Two patients in a Joplin nursing home died within a week of each other after staff decided not to perform CPR, despite the lack of a do not resuscitate order and despite a nursing home policy requiring life-saving measures be taken in cases where there is no advance directive.

Regulators with the federal Centers for Medicare and Medicaid Services later determined patients at NHC Healthcare in Joplin were in “imminent danger” and ordered immediate corrective measures.

A “statement of deficiencies” prepared by CMS and obtained by the Globe through an open records request under the Missouri Sunshine Law lays out a number problems at NHC, focusing in particular on the care of the two residents who died in February.

In the document, both of the deaths are described as “unexpected,” and records indicate one of those who died was at NHC for rehabilitation only and planned to be released to return home at some point. The report also details a failure of nursing home staff to follow physicians’ orders regarding the administration of treatments, prescription medications, and a lack of understanding as to when and on which patients CPR should be performed.

The documents are based on reviews of medical records, nurses’ notes and direct interviews with more than a dozen of the nursing home staff and the two patients’ primary care doctors. No identifying information for the patients, nurses or doctors is included; the document identifies the parties involved only with job titles and letters or numbers such as “Resident 1” and “RN F.”

Globe attempts to identify the patients through Newton County Coroner records, based on limited information about their deaths provided in the documents, were unsuccessful.

Authorities have allowed the nursing home to remain open and to continue operating after ensuring there are procedures and practices in place that will prevent repeat occurrences of the mistakes. A “plan of correction” included in the document says investigators will follow up at a later date to ensure there have been no further issues.

Multiple voicemail messages left this week for the administrator of NHC Healthcare, 2700 E. 34th St., were not returned.

Lisa Cox, chief of public information for the Missouri Department of Health and Senior Services, said that state agency inspects places such as NHC on behalf of CMS at the same time that it does its own annual licensing inspections. NHC’s last such inspection was conducted Oct. 31, 2018. Cox said that among the 520 nursing homes throughout the state certified for Medicare or Medicaid, there were 35 instances in 2018 in which one received an “IJ” citation — the level of violation NHC received after the deaths. An “IJ” rating indicates an isolated instance of “immediate jeopardy to resident health or safety,” according to Cox.

Records paint a clear picture of two patients’ final day:

‘RESIDENT 1’

“Resident 1” was admitted to NHC Healthcare on Feb. 1 with a urinary tract infection and a catheter already in place. The patient’s physician ordered NHC to conduct bladder training, a form of therapy to treat incontinence, for 45 hours upon admission, to discontinue the catheter at that point and then to monitor urine output for 24 hours thereafter.

In an interview included in the statement of deficiencies, the doctor said those orders were given because nurses had reported that the patient had been pulling on the catheter and losing blood through it. The doctor said all of the recommended steps should have been taken and documented and that monitoring the urine output was particularly important “due to the potential of urinary retention and possible sepsis.”

A certified medical technician, “CMT K,” told investigators that at one point the resident pulled the catheter out completely and staff did not replace it.

“Record review of the resident’s medical record showed no documentation related to the resident’s urinary tract infection, tracking of the resident’s urine output, or related to monitoring or removal of the Foley catheter,” the document says.

An hour before midnight on Feb. 9, the resident was reported as restless and confused, yelling and moaning. The behavior had been going on through much of the evening, beginning when a nurse had to help that patient to their residence hall from the nursing home’s dining room.

At some point that day, a doctor prescribed the patient the anti-anxiety medication Ativan, to be given in two half-milligram doses per day, to help with the agitation, outbursts and confusion. After helping the patient from the dining room, “LPN M” checked out an Ativan tablet and gave it to another nurse, “LPN L,” to administer the patient’s first half-milligram dose of the day around 6 p.m.

According to interviews with both nurses involved in giving the initial Ativan dose, it was not documented that the patient had been given the medication.

The unsettled behavior continued, and the patient eventually lost bladder control. Another nurse, identified in the document as “RN F,” had to help the patient to the bathroom to be cleaned up. After being helped in the bathroom, the patient continued to be restless and cried out. At 7:30 p.m., RN F gave another dose of Ativan.

At 11 p.m., the patient was still moaning and yelling out of confusion. RN F again signed out an Ativan tablet and gave it to the patient. After taking the third dose within five hours of the first, the nurse reported that the resident “calmed down and became sleepy.”

A few hours later, the patient was dead. When RN F discovered the patient’s body after midnight, it was still warm, though the nurse noticed it had begun to turn blue around the mouth and fingertips.

No cause of death was listed in any of the records released by the state.

Despite not having a physician’s orders to withhold life-saving measures such as CPR from the patient, RN F chose not to perform it upon discovering the patient.

The nurse gave contradictory explanations in an interview with investigators, according to the records. At first, officials were told the nurse said the patient’s chart included documents that specified they did not want to be resuscitated, even by CPR. But later, investigators were told RN F “just kind of assumed” all residents had a DNR — do not resuscitate — “in that type of facility.”

According to the document, during the interview with investigators, RN F reviewed the medical record of the patient who died in the early morning hours of Feb. 10 and was unable to find a do not resuscitate order or any other indication that CPR should not have been performed.

Another staff member told investigators in an interview that the nursing home’s staff had been in the process of placing stickers that would indicate each patient’s end-of-life wishes regarding resuscitation and CPR in their medical charts but that not all of the stickers had been placed in the charts at the time.

‘RESIDENT 2’

A monthly nursing summary report of the second resident who died at NHC Healthcare in February and is mentioned in the CMS statement of deficiency indicated “Resident 2” was “alert and oriented,” walked “as much and as often as desired,” was “independent with activities of daily living” and “able to voice needs.”

That report was dated Jan. 14, exactly a month before the resident’s last full day alive. Another evaluation from Feb. 8 said the patient was still independent and “cognitively intact.”

Resident 2 died a week later at approximately 1:10 a.m. on Feb. 15. There also was no cause of death listed.

According to interviews with staff detailed in the CMS document, the patient was found with no heartbeat just minutes after complaining to staff of difficulty breathing. RN F, in an interview with investigators, said another nurse, “LPN D,” requested RN F listen to the patient’s heartbeat and breathing. (The document does not explicitly say whether RN F is the same person who was involved in the care of Resident 1.)

RN F said in the interview that LPN D checked the resident’s chart and found that the patient’s wishes were that staff take all necessary steps to preserve the resident’s life, including CPR. RN F asked peers in the room, “Well, what are we going to do?” according to the interview with investigators.

“LPN D was unsure of what to do,” the document says.

RN F said in an interview that a third staff member, “RN E,” assessed the resident and told the other nurses that doing CPR wouldn’t help because the nursing home didn’t have a defibrillator. According to the CMS document, RN E said in an interview that it wasn’t “worth breaking the resident’s breast bone” to perform CPR, despite having no order to withhold resuscitation and the nursing home’s own policy that it be performed unless specifically ordered prohibited by a resident’s doctor or advance directive.

According to the report, the three nurses decided not to attempt resuscitation.

News tips

If you or a loved one has knowledge of incidents of elder or other medical abuse, contact The Joplin Globe by phone at 417-627-7250 or email news@joplinglobe.com.

The Adult Abuse and Neglect Hotline can be reached at 1-800-392-0210, and a rating and comparison system of nursing homes is also available at medicare.gov/nursinghomecompare.