Health inspection·June 1, 2023

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, review of the dialysis contact, and review of the facility policy on change in condition the facility failed to ensure Resident #65's emergency contact/ family was notified regarding his change in condition requiring cardiopulmonary resuscitation (CPR) and transport to the hospital. This affected one resident (#65) out of three residents reviewed for change in condition. The facility census was 64. Findings include: Review of the closed medical record for Resident #65 revealed an admission date of [DATE]. The resident expired at the hospital on [DATE]. His diagnoses included acute respiratory failure with hypoxia, dependence on renal dialysis, ventilator dependent, diabetes, atrial flutter, tachycardia, biventricular heart failure, and tracheostomy. Review of the care plan dated [DATE] revealed Resident #65 had advanced directives to be a full code. Interventions included full code, adhere to his desired code status, and inform the resident and/or responsible party should the resident change his decision regarding his code status. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #65 had impaired cognition and was rarely and/or never understood. He required oxygen, suctioning, and dialysis. He also had a tracheostomy and ventilator. He required two person staff assist with bed mobility and was unable to transfer and/or ambulate. Review of the nursing note dated [DATE] at 8:10 A.M. and completed by the Director of Nursing revealed Resident #65 was unresponsive and without vitals while at dialysis. The note revealed CPR was initiated and the emergency rescue squad (EMS) was called. CPR continued with (Automated External Defibrillator) AED in place until the ambulance arrived and he was transported to the hospital. The note revealed dialysis was to make the family aware of the resident's transfer. Interview on [DATE] at 8:20 A.M. with Resident #65's sister revealed she was upset that the facility and/or dialysis had not contacted her that her brother had a change in condition while at dialysis requiring CPR and transfer to the hospital. She revealed she was not notified until later in the day by the coroner that Resident #65 had passed away. Interview on [DATE] at 8:14 A.M. with Licensed Practical Nurse (LPN) #600 revealed she was Resident #65's nurse on [DATE]. She revealed he had gone to dialysis which was next door, and she was contacted over a walkie-talkie that he had stopped breathing and had no vitals requiring CPR. She revealed Page 1 of 2 365411 365411 06/01/2023 Andover Village Retirement Community 486 S Main St Andover, OH 44003

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few dialysis had contacted EMS and transported him to the hospital. She verified she had not contacted Resident #65's emergency contact/family as she thought dialysis had. She revealed she did not realize the family was not notified until they had called her upset on [DATE] early afternoon and stated they had received a call from the coroner that he had passed away. Interview on [DATE] at 10:12 A.M. with the Director of Nursing revealed any time there was a change in status at dialysis including requiring CPR and/or sending a resident to the hospital, dialysis was to contact the family. She verified on [DATE] while Resident #65 was at dialysis he had a change in condition requiring CPR and was sent to the hospital where he was later pronounced dead. She verified the facility and/or dialysis had not contacted the family as Resident #65's sister was notified later in the day on [DATE] by the coroner of her brother's passing. Interview on [DATE] at 10:59 A.M. with LPN #605 revealed he worked at the facility on [DATE] and was assigned the respiratory therapy duties as he revealed if the facility did not have a respiratory therapist that they would assign a specific nurse just to do those duties. He revealed dialysis had called for respiratory assistance to come to the dialysis center on [DATE] at approximately 7:45 A.M. He revealed when he arrived at the dialysis center, Resident #65's skin color was not good, and he had no pulse. He revealed they initiated CPR and contacted EMS who transported him to the hospital. He verified he had not contacted Resident #65's family regarding the change in condition. Interview on [DATE] at 1:56 P.M. with Dialysis Regional Operations Manager #610 stated, the nursing home should have called the emergency contact/ family for Resident #65's change in condition but dialysis should have contacted the family as well. She revealed both dialysis and the facility missed it and verified neither contacted the family. She revealed she felt it was the primary residence which would have been the facility's responsibility to contact the family. She revealed she did not have anything specific in writing that included who should notify regarding a change in condition but revealed she recently had a meeting with the dialysis staff after the incident had occurred on [DATE] and educated the staff that they were to contact the family regardless, so the same situation did not occur again. Interview on [DATE] at 2:15 P.M. with the Administrator revealed per the dialysis contract dated [DATE] the dialysis center and the facility would develop a systematic approach to handling situations if a dialysis patient had a change in condition. She verified she did not have anything in writing that acknowledged the systemic approach of who would contact the family regarding the change in condition. Review of the Home Hemodialysis Coordination Agreement, dated [DATE], between the dialysis center and the facility revealed the dialysis center and the facility would develop a systematic approach to handling situations where a dialysis patient had a condition change and/or became ill during dialysis including knowing who would be contacted, who decided whether to stop dialysis, and who documented the situation. There were no specific approaches listed as to who was responsible for notifications to the family in regards to change in status. Review of the facility policy labeled, Change in Resident's Condition or Status, dated [DATE], revealed it was the policy of the facility to promptly notify the resident, his/her attending physician and representative of changes in the medical/mental condition and/or status. This deficiency represents non-compliance investigated under Master Complaint Number OH00143046. 365411 Page 2 of 2