According to the New York State Department of Health (DOH) website, the Diamond Hill Nursing & Rehabilitation Center, a 120-bed facility located in Troy, New York, received 93 percent more health citations than other New York nursing care facilities. On average, most New York nursing homes received 2.2 citations per 100 occupied beds; however, Diamond Hill received 30.6 citations per 100 occupied beds. Overall, the facility was issued 35 citations; 21 of these citations–or 60 percent of them–were related to quality-of-care issues. In addition, the facility received 97.1 complaints per 100 occupied beds; the New York State average for most nursing homes is 34.4 complaints per occupied beds. Overall, the facility received a total of 111 complaints and has received $34,755 in fines over the past three years for providing substandard care.
In response to a complaint stemming from a March 2014 incident, the DOH cited Diamond Hill for failing to perform CPR on a patient who died. According to the DOH report, an elderly resident suffering from cirrhosis and heart failure told staff members that she wished to be resuscitated in the event of an emergency. On March 21, 2014, a certified nursing assistant (CNA) found the resident unresponsive in her bed. The CNA immediately went for help, and a “code blue” was called over the intercom. The assistant director of nursing (ADON) and the director of nursing (DON) were the first to arrive in the patient’s room. They directed staff members to call 911. The two supervisors determined that the resident lacked any signs of a pulse or respiration. However, both nurses decided that the patient “had expired prior to discovery and resuscitation would be fruitless.” In addition, the DON told a DOH investigator that CPR would have been “pointless.” A physician stated that he was called by someone from the facility and was told that CPR was not performed because the resident had been dead for at least two hours.
A licensed practical nurse (LPN) who went to provide assistance during the code blue told investigators that she “could not tell how long the resident had been gone” and that “there were no obvious signs to make this determination.” A registered nurse (RN) who responded to the code stated that the resident was “not really cold.” One CNA told investigators that she was told not to call an ambulance when she asked if she should. The CNA stated that not performing CPR against the patient’s wishes “went against everything they have been taught.” The facility’s CPR policy clearly states that CPR should be administered immediately and that 911 should be called if a patient without a DNR is found without a pulse or respiration.
