Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care.
F322 ß483.25(g)(2) NASO-GASTRIC TUBES
Based on the comprehensive assessment of a resident, the facility must ensure that a resident who is fed by a naso-gastric or gastrostomy tube receives the appropriate treatment and services to prevent aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers and to restore, if possible, normal eating skills.
F323 ß483.25(h)(1) ACCIDENTS
The facility must ensure that the resident environment remains as free of accident hazards as is possible.
The facility failed to: 1.) Provide necessary care and services to a resident when staff were not adequately trained in emergency response procedures and cardiopulmonary resuscitation (CPR) techniques to provide initial emergency care during a medical emergency; 2.) ensure emergency airway equipment was stocked and available to nursing staff during a medical emergency; 3.) assess, monitor and prevent aspiration in a high risk resident who had multiple episodes of vomiting and received tube feedings. These failures led to the death of Resident 1 who died after vomiting and then aspirating vomit into the lungs.
Resident 1 was a 44 year old female, admitted to the facility on 5/30/06 with a medical history that included, seizure disorder, deafness, and a history of multiple strokes. The document titled, Resident's Level of Care dated 5/30/06, documented the resident's code status was, "FULL RESUSCITATION."
Review of a neurology report dated 5/25/06, documented the resident's seizures were under "fair control" with none reported since 1/6/06. The resident's last stroke was in March of 2006, which left the resident with left hemiparesis (partial paralyses), right sided neglect and increased visual impairments. The resident had a PEG Tube (a tube surgically inserted into the abdomen to provide nutrition) placed 4 years ago following a major stroke which left the resident with an inability to swallow safely and therefore placed the resident at high risk for aspiration (inhalation of foreign material into the lungs).
During an interview on 6/29/06 at 11:30 a.m., Administrative Staff X stated the resident required one on one 24 hour private caregivers as an admission requirement to the facility. Administrative Staff X stated these caregivers just sat with the resident to, "keep an eye on the resident." These caregivers were not employed by the facility and were provided by an outside agency. There was no documentation in the clinical record of a care plan or physician's orders related to the private caregiver's role or duties performed.
Resident 1's tube feeding care plan, dated 5/30/06, documented the resident was at risk for aspiration and tube feeding complications related to swallowing problems. Approaches included monitoring for nausea and regurgitation.
Physician's orders dated 5/30/06 documented the resident was to receive 250 cubic centimeters (cc's) of formula provided through the PEG tube four times per day.
The resident's Medication Administration Record (MAR) dated 6/1/06 documented the resident received 1000 cc's of formula on 6/1/06 and 500 cc's on 6/2/06. There was no documentation of the amount of formula the resident received on the day shift on 6/2/06.
The resident's seizure care plan dated 5/30/06, documented Resident 1 was at risk for injury related to a history of seizures. Approaches and interventions included staff were to assist the resident during seizure activity by maintaining the resident's airway; monitor for signs and symptoms of toxicity to anti-seizure medications, which included nausea and vomiting; and notify the physician if signs and symptoms of toxicity occur.
Licensed nursing staff documented the following notations in the Interdisciplinary Progress Notes (IDT):
On 5/30/06 at 9:45 p.m., Resident 1 vomited approximately 120 cc's. There was no documentation of assessments performed or that the resident's family or the physician was contacted, as per the care plan.
On 5/31/06 at 2:00 p.m., the resident,"had small emesis (vomit) after bolus (feeding) at 12:00 p.m." There was no documentation of assessments performed or that the family or the physician was contacted, as per the care plan.
On 5/31/06 at 10:00 p.m., the resident had, "Emesis noted 1 hour after feeding and medications were given. Thick white material produced from mouth and nose." (The color of the tube feeding formula was light beige.) There was no documentation of further assessment or that the family or the physician was contacted, as per the care plan.
