Health inspection·May 30, 2025

F 0678 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure life sustaining measures were initiated to 1 (R1) of 3 residents reviewed for Cardio-Pulmonary Resuscitation (CPR) in a sample of 6. The findings include: R1's admission Record documents an admission date of [DATE] with diagnoses including Encounter for Palliative Care, Chronic Pain Syndrome, Amyotrophic Lateral Sclerosis (ALS), Anxiety, Major Depressive Disorder. Special instruction document Residential Hospice of Southern Illinois. R1's Hospice Initial Plan of Care dated [DATE] documents a start of care date of [DATE] with a Terminal Diagnosis of Amyotrophic Lateral Sclerosis (ALS). This same document is marked yes under the category of DNR (Do Not Resuscitate). R1's facility Care Plan documents a Focus area of R1's wish is to be resuscitated and CPR to be initiated if his heart stops with an initiation date of [DATE]. Interventions documented include: all staff should perform Heimlich maneuver if choking and proceed with CPR, all staff should provide CPR if R1 goes into cardiac arrest, if R1 should be hospitalized for routine tests/treatments/procedures please send copy of written CPR orders/signed POLST (Practitioner Order for Life Sustaining Treatment) with other orders, and nursing please ensure R1's chart is marked with a blue dot to indicate CPR status and obtain POLST from physician. R1's Practitioner Order for Life Sustaining Treatment (POLST) form dated [DATE] documents yes under Section A. Orders for Patient in Cardiac Arrest next to CPR. Under Section B. Orders for Patient Not in Cardiac Arrest is marked Selective Treatment: Primary goal is treating medical conditions with limited medical measures. This form is signed by V9 (Power of Attorney) and dated [DATE]. R1's Progress Note dated [DATE] at 8:42PM by V4 (Licensed Practical Nurse/LPN) documents, this nurse entered resident room at approximately 8:20PM to administer bedtime meds to resident and his roommate this nurse noted that resident was pale in color and skin was cold to the touch and resident did not appear to be breathing. No pulse detected. This nurse had CNA (Certified Nursing Assistant) to get 2nd nurse to verify. Both nurses confirmed at 8:25PM by auscultation of apical pulse for one minute. That resident had expired at 8:25PM. This nurse notified family at 8:35PM, administrator at 8:40PM, hospice at 8:38PM, and VA at 8:47. On [DATE] at 11:06AM, V4 stated she worked on [DATE] and her shift started at 6:00PM. V4 stated as she was passing her evening medications, she entered R1's room around 8:15PM-8:20PM and just glanced Page 1 of 2 145386 145386 05/30/2025 Southgate Health Care Center 900 East Ninth Street Metropolis, IL 62960

F 0678 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few at R1 in bed 1, and noted he appeared to be sleeping on his back with his arms on top of the blankets, and head of bed elevated 45 degrees. V4 stated she went over to Bed 2 and administered his medications and spoke with the family for a couple of minutes. V4 stated as she was leaving the room she looked at R1 and his skin was very ashen in color. V4 stated she then went to the bed side and noted R1's hands were ice cold, and she felt to see if R1's chest was rising at all. V4 stated she next checked for a pulse in R1's wrist and neck and could not feel a pulse. V4 stated she then stepped at the doorway and seen a CNA and asked them to get the other nurse and have her bring in the stethoscope. V4 stated V6 (LPN) arrived, and they both checked pulses and for 1 full minute and no pulse was detected. V4 stated she then left the room to make the phone calls to family, MD and Administrator. V4 stated I assumed (R1) was a DNR because he was under Hospice care. On [DATE] at 10:12AM, V9 (Power of Attorney) stated R1 was once a DNR but then changed to a Full Code with CPR only and no tubes (intubation). V9 stated she talked to R1 about this, and this is what they decided to do. V9 stated I feel like (R1) only had a few weeks left, but God knew that was the day for him to go home and he took him. V9 stated she was not so upset over the CPR not being done and if he was extremely cold it would not have helped anyway. V9 stated ALS has 5 stages and the last time R1 was evaluated he was stage 4, but he progressed quickly to the last stage. On [DATE] at 9:56AM, V12 (Medical Doctor/MD) stated he was R1's physician. V12 stated R1 had ALS that was progressing quickly as of recently. V12 stated he had seen R1 just 2 days before he expired and he noted increased weakness, and condition progressing quickly. V12 stated he suspects R1 passed from a Pulmonary Embolism, Cardiac Arrest, or a mucous plug due to his diagnosis. V12 stated he was aware that R1 was a Full Code status without intubation. V12 stated from what was reported to him, R1 was found extremely cold to touch. V12 stated he was not present but if he was here, he could not have done CPR on R1 with that observation of resident being extremely cold and without vital signs, as it would be ethically immoral. V12 stated he is 95% sure R1 would not have survived even with CPR and is 100% sure R1 would not have survived without intubation. V12 stated CPR would have only damaged R1's chest cavity for no reason. R1's Certificate of Death documents a date of death of [DATE] and documents the causes of death as a. Cardiopulmonary Arrest b. Respiratory Failure c. Amyotrophic Lateral Sclerosis. A facility Final Report dated [DATE] documents On the afternoon of Tuesday 5/13 about 2:30pm this writer was made aware of concerns about if CPR was performed on a Full code Hospice resident that had expired on the evening of 5/12 at 8:20pm. Full investigation began. After multiple interviews, witness statements, camera review and interview with Nurse in question, it was noted that (R1) was discovered dusky and cold at about 8:20pm on the evening of [DATE] and CPR was not performed. The facility policy titled Code Blue/DNR Procedures with an effective date of [DATE] and a revision date of [DATE], documents Responsibilities: It is the responsibility of the current nurse on staff to verify and adhere to each resident's code/DNR status. 145386 Page 2 of 2