The young man was admitted to the Texas nursing home for rehabilitation following a car accident that left him with a traumatic brain injury (tbi) and multiple facial fractures. On September 14th, a CNA called a nurse at the facility after she noticed that Evan was not breathing.
Rather than initiate CPR, the nurse scrambled to locate Evan’s medical chart to determine what his families were with respect to resuscitation.
In fact, seven minutes went by between the time the condition was recognized and chest compressions were initiated– missing a crucial 5-minute window to initiate CPR.
By the time paramedics got Evan to a nearby hospital, he was dead.
This incident was investigated by The Texas Department Of Aging and Disability Services when it was discovered the facility was in disarray and had many problems that threatened the safety of patients. Amongst the findings:
- 7 nurses lacked current CPR certifications
- Medical charts of 43 of the facilities patients contained no information regarding resuscitation wishes of the patient
- In other cases where resuscitation wishes were noted on the patient rooms, most of the time they were incorrect
- The facilities ‘crash cart’ contained inadequate medical equipment such as a missing blood pressure cuff, stethoscope and a working flashlight
Nursing homes need to be aware of their residents wishes– to be resuscitated– or not. Certainly, when CPR is requested, it should be initiated as quickly as feasible by staff that are properly trained in the procedure.
While I have no idea of this young-man’s prognosis at the time he was admitted to this facility, it is tragic that the caregivers who were responsible for caring for him lacked the basic training to at least position him for the best outcome possible.
‘Neglect’ cited in death of Fort Worth patient November 15, 2010 Star-Telegram by Darren Barbee
A short delay from out of hospital cardiac arrest to call for ambulance increases survival (PDF) Johan Herlitza*, Johan Engdahla, Leif Svenssonb, Marie Youngc, Karl-Axel A¨ ngquistd, Stig Holmberga, European Heart Journal
Nursing Home Injury Laws: Texas