$10K fine stems from resident death

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The Brookdale Deer Creek assisted living and memory care community has been fined a total of $10,000 by Florida's Agency for Health Care Administration for two violations stemming from the death of a resident in October 2014, according to a final order [PDF] recently issued by the agency.

The Agency for Health Care Administration says the Deerfield Beach, FL, community failed "to provide appropriate care and services to meet the needs of residents" and "failed to ensure access to adequate health care consistent with established and recognized standards."

The agency interviewed several people who work at the community (identified in the order as Emeritus at Deer Creek; Brookdale Senior Living and Emeritus Senior Living announced the completion of their merger on July 31, 2014). The report relays differing accounts of communication between several staff members, among them an aide and a med tech, as well as differing accounts of the assessment and care of the resident, who reportedly told the aide he thought he was having a heart attack at 7:45 a.m. on Oct. 12, 2014.

Ultimately, the resident was found unresponsive in the community's dining room around 9 a.m., according to the agency's report, which noted that no evidence exists that anyone called a physician or the resident's daughter after the resident initially had relayed his concerns and before he died. Some staff members said they told others to call 911 at various points during the hour and 15 minutes that passed since the resident's initial complaint. A nurse said she called 911 after the resident was found unresponsive. Paramedics arrived but stopped their assessment of the resident once the nurse determined that he had a do not resuscitate order in place. The resident was pronounced dead at 9:15 a.m.

The Florida Agency for Health Care Administration also maintains that the community "did not thoroughly investigate the events," that information in the resident's chart was incomplete or lacking, that community CPR and DNR policies weren't detailed enough and that 22 direct-care staff members were not current in their CPR training.

The community's administrator reported the adverse event to the Florida Agency for Health Care Administration on Oct. 17, 2014. The agency's order indicates that employment of the nurse and med tech was suspended immediately.

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