Highland Square Nursing And Rehabilitation

F 0678 Interview with LPN #346 on [DATE REDACTED] at 11:39 A.M. revealed she was working on [DATE REDACTED] on another unit downstairs when LPN #341 called for help. LPN #346 went to the third floor and assessed Resident #61 and Level of Harm - Immediate asked staff for the resident's code status. However, they couldn't find Resident #61's chart. LPN #346 stated jeopardy to resident health or she checked for pulses, and the resident was mottled. When EMS arrived, they declared Resident #61 dead. safety LPN #341 said she called the DON at that point, and she called Resident #61's sister. There was a nurse and two CNAs working on the third floor at the time and no code was called. Residents Affected - Few

Interview with CNA #368 on [DATE REDACTED] at 1:51 P.M. revealed on [DATE REDACTED] she was working on the third floor and went into Resident #61's room. Resident #61 was on the toilet, and she saw his hands were yellowish, CNA #329 asked Resident #61 if he was okay. CNA #329 said Resident #61 mumbled. LPN #341 was in and out of room several times. CNA #368 reported Resident #61's pulse was faint at first, but a couple minutes later

the pulse was gone. CNA #368 indicated Resident #61 was not taken off the toilet and CPR was not completed. EMS said Resident #61 was DOA and left the facility. CNA #368 reported the audible signal to

the call light system was disconnected that night; the cord from the annunciator panel at the desk had been disconnected. CNA #368 revealed when she arrived for her night shift she saw Resident #61's call light was

on but there was no sound. CNA #368 said she checked the call light panel and saw Resident #61's call light had been on for more than 30 minutes.

Interview with LPN #341 on [DATE REDACTED] at 1:56 P.M. revealed CNAs were outside of Resident #61's room when

they heard a sound on the wall and they entered the room. When LPN #341 entered the room Resident #61 was on the toilet. LPN #341 checked for a pulse and found no signs of a pulse. Resident #61 was slumped forward, his hands were purplish, face was pale, and his skin was warm. LPN #341 said she called 911 and asked the aides for his chart. A second nurse came up to help. LPN #341 had looked at the computer and Resident #61 was a full code. EMS arrived and declared Resident #61 dead. LPN #341 reported they were not able to complete CPR because they could not get the resident off the toilet.

A follow-up interview with LPN #341 on [DATE REDACTED] at 8:09 A.M. revealed at the time of the incident, she went to

the computer to find Resident #61's code status. LPN #341 stated she was not sure who found the chart, but

it was nowhere to be found on the third floor. LPN #341 confirmed Resident #61 did not have a pulse when

she first assessed him.

Interview with LPN #307 (unit manager) on [DATE REDACTED] at 8:33 A.M. revealed a resident's code status could be found in the electronic medical record and the nurses always had access to a computer.

Review of the facility's Emergency Procedure-Cardiopulmonary Resuscitation policy and procedure dated [DATE REDACTED] revealed if an individual was found unresponsive and not breathing normally, a licensed staff member who was certified in CPR/BLS was to initiate CPR unless it was known that a DNR order that specially prohibited CPR and/or external defibrillation existed for that individual or if there were obvious signs of irreversible death (e.g., rigor mortis). If the resident's DNR status was unclear, CPR was to be initiated until it was determined that there was a DNR or a physician's order not to administer CPR.

This deficiency represents non-compliance investigated under Complaint Number OH00165334.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 5 365316