| 1254 |
PRUITTHEALTH - EASTSIDE |
115391 |
2795 FINNEY CIRCLE |
MACON |
GA |
31217 |
2018-08-17 |
678 |
J |
1 |
0 |
RM0M11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and record review, the facility failed to accurately assess the Advance Directive status and provide continued Cardiopulmonary Resuscitation (CPR) for one resident (A) and failed to ensure the Advance Directive status was accurately reflected on the physician's orders for two residents (#2 and #3), from a total sample of 19 residents. An Abbreviated/Partial Extended Survey investigating complaint GA# 560 was initiated on [DATE] and concluded on [DATE]. The complaint was substantiated with deficiencies. On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Administrator and Director of Health Services (DHS) were informed of the Immediate Jeopardy on [DATE] at 3:30 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on [DATE]. The Immediate Jeopardy continued through [DATE] and was removed on [DATE]. The facility implemented a Credible Allegation of Compliance related to the Immediate Jeopardy on [DATE]. The immediate jeopardy is outline as follows: Resident (R) A had not executed an Advance Directive. RA experienced a change in condition on [DATE], becoming unresponsive while staff attempted to assist the resident out of the bathroom, after he had sustained an unwitnessed fall. Cardiopulmonary resuscitation (CPR) was initiated by certified nursing staff, and Emergency Medical Services (EMS) were notified. However, the resident's Advance Directive status was inaccurately assessed by licensed nursing staff as Do Not Resuscitate (DNR) and CPR was stopped, prior to the arrival of EMS services and in absence of Physician's Order to stop resuscitative efforts. The inaccurate Advance Directive status of DNR was obtained by licensed nursing staff from an incorrectly labeled form included in the Medication Administration Record (MAR) book. The DHS pronounced the resident's death at the facility on [DATE] at 7:09 a.m. at which time she notified the physician and family. The DHS was not aware the resident's Advanced Directive status was inaccurate until notified by the family later in the morning of [DATE]. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE] in the areas of 42 CFR 483.10 Resident Rights, F580; 42 CFR 483.21 Comprehensive Resident Centered Care Plans, F656; 42 CFR 483.24 Quality of Life, F678; 42 CFR 483.35 Nursing Services, F726; 42 CFR 483.70 Administration, F835; and 42 CFR 483.75 Quality Assurance and Performance Improvement, F868, all at a Scope and Severity (S/S) of a [NAME] Additionally, Substandard Quality of Care was identified at 42 CFR 483.24 Quality of Life, F678. A Credible Allegation of Compliance was received on [DATE]. Based on observations, record reviews, interviews and review of the facility's policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed on [DATE]. The facility remained out of compliance at a lower scope and severity of D while the facility continued management level staff oversight of the advance directive system and continued education. This oversight process included the analysis of facility staff's conformance with the facility's Policies and Procedures governing the accurate acquiring of the necessary steps to ensure the continuity of care. In-service materials, policies and records were reviewed. Observation, record review and interviews were conducted with staff to ensure they demonstrated knowledge of facility Policies and Procedures. Findings include: The facility had a Do Not Resuscitate Policy: Georgia. The policy included that a written list of all residents who have DNR orders would be kept in the front of the current MAR book. The Social Worker (SSD) would be responsible for keeping the list updated. The facility also had a Cardiopulmonary Resuscitation (CPR), one-person policy. The policy documented that the facility provided basic life support, including initiation of CPR, to any resident who experiences [MEDICAL CONDITION] (cessation of respirations and/or pulse) in accordance with that resident's Advance Directive or in the absence of Advance Directives or a DNR order. 1. Resident (R) A was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A review of the Advance Directives Checklist form, dated [DATE], revealed that the resident had not executed an Advance Directive and did not wish to discuss Advance Directives further at that time. The resident had a Physician's Order since at least [DATE] for oxygen to be administered continuously at two liters per minute via nasal cannula. R A was care planned for being at risk for falls, use of a wheelchair for mobility and able to ambulate short distances. A care plan was also in place, dated [DATE], for being at risk for respiratory complications. The care plan problem included that the resident would adjust his own oxygen setting and refuse to wear oxygen at times. During an interview on [DATE] at 12:07 p.m., a family member of R A stated that the resident was a full code and wanted to know why the resident was not sent to the hospital on [DATE]. R A experienced a change in condition on [DATE]. A Nurse's Note, dated [DATE] at 5:15 a.m., documented that a Certified Nursing Assistant (CNA) reported that the resident