Hopkins Center for Rehabilitation & Healthcare in Brooklyn was recently fined $10,000.00 by the New York State Department of Health for a citation issued during a 2012 inspection. The incident involved an 87 year-old female resident whose advanced directives were not completed and therefore not followed. The resident’s grand-daughter had executed a Do Not Resuscitate order (“DNR”). However, the staff at the facility failed to have the order signed by a physician.
One week later, the resident unfortunately went into cardiac arrest. Staff at the nursing home performed CPR (cardio pulmonary resuscitation), which was against the resident’s wishes. The resident was successfully resuscitated, but suffered a fractured rib. The Department of Health investigated the incident and found it resulted in “actual harm” to the resident.
Under federal regulations all nursing home residents have the right to formulate an advanced directive and to have the advanced directive followed. All residents are also afforded the right to refuse treatment and participation in experimental research.
According to the DOH investigation, a social worker at the Brooklyn facility documented that that DNR was executed on 12/27/11. However, on the date of the incident a week later, the DNR form was not part of the resident’s medical chart.
Upon being found unresponsive on 1/3/12, the nursing supervisor noted that the the DNR status was checked in the medical chart and on the resident’s identification band, but there was no indication that the resident had a DNR. Given the inconsistent documentation in the chart, the nurse determined the resident was a “full code” and CPR was started. It is hard to fault his/her in this situation. It seems the facility procedures and the failure to follow-up on the administrative task of completing the execution of the document is what resulted in this tragic incident.
After undergoing CPR, numerous attempts at the placement of an IV, and intubation, the resident died at the hospital at 10:55PM. A CT Scan confirmed the presence of a fractured rib.
The attorneys at Gallivan & Gallivan focus on issues of the elderly nursing home population. If you have any questions or would like to speak with us about a possible case of neglect or abuse, please contact us immediately.