On 6/2/06 at 11:15 p.m., "CNA reported resident was having a seizure. I went to room, noted resident seizing. When seizing stopped, resident layed [sic] on floor and compressions began. Compressions stopped when resident turned blue and emesis came out of nose and mouth. Absent pulse + respirations noted. 911 called and present at scene. Time of death 11:17 p.m." There was no documentation that staff attempted to clear Resident 1's airway or that CPR continued until the paramedics arrived.
During an interview on 7/5/06 at 11:30 a.m., CNA A (an agency hired sitter) stated she was with the resident the night the resident died. CNA A stated Licensed Staff B administered the resident's tube feeding at 9:15 p.m. Shortly before 10:00 p.m., CNA A assisted the resident to bed. At about 10:00 p.m., the resident began to vomit and attempted to sit up and get into a chair. CNA A pushed the call bell for staff assistance and assisted the resident to the chair.
CNA A stated after about five minutes, a non-licensed staff member arrived and reported the licensed staff were busy in report. CNA A requested the unlicensed staff member go out and get help. CNA A stated it took another "few" minutes before three licensed staff members arrived in the room. CNA A stated the resident continued to vomit.
CNA A stated she urged the licensed staff to suction the resident and stated licensed staff could not decide if a physician's order was needed to suction the resident. CNA A stated she told the licensed staff the resident was a full code and they should not need an order for suction. CNA A stated there was no suction machine in the room. CNA A stated Licensed Staff B then yelled out that the resident was having a seizure and called for the emergency cart. CNA A stated that someone ran out to get the cart and returned stating the emergency cart could not be located.
CNA A stated she and two other staff members moved the resident to the floor and an emergency cart was located and brought into the room. CNA A stated she heard Licensed Staff B say the cart wasn't stocked with the equipment needed for suction. CNA A stated Licensed Staff B performed chest compressions on the resident. CNA A stated vomit was coming out of the resident's mouth while Licensed Staff B performed chest compressions. CNA A stated Licensed Staff B did not attempt to clear the resident's airway or provide oxygen or "mouth to mouth" resuscitation.
During an interview on 7/11/06 at 10:15 a.m., Paramedic C stated the emergency response team received a 9-1-1 call on 6/2/06 at 10:26 p.m. from the facility for a resident having a seizure. The facility did not report a "code" (medical emergency requiring cardio-pulmonary resuscitation) was in progress.
Paramedic C stated that when the emergency response team arrived at the facility at 10:32 p.m., a staff member greeted them at the door and told them the resident was, "gone." Paramedic C stated he observed Resident 1 in bed, unresponsive and not breathing. Paramedic C stated several staff members were in the room and, "no one was doing anything."
Paramedic C stated Licensed Staff B told him she had performed CPR on the resident but stopped because, "It wasn't doing any good." (According to the 2005 American Heart Association guidelines, CPR should be continued until an advanced emergency defibrillator arrives or Emergency Medical System personnel take over. In addition, maintaining a patent airway and providing adequate ventilation is a priority in CPR.)
Paramedic C stated he asked if Licensed Staff B cleared or maintained the resident's airway during CPR. Paramedic C reported Licensed Staff B told him that she was going to do, "mouth to mouth," resuscitation but the emergency cart did not have a pocket mask so she only performed the chest compressions.
Paramedic C stated that as he worked on the resident, staff members told him the emergency cart at first could not be located and when an emergency cart was found, it wasn't stocked with the necessary equipment to clear the resident's airway. He stated staff present at the time did not provide information on what was on the cart. Paramedic C stated Administrative Staff X and another administrative staff came into the resident's room. Paramedic C stated he overheard staff members complain to the administrative staff that the emergency cart was not stocked with the supplies needed to clear the resident's airway.
Paramedic C stated he attempted to intubate Resident 1 to obtain an airway, but the resident's jaw was clenched. Paramedic C placed Resident 1 on a cardiac monitor. He stated no heart activity was detected. Paramedic C said he determined the resident was dead and called for the sheriff/coroner. Paramedic C stated he informed the sheriff/coroner when they arrived that an airway was not attempted by facility staff because supplies were not available, and that facility staff stopped CPR prior to Paramedic C's arrival at the facility.
