Confusion Lead to a Failure to Provide CPR at Facility
Resident at Hilltop Healthcare Rehabilitation & Skilled Nursing Center was cited by the MDH. The Minnesota Department of Health investigated an allegation of maltreatment, in accordance with the Minnesota Reporting of Maltreatment of Vulnerable Adults Act, Minn. Stat. 626.557, and to evaluate compliance with applicable licensing standards for the provider type.
According to the report, an alleged perpetrator, a licensed staff member, neglected the resident when they failed to initiate cardiopulmonary resuscitation (CPR) on a resident who was unresponsive (no pulse, heartbeat, not breathing).
Resident Dies When Facility Failed to Implement CPR
The Minnesota Department of Health determined neglect was substantiated.
The Minnesota Department of Health determined neglect was substantiated. The AP was responsible for the maltreatment. The resident’s Physician Orders for Life-Sustaining Treatment (POLST), signed by the resident’s medical provider and verbally confirmed by the resident’s family member indicated the resident wanted CPR performed if she had no pulse or was not breathing. The AP failed to initiate CPR after the AP found the resident not breathing and without a pulse and waited 40 minutes to notify nursing leadership of the resident’s condition. When nursing leadership arrived at the facility, they initiated CPR and called 911. The resident died.
When interviewed, the unlicensed staff member stated she was confused when the AP called her at home that night stating, “I thought, why is she calling me?” The unlicensed staff member stated the AP told her she did not know what to do and asked the unlicensed staff member for help. The unlicensed staff member stated everyone knew the residents’ POLSTs were kept in their hard copy charts directly behind a resident’s face sheet and were distinguished from other documents because of the POLST’s gold color.
According to the report, when interviewed, a nurse manager stated when she received the phone call from the AP she immediately told the AP to start CPR because she knew the resident was full code. The nurse manager stated she was “really upset” at the AP when she reviewed camera footage and saw the AP sitting behind the desk doing nothing. The nurse manager stated the AP should have been directing the code since she was the team lead and the only licensed staff in the unit, stating at a minimum the AP should have called the code then requested help from a more experienced staff person in the building. The nurse manager stated the resident’s family members were kind and understanding when they were told the resident’s CPR was delayed.
In conclusion, the Minnesota Department of Health determined neglect was substantiated.
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If you have questions or concerns about nursing home injuries and accident, from a failure to comply with Care Plan or other orders including those which lead to a wrongful death suffered by someone you love contact Attorney Kenneth LaBore for a Free Consultation at 612-743-9048.