complained of shortness of breath and was sitting on the commode in the bathroom, not wearing his oxygen. The CNA applied the resident's oxygen nasal cannula and the resident returned to bed. The note further documented that the CNA reported that the resident returned to the bathroom and pressed the call light again. The resident again complained of shortness of breath and was not wearing his oxygen. The note continued to document that the CNA replaced his oxygen and exited the bathroom. A subsequent nurse's note on [DATE] at 5:20 a.m., documented that the resident was observed on the floor, in the bathroom, between the commode and the wall. The resident stated he could not get up. The note further documented that the resident was moved, by staff, from between the wall and commode and into his room and became unresponsive. The note continued to document that CPR was initiated and an oxygen saturation level and carotid pulse were unable to be obtained. At 5:30 a.m., 911 was notified and an ambulance dispatched while CPR continued to be performed. A 5:40 a.m. Nurse Note entry documented that a MAR record review indicated that the resident was a DNR and CPR was discontinued at that time. At 5:45 a.m., the DHS was notified that R A had expired and at 5:50 a.m., EMS personnel arrived and were notified that the resident was a DNR, therefore they left the facility. Nurse's Note entry document that the DHS arrived and pronounced the resident as deceased at 7:09 a.m. and that the physician was notified at 7:15 a.m. and the resident's responsible party at 7:20 a.m. However, the DNR status that was documented on the MAR record, referenced in the [DATE] 5:40 a.m. Nurse's Note entry, was not accurate and was not consistent with the Advance Directives Checklist form that documented that the resident had not executed an Advance Directive. A review of the facility investigation, initiated on [DATE], revealed that the DNR list that was included at the front of the MAR book had been incorrectly labeled by the former Social Service Director (SSD). During an interview on [DATE] at 11:08 a.m., the former SSD, who came into the facility for the interview, confirmed that the DNR list was an error and should have been labeled as the behavior management list. There was no evidence that an attempt was made to verify the accuracy of the DNR form maintained in the MAR book and Resident A's Advance Directive status, through a review of his clinical record, prior to the cessation of CPR. During interviews on [DATE] at 4:24 p.m. with Licensed Practical Nurse (LPN) OO and on [DATE] at 7:28 a.m. with LPN PP, both of whom were present and responded to the resident's change in condition on [DATE], both confirmed that they did not look for Advance Directive information in the resident's chart. In addition, there was no evidence that the DHS verified R A's Advance Directive status prior to pronouncing his death on [DATE] at 7:09 a.m. During an interview on [DATE] at 1:45 p.m., the DHS confirmed that she did not verify the resident's Advance Directive status prior to pronouncing his death on [DATE]. During an interview on [DATE] at 11:47 a.m., the Medical Director stated that he would have expected the nurses, including the nurse who pronounced the resident's death, to have look at the resident's clinical record for the Advance Directive status. Review of the State of Georgia, State Office of Vital Records, Pronouncement of Death dated time of death [DATE] at 7:09 a.m. and signed by the DHS. Review of the Georgia Death Certificate Worksheet-Medical Record form revealed the following cause of death, [MEDICAL CONDITION], Chronic [MEDICAL CONDITION] Fibrillation, and Chronic Systolic Heart Failure which was signed by the MD on [DATE]. 2. Resident #2 was admitted to the facility on [DATE]. An Advance Directives Checklist form was completed on [DATE] and documented that the resident had not executed an Advance Directive at that time. The resident's Advance Directive status changed when a Physician's DNR Order Form for Adult Patient/Resident With Decision -Making Capacity: Georgia form was signed by Resident #2 on [DATE] and by the physician on [DATE]. However, a review of the clinical record revealed that the Advance Directive status was inaccurately documented on the (MONTH) (YEAR) Physician order for [REDACTED]. 3. Resident #3 was admitted to the facility on [DATE]. An Advance Directives Checklist form was completed on [DATE] and documented that the resident had not executed an Advance Directive at that time. The resident's Advance Directive status changed when a Physician's DNR Order Form For Adult Patient/Resident Without Decision-Making Capability With Durable Healthcare Power of Attorney Only: Georgia was completed on [DATE]. However, a review of the clinical record revealed that the Advance Directive status was inaccurately documented on the (MONTH) (YEAR) POF's. The (MONTH) (YEAR) POF documented that the resident's Advance Directive status as Full Code instead of DNR. The (MONTH) (YEAR) POF's were accurate for the DNR status. A facility investigation was initiated on [DATE] and the following concerns were identified and evidenced through review of Nurse Consultant email dated [DATE] stating Eastside will proceed with a self-imposed jeopardy for the following: A facility investigation was initiated on [DATE] and the following concerns were identified: 1. Failure to notify the resident's responsible party of a change in condition timely. 