Paramedic C stated Administrative Staff X informed him that licensed staff were not required to perform or know CPR, but it was encouraged.
On 6/29/06 at 8:15 a.m., during a tour of the facility, Administrative Staff X stated the facility did not have a formal policy for ensuring the emergency carts were stocked and stated licensed staff were expected to keep the carts stocked. Administrative Staff X stated the emergency carts were not equipped with a check list of supplies that were kept on the cart because the inventory of supplies was so basic, a check list was not needed.
On 6/29/06 at 9:00 a.m., (almost one month after the incident), observation of the suction supplies in the main dining room revealed no sterile, soft tipped suction catheter/glove set in the drawer or in the area near the suction machine.
During an interview on 6/29/06 at 11:40 a.m., Administrative Staff X stated she was called at home the evening of Resident 1's death and came to the facility. Administrative Staff X stated she did not know if suction was attempted on Resident 1 during CPR and did not know the details of how Licensed Staff B attempted to obtain the airway. Administrative Staff X stated she did not know if the suction machine or tubing was in the resident's room when she arrived at the facility, but recalled the emergency cart was in the room. Administrative Staff X would not provide their investigation of the incident when requested, but did state licensed staff should have kept up with CPR efforts until the paramedics arrived.
During an interview on 6/29/06 at 12:15 p.m., Administrative Staff X stated the facility used the Lippincott Nursing Manual for facility policies and procedures related to patient care issues such as suctioning, CPR and airway management. Administrative Staff X stated the facility did not have a written policy that instructed staff to refer to the Lippincott Manual, and stated licensed staff were informed of the manual during orientation.
Administrative Staff X provided a copy of Chapter 10 in the Lippincott Manual titled, "Respiratory Function and Therapy" which documented several airway management techniques using artificial airways, were indicated for patients with conditions, such as loss of consciousness, copious respiratory secretions, respiratory distress. A "Nursing Alert" documented to position the patient on the side and suction the oral cavity frequently to prevent aspiration of oral secretions or vomitus.
The Lippincott Manual of Nursing Practice, (Chapter 35, 8th edition) procedure guidelines for Cardiopulmonary Resuscitation documented equipment such as an arrest board, oral airway, bag and mask device, in addition to IV set up, defibrillator, emergency cardiac drugs, and electrocardiograph machine were to be available during CPR. Nursing actions included, open the [resident's] airway, determine the presence or absence of spontaneous breathing, perform rescue breathing, (mouth to mouth or mouth to mask) and maintain an open airway. If there was a palpable pulse, but no breathing present, rescue breathing would be initiated at a rate of 12 times per minute (once every 5 seconds) after the initial two breaths and rescue breathing and external chest compressions must be combined. The procedure guidelines documented the management of foreign-body airway obstruction or cricothyroidotomy (an emergency surgical procedure in which a hole is cut through a membrane in the patient's neck into the windpipe in order to allow air into the lungs) may be necessary to open the airway before CPR could be performed. During an interview on 6/29/06 at 1:50 p.m., Licensed Staff D stated she only worked with Resident 1 the first night the resident vomited and stated she did not contact the physician when the resident vomited. Licensed Staff D stated the resident refused vitals (blood pressure, temperature, respirations) that first night and she didn't want to force the resident because the resident was new to the facility. Licensed Staff D stated she had worked at the facility approximately 10 months and her CPR certification had expired at the beginning of the year. Licensed Staff D stated the facility had not provided inservices or training for CPR.
During an observation on 6/29/06 at 2:10 p.m., Licensed Staff D demonstrated use of the suction machine located in Nursing Station 1. The oxygen canister attached to the emergency cart was empty, the valve on the oxygen canister indicated the oxygen needed to be refilled. Licensed Staff D stated the facility did not have a system for making sure the emergency cart was kept stocked with the necessary supplies.
During an interview on 6/29/06 at 3:50 p.m., Administrative Staff X stated the facility did not monitor licensed staff to ensure they were current on their CPR and stated it was up to the licensed staff to keep up on their CPR certification. (According to the American Heart Association, Basic Life Support CPR certification for healthcare providers should be renewed every one to two years.)
