The New York State Department of Health (DOH) fined Glengariff Health Care Center, a 262-bed facility located in Glen Cove, New York, $22,879 for numerous deficiencies that contributed to the death of a 65-year-old resident. The affected resident had suffered from a stroke and was also diagnosed with multiple sclerosis and dysphagia, a medical condition in which a person has difficulty swallowing. Because the patient had difficulty with eating and swallowing food, his care plan called for aspiration precautions; such precautions identify patients who are at risk of choking and require that patients be supervised while eating.
On July 21, 2013, a certified nursing assistant (CNA) gave the resident his lunch tray around 12:15 p.m. The CNA then left the patient alone in his room to eat his meal. She stated that she always left the patient alone to eat and told a DOH investigators, “I let him eat alone; I don’t remember hearing that it wasn’t allowed.” However, when the CNA returned a 1:00 p.m. to collect the resident’s lunch tray, she found him slumped over in his wheelchair and foaming at the mouth. The CNA then notified a licensed practical nurse (LPN), who found the patient unresponsive and without a pulse. The LPN then summoned another nurse for assistance. The nurse quickly assessed the situation and left the room to announce a “code blue” over the intercom.
In the meantime, the LPN transferred the resident to his bed with the help of an aide. A nursing supervisor arrived in the patient’s room, but she quickly left to get a “crash cart.” When the nursing supervisor returned to the room with the car, she then initiated CPR. She did not use an Automated External Defibrulator (AED), a device that administers electrical shocks to help restart a patient’s heart. When 911 emergency personnel arrived, they used their AED in an attempt to save the resident, who was then transferred to the hospital. He died a short time later.
During an interview with DOH investigators, the Medical Director of the facility stated that he did not know about the nursing home’s policies and procedures regarding CPR. However, the director did state that “any patient on aspiration precautions should always be supervised when eating.” A DOH report concluded that staff members failed to provide CPR in a timely fashion and that the “Administration failed to develop and implement policies and procedures for CPR and aspiration precautions; failed to ensure staff were knowledgeable of when to initiate CPR.” The facility was also cited for failing to conduct a thorough investigation into the resident’s death.
According to the “Nursing Home Compare” website, the facility was rated as being much below average. The facility’s health inspection records were also rated as much below average.
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