Per a recent New York State Department of Health (DOH) survey, Avalon Gardens Rehabilitation & Health Center, a 353-bed Smithtown, Long Island nursing home facility, failed to have a proper system in place to quickly determine if a patient had a Do-Not-Resuscitate (DNR) in place. The DOH stated that the situation was widespread and placed residents in immediate jeopardy of suffering harm.
In December 2012, a three-year-old pediatric patient who was diagnosed with brain damage was admitted into the facility’s pediatric unit. Although the young child was in a vegetative state, the patient was placed on a ventilator. The child’s parents signed a DNR order informing staff members not to perform CPR in the event of a medical emergency. On February 1, 2014, a certified nurse’s assistant became concerned when she saw that the child’s face was pale. After the young patient was assessed by a nurse, a code blue was called. Nurses at the facility immediately arrived in the pediatrics unit and began performing life-saving measures on the child. When 911 emergency personnel arrived, they began performing chest compression. A staff member who observed what was happening immediately informed the emergency workers that the child had a DNR order. All life-saving measures were immediately stopped and the child soon died.
Facility policy states that a red dot should be placed in patient’s chart and wristband if he or she has a DNR order in place. Staff members later discovered that the child was wearing the band with the red dot on the ankle, not the wrist. An administrator stated that all staff members involved in the incident were suspended. On February 26, 2014, a DOH inspector observed that “nine residents on the pediatric unit did not have identification bracelets.”
In another instance, a 74-year-old patient was admitted to the facility in December 2011 with a diagnosis of diabetes, hypertension and anxiety. The patient did not have a DNR order in place. On February 12, 2014, a staff member found the resident unresponsive in bed. The resident was not wearing an identification bracelet and staff members did not know if the patient had a DNR. After a staff member left the room to review the patient’s chart, which indicated that the patient did not have a DNR, nurses began performing CPR on the patient. When 911 emergency personnel arrived, the patient was transported to the hospital where he was pronounced dead a short time later. One of the nurses involved in the incident stated, “CPR should be started immediately and [the resident] should have had a bracelet that tells you what to do.”
During the DOH’s investigation into an 82-year-old resident suffering from hypertension, investigators discovered that the resident had signed a DNR order, yet, in February 2014, a DOH inspector observed the elderly resident wearing a bracelet without a red dot.
The DOH’s website notes that Avalon Garden’s overall rating is “much below average.” Its health inspection rating is also “much below average.” Moreover, the facility was issued 10 fire safety deficiencies; the average New York nursing home received 2.6 such deficiencies.