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The Daily Tar Heel

Britthaven Examines Nursing Failure

Britthaven Nursing Centers has less than one week to submit a plan of correction in response to an investigative report citing its nurses' failure to follow facility procedures in response to a patient's death.

According to the Jan. 14 report released by the N.C. Division of Facility Services, a nursing employee did not know proper procedures to alert the nursing staff when she found Lois M. Edwards, 78, dead in her room Dec. 28 at Britthaven, located at 1716 Legion Road in Chapel Hill.

Edwards was discovered with her neck trapped between the bedrail and mattress and her lower body on the floor, reports state.

Although the nurse found Edwards unresponsive at 6 a.m., the report showed that cardiopulmonary resuscitation was not administered until 15 minutes later.

An interview in the report with the nurse on duty indicated that she initially panicked when she discovered Edwards. "'I wasn't sure what to do. ... What stumped me was that she ... had obviously been dead for several hours. ... I didn't start CPR right away. ... I admit I was wrong in that,'" the report stated.

Interviews with other nurses in the report indicated that three out of the five nurses who responded to Edwards did not know the facility emergency codes that are used to alert staff and summon help.

In the event of a cardiac arrest, one nurse said she would start CPR and call for help. "'I would page for the code. ... What is the code?'"

The report indicated that the nurse paused to think for "approximately 32 seconds" before remembering that it would be a Code Blue.

Britthaven is required to submit a plan of correction by Jan. 27 that will address the measures or changes that are needed to ensure the deficient practice will not occur again.

Bill Mullinix Jr., Britthaven's regional vice president of operations, said the nursing home's primary concern was for the loss suffered by the Edwards family.

"We had viewed this as a tragic accident from the very beginning," he said. But, he said, "we have taken all serious steps to ensure safety for all our current patients."

Mullinix said that the details of in-service training are internal information and that they are undisclosed to the public.

According to a memo attached to the survey report, inspectors concluded that the nurses' response to Edwards' death represented "isolated deficiencies" that possessed the "potential for more than minimal harm" unless corrective actions were taken.

Jim Jones, spokesman for the N.C. Division of Facility Services, said that after Britthaven submits its plan of correction, officials will evaluate the plan to determine if it fully addresses Britthaven's problems.

If the plan is accepted, inspectors will return to the nursing home to evaluate whether the plan has been implemented, Jones said.

"An interesting footnote is that although (Britthaven) was not required to report the death, they did self-report it," he said.

Mullinix said Britthaven has cooperated with all investigations.

"We immediately began retraining our staff the day of the accident," he said. "It was ongoing when the state (authorities) got there."

Mullinix emphasized that the nursing home's ongoing concern will continue to be the loss suffered by the Edwards family.

"This has been difficult for our staff and certainly for the family," he said. "I mean, we are in the business of taking care of people."

The City Editor can be reached at citydesk@unc.edu.

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