APPLEWOOD CARE CENTER
1090 RIO LANE, SACRAMENTO, CA 95822
Citation Number: 030004037
Citation Date: 6/21/2007
Violation Date: 2/4/2007
Class: AA
Penalty: $ 100000.00

72313. Nursing Services-Administration of Medications and Treatments. a) Medications and treatments shall be administered as follows: 2) Medications and treatments shall be administered as prescribed.

72523 Patient Care Policies and Procedures. (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved.

An unannounced visit was made to the facility on 02/26/07, with additional onsite inspections on 02/27/07, 05/07/07 and 06/11/07 to investigate complaint # CA00107145 regarding quality of care and treatment.

The Department determined the facility failed to:

1) Ensure that on 02/04/07 facility staff performed CPR (cardio pulmonary resuscitation) on Resident A until paramedics arrived and assumed care, as per a physician's order, dated 01/20/07, for "full resuscitation."

2) Follow their policy titled, "Death of Resident," by not ensuring nursing staff responded with CPR.

This failure resulted in Sacramento City Fire Department arriving at the facility and finding Resident A in bed and unresponsive with no facility staff in the resident's room performing CPR, as per Resident A's request "wants whatever it takes to sustain his life." A Fire Fighter indicated Resident A had a heart beat but he was not breathing. We did CPR for about 20 minutes. Resident A was pronounced dead at 6:12 p.m. on 02/04/07.

Review of Resident A's clinical record on 02/26/07 documented he was an 82 year old male originally admitted to the facility on 10/21/05 with diagnoses that included decubitus ulcer of the lower back, atrial fibrillation, unspecified protein-calorie malnutrition, unspecified deficiency anemia, hypertension and unspecified cerebrovascular disease. On 01/15/07, Resident A was transferred to a General Acute Care Hospital (GACH) for evaluation due to poor fluid intake, possible infected wounds and low albumin levels. Resident A was re-admitted to the facility on 01/20/07.

Resident A's Quarterly Minimum Data Set (MDS, a standardized assessment tool), dated 01/03/07, documented Resident A as having no long or short-term memory problems, as having modified independent cognitive skills for daily decision making, able to make himself understood and able to understand others. The MDS described Resident A as being independent with eating and as needing limited assistance with bed mobility, transfers, dressing, personal hygiene and locomotion off the unit.

Review of Resident A's clinical record revealed a form titled, "All Active Orders for February 2007," revealed an order dated 01/20/07 for "full resuscitation."

Review of a form titled, "Applewood Care Center Physician Orders," "Noted By: [Registered Nurse (RN) 1]" and dated 01/20/07 revealed Resident A was "Full Resuscitation: Full Code."

Review of Resident A's clinical record revealed a form titled, "Treatment Decisions," dated 01/20/07 and signed by the physician. According to the form there was a check mark in the box "Yes" next to the treatment options: cardiopulmonary resuscitation, intubation, artificial means of nutrition, antibiotic therapy, oxygen therapy and transfer to acute hospital, indicating Resident A wanted all the treatments options done. On the line labeled, "Comment," RN 1 wrote "Resident stated to me he wants whatever it takes to sustain his life." After this documentation, RN 1 signed her named and wrote "unable to sign" indicating Resident A was unable to sign his name.

An undated "Licensed Nurses Progress Note," timed at 4:30 p.m. revealed Registered Nurse (RN) 1 documented, "Advanced directives signed by resident (Resident A), who indicated to me (RN 1) that he wants everything-"whatever it takes to sustain his life."

On a "Licensed Nurses Progress Note," dated 02/04/07 at 5:40 p.m., RN 1 documented she was called by Certified Nursing Assistant (CNA) 3 to come to Resident A's room. RN 1 went to the room and found Resident A in a sitting position in a geri chair "unresponsive and unconscious but still breathing." RN 1 documented she left the room to call 911. After calling 911 and giving them information regarding Resident A, RN 1 went back to Resident A's room. Upon returning to the room RN 1 charted Resident A was "still breathing" and O2 (oxygen) was started at 2 L/min. According to the Progress Note Resident A was assisted back to bed and at that time he "was still breathing but shallow." RN 1 documented a second call was placed to 911 by another nurse (Licensed Vocational Nurse - LVN 2) while RN 1 remained with Resident A, who was described as having a "pulse with shallow breathing." A "few minutes" later RN 1 documented "no pulse felt" and "CPR initiated with 15 compressions with 2 breath, pulse checked, extremities blue." RN 1 further wrote, "while this was going on Paramedics walked in charge and (sic) nurse still in the room with resident. Paramedics took over. After 15 minutes Paramedics said he is gone and called Police Department."

