| 6400.33(a) | Individual #1 was seen in the emergency department on 1/19/15 and diagnosed with an upper respiratory infection. Due to shaking, coughing with emesis and vomiting, Individual #1 was taken again to the emergency department on 1/30/15 and the diagnosis was the same. A chest x-ray was completed and showed that Individual #1's lungs were "grossly clear." Individual #1 was prescribed an antibiotic and medication for nausea and/or vomiting. Additional instructions were to follow up with primary care physician within 2-3 days. The nursing notes regarding Individual #1, dated 1/31/15 read "awake and alert today...po intake good, remains afebrile, intermittent cough continues, no emesis; and on 2/1/15, "seen today lungs clear, afebrile...eating well, no emesis." On 2/2/15, at 5:00 AM, Individual #1 reported to Staff Person #1 that s/he did not "feel good." At 5:30 AM, Staff Person #2 reported that Individual #1 appeared tired which s/he had for the past few days. At approximately 7:25 AM, Staff Person #1 called Staff Person #2 into the room because Individual #1 "felt warm." Individual #1's temperature was not taken. Staff Person #2 attempted to call Staff Person #3, the "on-call" supervisor, but did not get an answer. Staff Persons #1 and #2 dressed and put Individual #1 into his/her wheelchair and then wheeled him/her into the kitchen. Staff Person #2 proceeded to prepare Individual #1's medications, while Staff Person #1 proceeded to assist other individuals. Staff Person #2 was speaking to Individual #1, but when there was not a response, s/he called Individual#1's name, repeatedly. Upon hearing Staff Person #2 calling the individual's name, Staff Person #1 entered the kitchen. Individual #1 appeared pale, grayish in color and was unresponsive when shaken. Staff Person #1 checked Individual #1 for a pulse, none could be found nor did it appear that Individual #1 was breathing. At 7:40 AM, Staff Person #2 called the Staff Person #3, the "on-call" supervisor, who instructed him/her to call 911. Staff Person #2 immediately called 911. The 911 dispatcher gave instructions to lay Individual #1 on the floor and on the administration of CPR. Staff Person #1 and Staff Person #2 wheeled Individual #1 from the kitchen to the living room and lowered him/her to the floor. Staff Person #2 began chest compressions and then Staff Person #1 took over doing chest compression until EMS's arrived. EMS continued manual compressions and intubated Individual #1. Individual #1 was transported to the hospital via ambulance. The hospital records read: Individual was "down 15 minutes prior to EMS, unclear bystander CPR (?)." Individual was pronounced dead at the hospital at 8:26 AM. | An individual may not be neglected, abused, mistreated or subjected to corporal punishment. | The Medical/Psychiatric Emergency policy was revised so that staff (1) can more clearly identify when 911 is to be called, (2) call 911 when such situations occur, (3) follow instructions from EMS personnel and (4) notify management staff after EMS staff are providing on-site intervention. This was completed by Executive staff by: 2/20/2015. During a mandatory training module presented by the CCI Human Resources Department, the revised policy was reviewed by direct support and management staff and nursing personnel. This was completed by: 4/18/2015.The revised policy was placed in all Management Handbooks by management staff. This was completed by : 5/5/2015.The revised policy will be reviewed with new hires at Induction Training by the Human Resources Trainer, and annually with all staff during First Aid, CPR and health-related regulatory reviews. Additionally, during On The Job trainings for staff new to working at a particular site the manager or night shift supervisor, or their designee will review the revised OJT checklist. This will be on-going. All nurses were reminded that follow-up appointments are to be made as recommended subsequent to an Emergency Room visit or hospitalization. This was completed by executive staff already but will be reviewed during the nursing staff meeting scheduled in May.TD: 5/27/2015.Based on the CCI Medical Screenings / Interventions policies and procedures a designated group of staff (Best Possible Health Committee) will design a training module addressing various health related issues which may be experienced by people receiving services and expected interventions by staff relative to such issues. The training module will be presented sequentially during regular monthly staff meetings. D for design of training: 8/8/2015 Implementation will be on-going. |
05/04/2015
| Implemented |