Compliance Perspective – Resident Death:
The Compliance Officer should review the facility’s policies and procedures with the Administrator, the Director of Nursing and the Compliance Committee to ensure that the facility has a policy in place to ensure the proper care for residents when they are attending special programs and services in the facility. Staff should be trained about the policy and assigned accordingly whenever a special event or program occurs. Staff must also be trained on the function and operation of all equipment and devices used by residents, e.g., ventilators, portable concentrators, and portable liquid tanks. Training will also include how and to whom staff should report equipment malfunctions and a review of the Tag Out-Lock procedure. The Compliance Officer will ensure that an audit is conducted regularly to determine which residents are using equipment or devices that could have lethal results should they malfunction. Also, an audit should be performed on a regular basis to ensure that all equipment or devices are checked weekly and evaluated to make sure they are performing properly.
Last summer during a worship service being held at a Minnesota nursing home, the ventilator tube of a resident attending the worship service became detached setting off an alarm. However, there were no nursing staff around to respond, and it was over an hour b
efore anyone noticed the detached tube and consequently the resident died.
This past January, the Minnesota Department of Public Health (MDPH) issued a report citing the nursing home for neglect in the resident’s death.
The deceased man was a long-term resident of the nursing home and totally reliant on the ventilator. It is reported that when the man was brought into the worship service around 2 p.m., his ventilator was functioning badly, and it was only a few minutes after he arrived that the ventilator’s alarm went off. A pastoral staff member involved in the service reportedly heard the alarm going off but had been told previously to ignore it. About an hour later, this same staff member noticed that the resident’s color was poor and called for help. At that point nursing staff responded, connected the ventilator tube and summoned 911 emergency services. The EMTs arrived and the resident was pronounced dead at 3:36 p.m.
The resident’s death was determined to be the result of asphyxia related to the ventilator tube’s being disconnected. The resident’s physician reported that the results of his recent examination of the resident would indicate that the man would not have died otherwise.
The nursing home did not appeal the finding; but, responded to the incident by creating a policy that requires “ventilator-trained staff to be available at all activities where ventilator-dependent residents attend.
The nursing home’s spokesperson issued this statement, “When an unfortunate incident occurs, the facility’s team — supported by additional nursing, medical, and professional staff — systematically reviews all processes and procedures related to the incident. From that review, any changes determined necessary are implemented immediately and without delay, in order to assure no other residents are placed at risk.”
