In the August event, a resident was found deceased in her bed by a CNA. The CNA immediately got an RN, who determined that the resident was cold, stiff, and mottled half way up and deemed calling the ambulance unnecessary as it would just result in the EMTs telling the RN to contact the coroner. The RN indicated the resident had no pulse, no respirations, and no blood pressure. The POST for this resident was to administer CPR even if pulse and breathing are not detected.
The other event documented was the facility failed to ensure clear and consistent documentation of advanced directives, 4 of 6 residents were affected by this. The inconsistent documentation included not updating current POST, no updating proper stickers that indicate directives, miscommunication between the POST and the computerized profile, and RN not being CPR certified. The immediate jeopardy began on 4/5/15 and was removed on 8/10/15 when the facility began to in-service staff on CPR and how to determine resident’s codes. The facility has also mention discussion of replacing the stickers with a sheet of colored paper for a quick reference on resident’s proper POST.
To review a summary of the 2015 IJ/SSQCs and the August 2567, click here.