2. Failure to continue CPR once started, without a stop order from the physician. 3. Failure to have accurate DNR lists in the front of the MAR. The facility implemented the following actions to address their identified concerns: 1. A complete audit of all residents' charts to confirm the accurate Advance Directive status. The audit will include Physician's Order, documentation on the Physician's Order Form (POF), documentation on the list in front of the MAR, appropriate signatures from two physicians if the resident is not competent, responsible party signature if the resident is not competent, documentation on the care plan and on the CNA guide. The Advance Directive facility checklist will be used to record the audit. New admissions will have their Advance Directive status verified and documented on admission. New admissions will be verified for accuracy by the DHS or Clinical Care Coordinator (CCC). New admissions will be added to the audit tool and continued until substantial compliance is maintained for three months. Issues identified as a result of the audits will be corrected immediately. 2. Education provided to the Social Worker (SSD) related to the importance of accuracy of advance directive status and completeness of all required paperwork including the list of DNR's in front of the MAR. 3. Education to Registered Nurses (RN) that will be on-call to pronounce, that will include coming to the facility immediately even if they are told the resident was a DNR. 4. Education to nurses regarding once CPR is started (even if in error), it cannot be stopped unless a physician orders it stopped. This may be a facility physician, if the CPR was started in error, or the emergency room physician once the ambulance personnel arrive and call the physician. When looking to confirm an advance directive status during an emergency, the chart must be opened and reviewed; looking for Advance Directive paperwork and an order on the POF. Never rely on the list in front of the MAR. 5. These audits and education pieces will be brought to daily stand-up meetings and reviewed by the Administrator. Results will be brought to Quality Assurance Performance Improvement (QAPI) monthly for three months or until substantial compliance is obtained for three months. Review of the facility's implementation of action related to the self-imposed jeopardy that record review revealed the actions were incomplete, and that residents were still at risk including: Care plans did not accurately reflect Advanced Directives, the survey team identified a resident who had no Advance Directive Sheet in their record and that only Licensed Nurses had been educated. An interview on [DATE] at 3:30 p.m. with the Administrator and the DHS revealed that the facility Policy and procedure titled Do Not Resuscitate Policy had not been reviewed or updated as of [DATE]. Therefore, this action did not remove the IJ related to accuracy or documentation of Advance Directives. The facility implemented the following actions to remove the Immediate Jeopardy per the A[NAME] dated [DATE] related to Advanced Directives: On [DATE] the Facility Administrator, Director of Health Services (DHS), Area Vice President (AVP), Senior Nurse Consultant (SNC) and Senior Vice President of Clinical Services (SVPCS) met via telephone conference for immediate QAPI interventions to the cited incident. The Medical Director was notified of the interventions via phone on [DATE] and concurred with initial self-imposed interventions as detailed in the below A[NAME]. DHS called MD to follow-up on [DATE] to provide additional interventions and plan progress. 1. A review of the Do Not Resuscitate Policy: Georgia by the Area Vice President (AVP) and Senior Vice President of Clinical Services (SVPCS) was conducted on [DATE]. A policy revision was recommended to remove A written list of all patients/residents who have DNR order will be kept in the front of the current MAR book. The Social Worker (SSD) will be responsible for keeping this list updated. Policy revision was completed by corporate office and published on [DATE] reflecting removal of the above referenced section. The new policy was reflected in education listed in #3 below. 2. The Social Worker (SSD) was terminated on [DATE] for failing to ensure accuracy of the DNR list per policy. 3. All licensed and certified staff were educated from [DATE] through [DATE] by the DHS and CCC to verify advance directive/code status via the resident's chart. Fourteen of 14 LPN's were educated as of [DATE] (100%), seven of eight RN's were educated as of [DATE] (87.5%). Twenty-nine of 34 active CNA's completed education as of [DATE] (85%). 4. All newly hired licensed and certified staff will be educated during orientation. Licensed and certified staff who have not received this education, due to scheduled vacation, FMLA, or an as-needed work status will not work until this education is completed. 