The Nebraska Department of Health and Human Services has completed its investigation into how a woman was mistakenly pronounced dead at a Waverly nursing home last month.
Investigators interviewed facility staff and others after the incident involving the 74-year-old woman, who was on hospice care because of a terminal illness.
At 9:30 a.m. June 3, a nursing assistant told a registered nurse that the woman was "not breathing." The registered nurse noted that the resident "had no carotid pulse," which can normally be felt on either side of the neck just below the jaw.
Ten minutes later, the registered nurse told the hospice nurse that the resident had no pulse, and notifications to the physician and funeral home were sent out.
Around 9:55 a.m., the nursing home contacted the woman's next of kin.
The person who was contacted had just arrived at the facility and received the call about the resident's death as they were in the facility's parking lot.
They entered the building after the call but did not want to see the woman at that time, according to the report.
More than an hour later, at about 11:10 a.m., the 74-year-old was picked up at the nursing home by a transport company to be taken to Butherus Maser & Love Funeral Home near 40th and A streets in Lincoln.Â
The HHS surveyor who completed the report interviewed the funeral director on June 4. The funeral director said the woman was brought to the funeral home at approximately 11:45 a.m. in a body bag on a gurney.
Staff at the funeral home then moved the 74-year-old from the gurney onto a table to begin the embalming process. After the funeral director adjusted the woman's head, they heard a noise "like a gasp or grunting sound," according to the report.
Staff then discovered the woman was breathing and called 911.
The woman was transported to Bryan East Campus, where she died later that afternoon. The funeral director said the resident had been at the funeral home for about five minutes total.
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According to the report, the person who had been contacted about the death of the 74-year-old woman was notified by hospital staff at about 12:40 p.m. that the resident was found breathing while on a table at the funeral home.
The person told the HHS investigator that they were upset by the incident because "I would have gone in to see (the 74-year-old woman) while at the facility if I had known (she) was still alive."
That person ultimately arrived at the hospital before the resident died.
An HHS review of the facility's checklist for a death in the nursing home revealed that several steps had been skipped that morning, likely leading to the mistake.
Nurses at The Mulberry at Waverly are instructed to "note the absence of vital signs, no (blood pressure), no pulse, no respirations."
Next, they are supposed to have a second licensed nurse verify vital signs. If a second nurse is not available, the director of nursing is to be notified and the Lancaster County Sheriff's Office should be called to come out and verify the death.
The registered nurse in this case "failed to take the resident's blood pressure," and did not have a second nurse verify vital signs, despite the fact that another nurse was confirmed to be on duty at 9:40 a.m. that day, according to the report. The facility suspended the nurse.
Lancaster County Sheriff's Office Chief Deputy Ben Houchin said at a news conference the day of the incident that the Sheriff's Office was not called to the nursing home about a death.
On June 6, The Mulberry at Waverly updated its process for the death of a resident, revising the checklist it had in place and educating all staff on the new changes.
Those changes were not noted in the report.
During its investigation, HHS also examined the records of two other residents who had died recently.
Another resident's records showed "no evidence of documentation regarding the unidentified nurse completing an assessment to determine the absence of vital signs." The Mulberry at Waverly nurse consultant said an assessment should have been done and documented.
A letter sent to The Mulberry at Waverly from HHS on June 24 said the facility "failed to completely and accurately assess patients after they have a change in condition."
As a result of the HHS investigation, the facility was put on probation for 180 days beginning July 9. It is the second time this year the facility has been put on probation. It is unclear how this probation affects a previous 180-day probation period that started March 13 after the nursing home failed to follow a medical provider's orders in the death of another resident.
A 74-year-old woman who was thought to be dead at The Mulberry at Waverly nursing home on June 3 began showing signs of life later in the day at a Lincoln funeral home. She was taken to the hospital and later died, according to the Lancaster County Sheriff's Office.