A nursing home in Waukegan was fined after a delay in CPR for a resident led to his death and the nursing assistant who found the resident said she “didn’t know what to do,” an investigation showed.
Elevate Care Waukegan, located at 2222 Audrey Nixon Boulevard, was among six nursing homes in the state that were cited for an “AA” violation by the Illinois Department of Public Health (IDPH) in the fourth quarter of 2024.
An “AA” violation under Illinois’ Nursing Home Care Act is the most severe type of violation and is issued when a violation of rules creates “a condition or occurrence relating to the operation and maintenance of a facility that approximately caused a resident’s death,” the statute says.
An IDPH investigation into Elevate Care Waukegan was completed on October 8, 2024.
IDPH alleged that Elevate Care Waukegan did not meet resident care policies, life-sustaining treatments and general requirements for nursing and personal care.
Based on interviews and record reviews conducted by IDPH, state health officials said Elevate Care Waukegan failed to have an effective process in place for staff to quickly identify a resident’s code status and the facility failed to immediately provide cardiopulmonary resuscitation (CPR) to a resident (R1) who was found not breathing and pulseless.
“These failures led to a delay in R1 receiving CPR and R1 dying in the facility. These failures apply to 1 of 6 residents (R1) reviewed for deaths in the facility in the sample of 6,” the IDPH complaint said.
The resident was cognitively impaired with diagnoses of dementia, stroke, dysphagia and schizophrenia and was dependent on the staff for all care.
The resident’s care plan stated that they wanted full treatment and CPR in the event of a cardiac arrest.
Their physician orders for life-sustaining treatment also stated that staff should attempt CPR and provide treatment in the event of a cardiac arrest.
On September 20, 2024, staff reportedly found the resident unresponsive and pulseless in his room at 6:29 p.m., the complaint said.
A registered nurse (RN) started CPR on the resident until the paramedics with the Waukegan Fire Department arrived on scene at 6:35 p.m. and took over CPR.
The resident was pronounced dead in the facility at 7:10 p.m., IDPH said. The cause of death was ruled as cardiopulmonary arrest.
In an interview conducted by IDPH, a certified nursing assistant (CNA) said she fed the resident dinner that same evening.
“(R1) was fine at dinner. I fed him in his room while he seated upright in his Geri Chair (reclining wheelchair). When I went back to check on him, about a half hour later, he didn’t look right. He was still sitting in his chair. His eyes were open. I called out his name and he didn’t respond. He didn’t look at me. I didn’t check to see if he was breathing. I don’t know if he had a pulse. I didn’t know what to do,” the CNA said.
“I left the room to go find the nurse (V7, RN). I found the nurse (V7) in another resident’s room and asked him to come look at (R1). (V7) walked down to (R1’s) room with me. He checked for a pulse on (R1) and tried to get (R1) to respond. (V7) then walked out of (R1’s) and said he had to go check to see what (R1’s) code status was. (V7) went to the nurses station and checked (R1’s) code status on the computer. (R7) came back into the room and started CPR on (R1) because he said (R1) was a Full Code,” the CNA said.
The CNA said she was CPR certified but did not check the resident for a pulse or yell for help when she found him unresponsive because she “didn’t know what to do” and was “nervous.”
The CNA further said that from the time she entered the resident’s room and found him unresponsive to the time the RN started CPR on the resident was “probably at least a few minutes.”
“We had to get (R1) up out of his chair to do CPR,” the CNA said.
When the CNA was asked how to quickly identify a resident’s code status, she said, “I don’t know. I would have to ask the nurse.”
The RN was also interviewed by IDPH.
“(V5) asked me to come look at (R1) because she said he didn’t look right. I got up and went down to (R1’s) room. He was up in his wheelchair. He was not responding to me. I tried to feel for a pulse on him, but I couldn’t feel one. I didn’t know if he was a Full Code or not, so I went out to a computer at the nurses station to check. I saw in the computer (R1) was a Full Code. I went back in to his room and tried to feel for a pulse again. I didn’t feel a pulse on (R1), so I called a code and started CPR on him,” the RN said in the interview.
“If I don’t know a resident’s code status, I have to check their medical record on the computer at the nurses station,” the RN added.
The resident’s physician said that if a resident that is a full code is found not breathing and without a pulse, then staff should start CPR immediately because a delay in CPR could cause death.
The physician said he did not know the details surrounding the resident’s death in the facility but stated, “I just know he died of cardiac arrest.”
The director of nursing was interviewed and said, “If staff find a resident unresponsive and the resident is a Full Code, they should check for a pulse and start CPR immediately. Staff are not to leave the resident. They are supposed to shout for help. There really isn’t a quick way to verify the code status of a resident. Staff either have to check the chart in the computer or check the DNR (do not resuscitate) lists we have located in the binders on the crash carts on the floors.”
Three licensed practical nurses (LPNs) said that the only way to verify a resident’s code status is to leave the resident’s room to check the electronic medical records on the computers in the nurses stations, the complaint said.
Two other CNAs were interviewed and both said that they did not know how to check a resident’s code status.
Elevate Care Waukegan was fined $50,000 for the “AA” violation.