BLUEFIELD, VA- WESTWOOD CENTER

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** 34307

Based on staff interview, clinical record review and facility document review the facility staff failed to provide basic life support, including cardiopulmonary resuscitation to one of 57, residents, Resident #2.

The findings included:

For Resident #2, an agency-contracted staff failed to check code status and failed to initiate basic life support, including cardiopulmonary resuscitation for Resident #2. Resident #2 expired at the facility.

Resident #2’s face sheet listed diagnoses which included but not limited to acute respiratory failure, chronic obstructive pulmonary disease, chronic kidney disease with heart failure, and diabetes mellitus-type II.

Resident #2’s most recent minimum data set with an assessment reference date of [DATE] assigned the resident a brief interview for mental status score of 3 out of 15 in section C, cognitive patterns. This indicates that the resident was severely cognitively impaired. Resident #2’s clinical record was reviewed and contained a physician’s order summary which read in part, Full code.
Resident #2’s clinical record contained a Virginia Physician’s Orders for Scope of Treatment form dated [DATE], which read in part A. Cardiopulmonary Resuscitation (CPR): Person has no pulse and is not breathing. [x] Attempt Resuscitation. [] Do Not Attempt Resuscitation (DDNR/DNR/No CPR). The box for attempt resuscitation was marked on this form.

Resident #2’s clinical record contained nurse’s progress notes dated [DATE], which read in part [DATE] 06:30 Resident unresponsive, no respirations or lung sounds, . [name omitted] RN, DON [registered nurse, director of nursing] to be notified for further instructions-signed by licensed practical nurse (LPN) #3, [DATE] 07:02 Notified . [name omitted] RN, DON to report resident unresponsive, stated ‘make a note of it and an RN will be there shortly to pronounce’-signed by LPN #3, [DATE]:40 Notified at approximately 0830 that resident has passed away. DON advised me that resident was a full code but that the nurse assigned to . [Resident #2] got confused about the resident’s code status, therefore she did not initiate CPR. The resident was listed as a Full Code but there had been discussion earlier of the resident moving to an end of life  comfort care status. The nurse was an agency nurse and her contract was terminated by the facility. MD was notified. Resident son was notified by me of the incident. He was understanding and advised that he felt like it would not have helped. OLC [Office of Licensure and Certification], APS [Adult Protective Services], Ombudsman and DHP [Department of Health Professions] have been notified as well-signed by administrator and [DATE] 14:28 Notified by . [name omitted] Agency nurse at approx. 0702 am via phone that resident had passed away. This nurse advised . [name omitted] to call on call provider and family. This nurse was advised by . [name omitted], resident had DNR on her chart. [name omitted], FNP [family nurse practitioner] advised this nurse via phone that resident had a full code on her chart but nurse . [name omitted] was confused about code status. This nurse called administrator to advise her that . [name omitted] the agency nurse did not start cpr. The resident was listed as a Full Code in pcc [point click care]. Previously, there had been discussion of end of life care. [name omitted], FNP was notified. Resident’s son was notified by administrator of the incident. He was understanding and advised that he felt like it would not have helped.
The agency nurse . [name omitted] contract terminated by the facility.-signed by DON.

During an interview with the facility administrator on [DATE] at 11:40 am, the administrator stated that the resident’s family had been to the facility earlier in the week to discuss the possibility of comfort care for Resident #2. Administrator stated, evidently there was some confusion, and a CNA [certified nurse’s aide] told the nurse that the resident was DNR. Administrator stated that the nurse’s excuse was that the computers were down, but there is a copy of each resident’s code status in their paper chart located at the nurse’s station. Administrator stated that nurse was an agency staff, and not a facility staff, and that her contract was terminated. Administrator stated that a 100% audit of code orders was completed, and a full plan of correction done immediately. This was provided to the surveyor for review.

Surveyor spoke with the director of nursing (DON) on [DATE] at 2:20 pm and asked her to relate the events of [DATE]. DON stated, I was called at home around 7 am by . [LPN #3] and informed that Resident #2 had passed, and she needed someone to pronounce. I told her that an RN was on the way. I called the FNP to let her know that Resident #2 had passed, and she had her computer up, and informed me that Resident #2 was a full code. I then called the administrator. Once I arrived at the facility, I checked Resident #2’s chart to confirm code status. She was a full code.