Aviata At Tallahassee

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 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] 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]. 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] 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] 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] 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] 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] 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] by social services indicated Resident #1 was a FULL CODE.

Hospice nursing notes dated, [DATE] & [DATE] indicated Resident #1 was a FULL CODE. A review of Resident #1's care plan, revised on [DATE], 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], revised on [DATE]) 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

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