On Christmas Eve last year, the staff at Woodland Oaks Healthcare Center in Ashland failed to perform CPR on a dying resident, a state citation alleges, even though the resident had signed an order asking for resuscitation.
In February 2008, John Karem said, he arrived at Jefferson Manor Nursing Home in Louisville to find an emergency medical technician performing CPR on his 95-year-old mother, Eva. This was done, her son says, even though the nursing home had do-not-resuscitate — or DNR— orders on file.
The two alleged incidents point to a gap in Kentucky law that can lead to errors at the bedside of the dying: There is no uniform regulation about how to denote a patient's wishes regarding resuscitation in a long-term care facility or a hospital, according to Sadiqa Reynolds, inspector general for the Cabinet for Health and Family Services.
"What we saw on the night of our mother's death was a large man pounding on her chest," said Karem.
"Was she somehow aware that this was not going the way she wanted?" he asked. "The questions keep coming. ... But the pain, agony, frustration and anger just linger."
Karem says he has filed a complaint with Reynolds' office in his mother's case and met last week with Reynolds and state Rep. Bob DeWeese, to try to come up with a better way to alert caregivers to a person's wishes and prevent errors.
"We will continue to talk with provider groups, advocates, families, legislators and surveyors to ensure that whatever action is taken is well thought out and clear, because we all have the same goal of respecting residents' wishes," Reynolds said.
Federal and state laws require that hospitals and nursing homes keep do-not-resuscitate orders in a patient's chart. But when it comes to how those orders are carried out at the bedside, it is up to the facility. Some use color-coded wrist bands, colored tape on residents' doors or stickers on their charts.
In Ashland, the resident's death led to the state issuing Woodland Oaks the most serious citation a nursing home can get. "The facility failed to ensure their system for identifying residents' code status was accurate and effective," said the Type A citation issued Jan. 12.
The nursing home was also cited for failing to identify the incident as potential neglect, which delayed an investigation, according to the citation, which the Herald-Leader obtained through an open-records request.
The nursing home is appealing the citation, according to Cheryl Harrison, an attorney for Woodland Oaks.
"We strongly and categorically deny these allegations," said Harrison. "We have investigated the matter and the allegations are simply not supported by the facts."
Beth Fisher, a spokeswoman for the cabinet, said that Woodland Oaks had corrected the problem that led to the citation.
'Far from ... a solution'
In Kentucky, groups are debating whether guidelines for adhering to a patient's wishes should be the subject of proposed legislation in the General Assembly or simply added to existing administrative regulations.
Bernie Vonderheide, president of Kentuckians for Nursing Home Reform, attended the meeting last week with Karem and Reynolds. Vonderheide said that any solution should be mandated so that it will be followed uniformly. He said he likes the idea of a uniform color-coded wrist band, but is open to other ideas.
Tim Veno, president and CEO of the Kentucky Association of Homes and Services for the Aging — a group that represents long-term care providers — was also at the meeting and is asking that a panel of professionals come up with recommendations.
He doesn't think a new law is necessary if best practices are followed.
Veno, a former inspector general for the cabinet, said that one concern is that wrist bands could cause skin irritation, since residents would wear them for extended periods.
DeWeese, R-Louisville, said he is in favor of a working group to decide how to move forward.
"We are far from having a solution," said DeWeese. "We are trying to create a system that would decrease the chances of these things happening."
In the Louisville case, John Karem provided the Herald-Leader with a copy of a DNR order sent to Jefferson Manor by Louisville physician John U. Varga a day before Karem's mother died.
In a Feb. 23 statement, Varga confirmed that order and said he hoped that the unfortunate incident would lead to changes that would prevent "unnecessary disrespect, trauma and cost" in the future.
Pat Mulloy, president of Louisville-based Senior Care Inc. which owns Jefferson Manor, declined to comment.
Uniform procedures sought
Hospitals are trying to fix the problem too. The Kentucky Hospital Association recently surveyed hospitals about their methods and next month is putting together a team that will decide on voluntary uniform procedures, possibly including a colored wrist band, according to spokeswoman Elizabeth Cobb.
In Lexington, Central Baptist Hospital places information about a patient's DNR status on the front of his or her chart and each member of the medical team that responds to the bedside has the correct information, said spokeswoman Ruth Ann Childers.
She said that Central Baptist does not use colored wrist bands because there is no uniform color for DNR bracelets. She said Central Baptist will put a staff member on the Kentucky Hospital Association team.
University of Kentucky Chandler Hospital has several overlapping methods to document DNR status, said palliative care medical director Kristy Deep. The status is included in a patient's electronic medical record and denoted by a colored placard on a patient's chart that accompanies patients when they leave their rooms for tests. Additionally, the status is displayed on a board at the nurse's station and communicated at shift changes.
Cobb said she knew of no DNR errors at the bedside at Kentucky hospitals.
But a 2007 study by two physicians at the University of California, San Francisco, showed that there were several reports of resuscitation errors in a survey of 127 medical centers across the United States.
Survey respondents described a case in which CPR was withheld despite a stated preference to be revived and cases in which CPR was administered on patients who had signed DNR orders.
At those hospitals, methods of identifying a DNR order varied significantly. The California researchers concluded that a uniform colored wrist band used nationwide would prevent errors.
One group in Kentucky that does have a uniform policy is emergency medical service technicians, who require a signed order in hand or a DNR bracelet before they agree not to resuscitate.
Karem said that a uniform colored wrist band for nursing home residents would cost very little and would eliminate confusion. "It would provide the home with accountability and would diminish liability," he said.