Review of the facility's interview with RN 1, dated 02/05/07 at 8:30 a.m., revealed RN 1 "started CPR, I did first chest compressions @ 2 breaths there was no pulse I continued the chest compressions just when I was checking for pulse the paramedics came and took over. The Paramedics requested for a copy of advance directives, I left the room to the nurses station to get copy of the advance directives..."

Review of the facility's interview with LVN 2, dated 02/05/07 at 2:45 p.m. revealed "[RN 1] came out of the room, she said something but I didn't know what she said. I think she indicated that we need help here. I went down to Rm 36 (Resident A's room). I saw resident (Resident A) sitting up in the gerichair leaning to the side, eyes were open, resident was not responding. I ran down to the hallway looking for the board, first into the med room, then I noticed the back board on the crash cart. I took the back board to Room 36 [RN 1] grabbed the oxygen tank, took it to Rm (room) 36. She started using the Ambu bag to bag the resident, [RN 1] then made a comment saying this was not working, instructed the CNA to help her transfer resident to bed with the back board in place behind the resident. I was not there when [RN 1] started the chest compression. I left the room after [RN 1] state his condition has changed call 911 again. I left to go back to the nurses station to call 911 back. When I called 911 they had me on hold then someone said paramedics are here then I hung up the phone because there was no reason for me to keep holding, since the paramedics were here.....When I went back to Rm 36 the paramedics state to me that he noticed that no one was doing CPR when they arrived and they asked if anyone started CPR, I said, "No" because "I didn't start CPR, I don't know if anyone started CPR after I left the room."

Review of the facility's interview with Certified Nursing Assistant (CNA) 3 on 02/05/07, who witnessed Resident A become unconscious and was present in the room at the time CPR was being performed by RN 1. CNA 3 stated, "The nurse started chest compressions, check for pulse there was none. She started chest compression again, when she was checking for pulse the paramedics came."

Review of the facility's investigation report revealed a statement, by CNA 4, dated 02/04/07. According to CNA 4's statement, "Soon the ambulance arrived and [RN 1] was there until they came."

During a telephone interview with RN 1 on 03/01/07 at 6:30 p.m. confirmed what she reported during the facility's interview, on 02/05/07. RN 1 could not remember if CNA 3 was in the room and that the Fire Department was "incorrect" in stating that no one was in the room when they arrived.

LVN 2 was interviewed, via telephone, on 02/27/07 at 3:55 p.m. confirmed what she stated during the facility's interview on 02/05/07 and that RN 1 was in Resident A's room when the Fire Department arrived but didn't know what she was doing because she was at the nurse's station.

CNA 3 was interviewed on 02/27/07 at 2:45 p.m. According to CNA 3 he was feeding Resident A dinner in a geri chair when he starting coughing then slumped over. CNA 3 stated he performed the Heimlich maneuver with no response. He went to the door and called for help. RN 1 arrived and tried to wake Resident A but still there was no response. CNA 3 stated RN 1 left the room to call 911, while he remained in the room trying to wake Resident A. RN 1 then came back with oxygen and with the help of RN 1 and CNA 4 they put Resident A back in bed. CNA 3 stated RN 1 started doing compressions.

During another interview with CNA 3 on 03/29/07 he wrote a hand written statement that indicated "when the paramedics arrived I was inside the room of [Resident A] alone with [Resident A] when the (paramedics) are in front of the door then I left the room," indicating RN 1 was not doing active CPR when the paramedics arrived in the room.

During an interview with CNA 4 on 03/29/07 at 3:30 p.m. she provided a hand written statement, dated 02/29/07 (sic 03/29/07), that revealed, "...about 5:35-5:40 p.m., I hear [RN 1] voice please call 911, [Resident A] looks not good. When I came to room [RN 1], [LVN 2] and [CNA 3] was there. [RN 1] ask me take tray and bring to kitchen. I heard voices, another resident, from next rooms call for help and because it was 3 people there RN 1 tell me go to help another resident. Before I left I see [RN 1] doing CPR. How many and how she was doing I am don't know. When paramedics arrive I was by nurse's station."