5. All licensed and certified nursing staff were educated from [DATE] through [DATE] to continue CPR (even if in error) until a physician orders it stopped, or the resident becomes responsive. Fourteen of 14 LPNS were educated as of [DATE] (100%), seven of eight RN's were educated as of [DATE] (87.5%), and 29 of 34 active CNA's completed education as of [DATE] (85%). 6. The facility DHS, Nurse Managers and/or Administrator will conduct mock code drills to ensure compliance weekly for four weeks and monthly for two months. Results will be communicated by the DHS at QAPI monthly meetings for three months. The State Survey Agency validated removal of the Immediate Jeopardy as follows: 1. Record review of the facility policy titled Do Not Resuscitate Policy: Georgia by AVP and SVP of Clinical Services dated [DATE], revealed the section A written list of all patients/residents who have DNR order will be kept in the front of the current MAR book. The Social Worker (SSD) will be responsible for keeping the list updated had been removed. 2. Review of the personnel records for the SSD confirmed separation notice dated [DATE]. 3. Review of the in-service sign in sheets with the CCC on [DATE] at 1:20 p.m. revealed that on [DATE], [DATE] and [DATE] that 100% of the RNs, LPNs, and that 29 CNAs had been in-serviced on the new policy and procedures to verify code status of residents via the resident's chart, change in condition, nursing runs the code, that once CPR is started then it cannot be stopped without a doctors order and that mock code procedure had been put into place. The facility provided evidence that four mock drills had been conducted by [DATE], with sign-in sheets and evaluation had been completed. The mock codes drills will continue. 4. An interview with the CCC on [DATE] at 1:20 p.m. confirmed that one new staff member had been hired on [DATE] and verified through sign-in sheets that the new staff person had been educated. The CCC confirmed that any new staff, or any staff, not already in-serviced, would be in-serviced on the new policy and procedure for checking the Advanced Directive Status, change in condition, and nursing runs a code and that once CPR is started it cannot be stopped without a doctor's order chart prior to working. 5. An interview with the CCC on [DATE] at 1:20 p.m. verified per review of the sign-in sheets and in-service records that licensed staff and certified staff were educated to continue CPR (even if in error) until they had MD (physician) orders to stop or if the resident becomes responsive. 6. Observation on [DATE] at 11:50 a.m. of a Code Blue being announced in a resident's room over the intercom. Observation of the mock drill in progress by the surveyor revealed that the DHS and Corporate Nurse Consultant were guiding the nurses and CNA's on roles which included: providing CPR and rescue breathing on CPR mannequin, role delegation, step by step instruction on use of AED (Automated External Defibrillator) use, continuation of CPR until mock EMS arrival to take over, notifying the MD, family and charting afterwards. The DHS made a point to clarify that licensed nurse oversees the code, should be in the room with the resident. The mock drill list was reviewed with staff. Staff present ran smoothly through the drill. Review of the Mock Code Drills education checkoff sheet revealed the following: date, time, number of participants (see sign in sheet), nurse in charge on scene, nurse assigned duties, crash cart present and AED utilized and reviewed, scribe assigned and writing, paged code, chart brought to room or reviewed for code status, 911 called, MD and RP called and documented in chart, crash cart restocked and sealed. Record review of Mock Drill form dated [DATE] and interview with the DHS on [DATE] at 1:45 p.m. confirmed the Mock Drills will be conducted weekly for four weeks then monthly for two months. The DHS confirmed that she will present the findings to the QAPI committee monthly. Interviews were conducted with Licensed Practical Nurses (LPN) and Registered Nurses (RN) on [DATE] at 2:15 p.m. with LPN TT and LPN BB, [DATE] at 2:25 p.m. with LPN EEE and LPN UU, [DATE] at 3:45 p.m. with RN FF and LPN KK, [DATE] at 4:00 p.m. with LPN HH, [DATE] at 11:18 a.m. with LPN MM and on [DATE] at 11:30 a.m. with LPN LLL, the Minimum Data Set (MDS) Coordinator revealed that they had participated in in-services on the new policy and procedures for verifying a resident's Advance Directive via the resident's chart, not to discontinue CPR once started even if in error, and the process for conducting a code and roles during the code. They confirmed participating in a Mock Code Drill. Interviews were conducted with Certified Nursing Assistants (CNA) on [DATE] at 2:04 p.m. with CNA XX and CNA ZZ, [DATE] at 2:10 p.m. with CNA GG and CNA VV, [DATE] at 2:35 p.m. with CNA DD and CNA YY, [DATE] at 2:39 p.m. with CNA WW and CNA II, [DATE] at 3:35 p.m. with CNA DDD, [DATE] at 3:40 p.m. with CNA JJ and CNA CCC, [DATE] at 4:00 p.m. with CNA BBB, and [DATE] at 4:05 p.m. with CNA AAA revealed that they had participated in in-services on the new policy and procedures for verifying a resident's Advance Directive via the resident's chart, not to discontinue CPR once started even if in error, and the process for conducting a code and roles during the code. They confirmed participating in a Mock Code Drill. |
2020-09-01 |