midnight. RN A said she had never received any training from the facility regarding Emergency Procedures or CPR.

Record Review of an in-service education form dated [DATE] included topics Code Status Guidelines and Advanced Directives and Code Blue reflected RN A was in attendance.

Record review of a National CPR Foundation Provider Card indicated RN A was certified in Standard – CPR / AED issued [DATE] and expiring [DATE] .

During an interview on [DATE] at 1:00 PM the ADON said she remembered Resident #1 expiring. The ADON said RN A called her that night and told her Resident #1 was deceased and asked what Justice of the Peace and funeral home to notify. The ADON said if there was no preference in Resident #1’s chart she was unsure and would call her back. The ADON said she assumed RN A had initiated CPR for Resident #1 due to his Full Code status and did not ask for clarification.

During a telephone interview on [DATE] at 2:30 PM, NP said she first learned that Resident #1 was
deceased on the morning of [DATE] when she received a message left with her answering service. She said RN A never called her on the night of [DATE] and she did not give RN A any directions or guidance. She said CPR should have been initiated immediately on a nonresponsive resident who is a full code.

During an interview on [DATE] at 3:00 PM the ADM said he remembered Resident #1 expiring. The ADM said he was not at the facility but was given report regarding Resident #1’s death. The ADM said he had been informed CPR was not initiated on Resident #1. The ADM said staff are expected to follow facility policy and initiate CPR for any resident who is Full Code. He said an RN may pronounce death if there are obvious signs of irreversible death . (e.g., rigor mortis, decomposition, decapitation) The ADM said the facility had begun disciplinary action with RN A for failing to follow policy when she self-terminated her employment at the facility. He said all staff receive education in Abuse, Neglect, and Exploitation on hire and the facility has frequent in-services to reinforce training.

During a telephone interview on [DATE] at 4:00 PM . CNA B said she worked the overnight shift on [DATE]. CNA A said she checked on Resident #1 at approximately 8:00 PM and assisted him to the restroom and he did not appear to be in distress. She said RN A was Resident #1’s nurse that night.

Record review of the facility’s Abuse, Neglect, and Exploitation policy last revised [DATE] indicated:.The facility will develop and implement written policies and procedures that:
a. Prohibit and prevent abuse, neglect, and exploitation of residents .

Record review of the facility’s Emergency Procedure – Cardiopulmonary Resuscitation policy last revised February 2018 indicated: .If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR unless:

a. It is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exists for that individual; or

b. There are obvious signs of irreversible death (e.g., rigor mortis) .

The Administrator was notified that an Immediate Jeopardy situation was identified due to the above failure and provided with the Immediate Jeopardy template on [DATE] at 5:22 PM.