Aviata At Tallahassee
Inspection Findings
F-Tag F0678
F 0678
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Level of Harm - Actual harm Residents Affected - Few
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review, policy review and staff interviews, the facility neglected to provide basic life support, including cardiopulmonary resuscitation (CPR) to 1 of 3 residents (Resident #1). The facility neglected the resident's needs for emergency care allowing the resident to expire despite a full code status.The findings include: A
review of the electronic medical record (EMR) revealed Resident #1 expired on [DATE REDACTED] at 1:05 PM and that CPR was not performed. Staff A, a Registered Nurse (RN), provided a statement of events that took place
on [DATE REDACTED]. At 1:05 PM, the nurse observed that the resident was not breathing. She checked vital signs with respirations 0, blood pressure 0, and oxygen saturation 0%. On 1:09 PM, Staff A notified the hospice nurse by phone to tell of Resident #1's death. At 3:00 PM, another nurse working in the facility noted Resident #1 was a full code. At 3:02 PM, 911 was called and CPR was started on Resident #1. At 3:06 PM, Paramedics arrived and continued CPR on Resident #1. At 3:25 PM, Paramedics declared Resident #1's death. In an interview with the Director of Nursing (DON) on [DATE REDACTED] at approximately 3:30 PM, the DON stated it is the expectation of the nurse to complete a CPR flowsheet and document a timeline of events in
a nursing note anytime CPR is completed. In an interview with Staff B, a Licensed Practical Nurse (LPN) on [DATE REDACTED] at approximately 12:01 PM, the LPN was asked where the code status for any resident could be found. The LPN replied, the code status is in the EMR and the advance directives book at the nurses station. In an interview with Staff E, an LPN on [DATE REDACTED] at approximately 4:11 PM, the LPN stated for an unresponsive resident you would always check for breathing and a pulse and verify the code status of the resident, found in the EMR and the advance directives book at the nurses station. In an interview with Staff F, an LPN on [DATE REDACTED] at approximately 4:23 PM, the LPN stated that a yellow DNR form must be signed and completed in order to not perform CPR. If you have a resident that requires CPR you would document the timeline of events, starting with the condition of resident prior to the code, to the time the residents body is taken out of the facility. An order dated [DATE REDACTED] for FULL CODE (FULL CODE indicates CPR is desired in
the event a resident's heart stops beating) was observed in the EMR.The advance directive discussion document completed on [DATE REDACTED] by social services indicated Resident #1 was a FULL CODE. Hospice nursing notes dated, [DATE REDACTED] & [DATE REDACTED] indicated Resident #1 was a FULL CODE. A review of Resident #1's care plan, revised on [DATE REDACTED], stated Resident has an advanced directive: FULL CODE.A review of the EMR did not include a CPR flowsheet or a nurses note summarizing the event and timeline. A review of the facility policy named Florida Cardiopulmonary Resuscitation (CPR) (effective [DATE REDACTED], revised on [DATE REDACTED]) stated, Cardiopulmonary resuscitation (CPR) will be provided to all residents who are identified to be in cardiac arrest unless such resident has a fully executed Florida Do Not Resuscitate (DNR) order.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
Facility ID:
If continuation sheet
Event ID:
AVIATA AT TALLAHASSEE in TALLAHASSEE, FL inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in TALLAHASSEE, FL, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from AVIATA AT TALLAHASSEE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.