During an interview on 6/30/06 at 9:30 a.m., Family Member Z stated the resident rarely vomited and when the resident vomited, it was an indication the resident was ill and needed prompt evaluation by the physician. Family Member Z stated the facility never notified her that the resident had episodes of vomiting during the 3 days the resident resided at the facility.
During an interview on 2/7/07 at 3:25 p.m., Licensed Staff B stated she was the nurse for Resident 1 the night the resident died. Licensed Staff B stated that evening, at approximately 11 p.m., while Licensed Staff B was in report with Licensed Staff D and another licensed staff, a CNA came down the hall and reported Resident 1 was having a seizure. Licensed Staff B stated she checked the resident's chart and noted the resident was a full code.
Licensed Staff B stated when they arrived in Resident 1's room, the resident was in the wheelchair vomiting. Licensed Staff B stated they moved the resident to the floor and Licensed Staff B started chest compressions. Licensed Staff B stated she could not perform mouth to mouth because the resident was actively vomiting. Licensed Staff B stated she protected the resident's airway by moving her head to the side when she vomited. Licensed Staff B stated there was no suction machine in the resident's room.
Licensed Staff B stated she asked Licensed Staff D and the other licensed staff, to get the emergency cart in order to suction the resident and bring other supplies, such as oxygen and a bag mask, to clear the resident's airway. Licensed Staff B stated nobody could locate the emergency cart.
Licensed Staff B stated the environment became chaotic and could not recall if an emergency cart was ever located. Licensed Staff B stated there was no equipment available to clear the resident's airway. Licensed Staff B stated because of the risk of disease, she would not perform mouth to mouth on a resident without a barrier device and said it probably wouldn't have done any good since suction equipment was not available to clear the resident's airway.
Licensed Staff B stated other licensed staff and several CNA's were present during the emergency and nobody else in the room, "did anything" and stated, "everybody just stood there, frozen." Licensed Staff B stated she was the only one who attempted to do CPR and became fatigued. When the resident turned blue and stopped breathing, Licensed Staff B stated she made the wrong decision and stopped the chest compressions before the paramedics arrived. Licensed Staff B stated staff moved the resident to the bed and waited for the paramedics. Licensed Staff B stated when the paramedics arrived, the paramedics admonished her for stopping CPR prior to their arrival and told Licensed Staff B to place the resident back on the floor to continue chest compressions while the paramedics attempted to establish an airway and revive the resident.
Licensed Staff B stated Administrative Staff X arrived after the resident died. Licensed Staff B stated she told Administrative Staff X that staff needed an inservice on where the carts were and what needed to be on them so an incident like that would not happen again. Licensed Staff B stated Administrative Staff X told her the facility was not required to have a fully equipped emergency cart.
Licensed Staff B stated that prior to the night of Resident 1's death, the facility had not offered inservices on CPR or emergency procedures and stated that was probably because most of the residents in the facility had, "Do Not Resuscitate" orders. When asked where she would go to obtain information about facility policies, Licensed Staff B stated she would ask the administrator or Administrative Staff X. Licensed Staff B stated she was not aware of any manuals the facility used for patient care policies and was never instructed to refer to one specific manual when she worked at the facility.
The coroner's report and death certificate for Resident 1 issued 6/6/06, documented the cause of death as, "1) ASPIRATION; 2) GENERALIZED SEIZURE; 3) SEIZURE DISORDER." The coroner did not perform an autopsy.
In summary, the facility failed to ensure staff were adequately trained in emergency response procedures and CPR techniques to provide initial emergency care to Resident 1 during a medical emergency. The facility failed to ensure emergency airway equipment was stocked and available to nursing staff during a life threatening emergency situation. In addition, the facility failed to assess for and prevent aspiration for Resident 1 who was at high risk for aspiration and received tube feedings, and had multiple episodes of vomiting in the days preceding the resident's death.
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 to the resident and was a direct proximate cause of the death of this resident.