Based on interview and reviewing CNA 4's written statements, dated 02/04/07 and 03/29/07, it was determined CNA 4 was not able to confirm if RN 1 was performing active CPR on Resident A when the paramedics entered resident's room.

Review of the "Sacramento City Fire Department Fire Report," dated 02/04/07, revealed "E (Engine) 13 arrived (at the facility approximately 5:47 p.m.) and found Pt. (patient) in bed, unresponsive. No staff in room on scene. Staff was gathering paperwork for Pt. E 13 began CPR. M (Medic) 11 assisted E 13 with Pt. care, treatment, CPR. E 13 continued ALS (advance life support) treatment and Pt. was called (pronounced dead) at 1812 hrs. (6:12 p.m.). SPD (Sacramento Police Department) on scene."

Review of the Patient Care Report (PCR), dated 02/04/07, revealed Resident A was found "unresponsive/apneic U/A (upon arrival) @ convalescent facility. Found Pt. apneic in bed. [sign for no] CPR U/A E 13. Charge Nurse states she did a couple rounds of CPR. [sign for no] BLS (basic life support) airway PTA, U/A of E13 started CPR, BLS airway. Per CNA in room was feeding him (Resident A) then witnessed him go unconscious than called for charge nurse. Pt given advanced airway with three rounds of medication with no change. Pt called (pronounced dead) on scene TOD (time of death) 1812 (6:12 p.m.)"

The Captain of Engine 13 was interviewed, via telephone, on 03/22/07 at 2:55 p.m. He stated they were the first to arrive and there was "no active CPR upon arrival to room (Resident A's room)." The Captain did remember "staff saying they had been doing CPR but had stopped to get paperwork."

On 03/29/07 at 2:30 p.m. Fire Fighter (FF) 5 was interviewed regarding the incident that occurred on 02/04/07 with Resident A and provided a hand written statement, dated 03/29/07. According to the statement, "E 13 arrived on scene at Applewood for an unresponsive male. When we got to the room I saw one dark skinned female wearing a maroon/purplish nurse type scrub top. My partner (Fire Fighter 6) asked, "What happened." The lady replied that this was not her patient she was from another wing. Then she exited. We then accessed patient and began CPR. No CPR was being done upon our arrival."

On 03/29/07 an interview with Fire Fighter 6 was also conducted, regarding the incident that occurred on 02/04/07 with Resident A. Fire Fighter 6 also provided a hand written statement, dated 03/29/07, that revealed, "Upon arrival as I walked in toward the nurses station I asked where is the Pt they told us where to go. As I walked down the hallway there was a lady in purple scrubs standing in the doorway. I asked her what had happened and she said this was not her wing and did not know. As I entered the room Pt was lying in bed no one in the room doing CPR. E 13 crew started CPR 3 airway procedures. I asked if anyone knew how long he was down I got no answer. At this time after all our efforts Pt was called (pronounced dead) at 1812. When I went to the nurses station to do my report I started to ask the nurse at the station if she was an RN. She said yes. I asked if the staff was CPR trained, she said yes. I asked her was there any CPR being done because upon our arrival there was no CPR or airway being done, her answer was I did a couple rounds then came to get the paperwork. As I tried to get further questions answered on the time line of this Pt from being alert & eating to unconscious, I could not get any straight answers because the male CNA that had witnessed it was taking care of other pts. During my report writing it was very hard to get a clear answer or get the big picture of what happened due to very scattered information."

Review of the Sacramento Police Department report revealed Officer 7 and Officer 8 were dispatched and arrived at the facility at approximately 6:35 p.m. According to the report Officer 7 interviewed Fire Fighter 6, on 02/04/07, at approximately 6:36 p.m. Fire Fighter 6 stated, "When we walked into the room, there was only one female nurse (RN 1) in the room. She was just standing there. There may have been a cannula for oxygen hooked up to [Resident A] through his nose, but I'm not sure. Even if it was hooked up, this amount of oxygen was not doing him any good. He needed much more oxygen then was being given to him. I initiated CPR right away at approx. 1753 hours (5:53 p.m.). [Resident A] had a heart beat but he was not breathing. We did CPR for about 20 minutes. [Resident A] was pronounced dead at 1812 hours (6:12 p.m.)"

