There has been yet another elder group home tragedy. An assisted-living resident living in a state in the Midwest was deprived of emergency resuscitation while he was choking because personnel thought he had a do-not-resuscitate order in his file. An ambulance was waiting outside to help, while, inside, nursing home staffers advised emergency personal to stop CPR because of the suspected order. However, the facility’s operator has now been blamed, as staffers withheld CPR because of another resident’s DNR order.
Nursing home deaths appear to be increasing in recent years, as medical errors may be escalating. Pennsylvania health officials are just as concerned as those in other states.
The Minnesota Health Department discovered that this mistake occurred from a simple, yet dangerous, filing procedure. At this facility, all clients’ DNR orders were contained in one binder. Instead of placing these critical resident orders in separate folders, one for each client, using only a single binder paved the way for this tragic error.
As a result of the tragedy and the Health Department report, each resident now has a separate binder with DNR and other critical emergency information. The deceased man had been a resident at the facility for mentally diminished clients since 2010, suffering from hypertension and advancing kidney failure.
Apparently, the resident was coughing in his room. When facility staff called 911, first responders said CPR was required. When personnel found what they believed to be the client’s DNR order, however, they had emergency professionals halt their resuscitation efforts. Consequently, the resident was never even moved to the ambulance, where further emergency procedures may have saved his life.
The facility has a successful 35-year history of providing senior care for mentally diminished clients. This tragedy displays that even seemingly insignificant administrative actions can possibly cause serious personal injury or death in nursing homes throughout the nation.
Source: Star Tribune, “Brooklyn Park group home is faulted in choking death,” Paul Walsh, June 13, 2012