Care facilities fined for failure to administer CPR, failure to call 911

By: Clark Kauffman

A pair of Iowa care facilities are facing sanctions for failing to provide medical assistance for their residents, two of whom died.

Earlier this month, the Iowa Department of Inspections and Appeals proposed, but held in suspension, an $8,700 fine for the Aspire of Donnellson nursing home. In that case, the home had failed to attempt cardio-pulmonary resuscitation, or CPR, for two residents, both of whom died.

In the first of those two cases, according to state reports, a male resident of the home was found in his bed at 5:15 a.m. on Jan. 18, ashen colored with no pulse or respirations. The aide who found him later told inspectors the man was still warm when found. According to the inspectors, the aide had checked on the man after noticing his light was on, suggesting he was up or at least awake.

After noticing the man wasn’t breathing, the aide summoned a nurse and asked whether they should initiate CPR. The aide allegedly told inspectors the nurse never answered and instead called the family to report the man was dead.

The nurse told inspectors that he had not been “exactly sure” about the resident’s code status which would indicate whether attempts to resuscitate him should be made, according to state reports. He acknowledged, however, that it was later determined the man was “full code,” indicating CPR should have been attempted.

Eleven days after that incident, a female resident of the home was found unresponsive in bed at about 10 p.m. The woman’s guardian and family were notified, and a funeral home was summoned to pick up the body. Although the resident was “full code,” no one on staff had attempted CPR, according to state reports.

According to inspectors, the nurse who examined the resident that night later stated she didn’t know the resident’s code status. but said the woman’s hands and feet were purple in color. An aide who was present said the woman was still warm when found. A third employee who worked that night told inspectors she didn’t know how to determine a resident’s code status and hadn’t been trained in such matters, according to state records.

Separately, the state inspections department fined the Silvercrest Garner Farms assisted living program $3,500 for failing to promptly contact emergency medical services for a resident who was in respiratory distress.

Early on the morning of March 2, the staff found a resident on the floor, with her oxygen-saturation level somewhere in the range of 90% to 100%, according to state records. (Typically, an oxygen-saturation level below 92% is considered dangerous.) The staff reported they telephoned the on-call nurse and left a message but never received a call-back.

Later that day, the resident was again found on the floor, this time with their oxygen-saturation level in the 80s, suggesting urgent intervention was needed. Again, the staff reported calling the on-call nurse and leaving a message, but without receiving a call-back.

The following evening, the resident’s daughter found the resident lying on the floor with an oxygen-saturation level in the 80s. The daughter asked that her mother be sent to the hospital and 911 was called.

According to state inspectors, the director of nursing later concluded the staff had failed to ensure that the correct on-call schedule for nurses was available to workers. The on-call nurse the staff had been trying to reach wasn’t even employed by the facility at the time of the incident, according to inspectors.

The inspectors’ report does not indicate whether the resident survived, but notes that after she was taken to the hospital, she was admitted for treatment of COVID-19.

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Care facilities fined for failure to administer CPR, failure to call 911