Review of the Sacramento Police Department report revealed Officer 7 interviewed CNA 3 on 02/04/07 at approximately 6:50 p.m. According to the report CNA 3 "saw [RN 1] do approximately 12 compressions on [Resident A] and two breaths. After that she stopped doing CPR. I was in the room when the fire department arrived. I never saw [RN 1] give [Resident A] any oxygen."

The Sacramento Police Department report revealed RN 1 was interviewed by Officer 7 on 02/04/07, at approximately 7:55 p.m. According to the report RN 1 stated the following: "I did CPR on [Resident A]. I did about 12-15 chest compressions and then I did two breaths. I stopped doing CPR after the two breaths. I did not have a CPR mask and I was scared for myself. I thought he was dead anyway. I stood around not doing anything for 1-2 minutes before the fire (Fire Department) arrived. I do know how to give CPR, but I didn't have a mask. I don't even know where the masks are located here."

The facility's Director of Nurses (DON) was interviewed on 05/07/07 at 10:35 a.m. She was asked if the facility had CPR masks, besides an ambu bag, she confirmed the facility did and stated they were located on the crash cart.

In the Sacramento Police Department report the Officer 7 wrote, "[RN 1] appeared nervous and was uncooperative at first. She refused to give us her birthday and advised that she didn't want to give us any more information. Her story was inconsistent and changed several times. At first she stated she gave CPR until fire (Fire Department) arrived and then changed her story saying that she stopped because she didn't have a mask. When we first interviewed her, she never mentioned giving the victim (Resident A) oxygen and later advised that she had."

The Sacramento Police Department report revealed Sergeant 9 arrived at the facility around 7:12 p.m. After speaking to Officer 7 and Officer 8, Sergeant 9 spoke to RN 1. "I (Sergeant 9) asked [RN 1] if Patient (Resident A) had a "DNR" (do not resuscitate) order on file with the medical staff. [RN 1] seemed to be familiar with the term "DNR" and said [Resident A] did have a do not resuscitate order in his file. I asked [RN 1] to provide me with a copy of the order. [RN 1] retrieved [Resident A's] file and removed a single sheet of paper labeled "Applewood Care Center Treatment Decisions." This unsigned form was dated 01/20/07 and stated, "Resident stated to me that he wants whatever it takes to sustain his life. [RN 1]. Unable to sign." Another employee standing next to [RN 1] told [RN 1] that the form was not a do not resuscitate order."

Review of an undated policy titled "Death of Resident," under the section "Unexpected death and resident is a full code" revealed "Nursing staff shall respond with CPR and call 911 for transport to an acute care hospital." Under the section, "Pronouncement of death," revealed "A resident may be declared dead by a licensed physician or osteopathic physician."

Review of 13 licensed staff (Registered Nurses and Licensed Vocational Nurses), employed by the facility as of 02/01/07 to current, revealed all had current CPR certification, including RN 1, who had an American Heart Association card. According to the "2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Part 2: Ethical Issues" under the heading, "Terminating a Resuscitation in a BLS (basic life support) Out-of-Hospital System" revealed, "Rescuers who start BLS should continue until one of the following occurs: * Restoration of effective, spontaneous circulation and ventilation. * Care is transferred to a more senior-level emergency medical professional who may determine that the patient is unresponsive to the resuscitation attempt. * Reliable criteria indicating irreversible death are present. * The rescuer is unable to continue because of exhaustion or the presence of dangerous environmental hazards or because continuation of resuscitative efforts places other lives in jeopardy. * A valid DNAR order is presented to rescuers."

The 05/05/07, Sacramento County Coroner's Final Report of Investigation identified Resident A's cause of death as "asphyxia due to obstruction of airway by food bolus".

The Department determined the facility failed to:

1) Ensure that on 02/04/07 facility staff performed CPR (cardio pulmonary resuscitation) on Resident A until paramedics arrived and assumed care, as per a physician's order, dated 01/20/07, for "full resuscitation."

2) Follow their policy titled, "Death of Resident," by not ensuring nursing staff responded with CPR.

This failure resulted in Sacramento City Fire Department arriving at the facility and finding Resident A in bed and unresponsive with no facility staff in the resident's room performing CPR, as per Resident A's request "wants whatever it takes to sustain his life." A Fire Fighter indicated Resident A had a heart beat but he was not breathing. We did CPR for about 20 minutes. Resident A was pronounced dead at 6:12 p.m. on 02/04/07.

The above violations presented an imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result and was a direct proximate cause of the death of the patient.