| 1255 |
PRUITTHEALTH - EASTSIDE |
115391 |
2795 FINNEY CIRCLE |
MACON |
GA |
31217 |
2018-08-17 |
835 |
J |
1 |
0 |
RM0M11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and record review, the facility administration failed to ensure effective monitoring of the Advance Directive system and failed to ensure staff were trained to respond appropriately during an emergency situation in an effort to prevent errors or delays in emergency resuscitative efforts. The facility had a census of 64 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. R A 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 Position Description for the job title of Administrator. The description included that the purpose of the job was to direct the day-to-day functions of the nursing center in accordance with Federal, State, and local regulations that govern long-term care centers, and as may be directed by the Area Vice President, to provide appropriate care for residents. The position description also included a key responsibility of the ability to apply standards of professional practice to operations of nursing facility and to establish criteria to assure that care provided meets established standards of quality. Review of the facility Quality Assurance and Performance Improvement (QAPI) policy revealed a QAPI meeting reference guide documented that the Administrator was responsible for preparing and/or assigning specific information listed in the agenda for the QAPI meeting. During an interview on [DATE] at 12:46 p.m., the Administrator confirmed that she did oversee the QAPI meetings. Review of the facility policy which was in place to address obtaining and maintaining resident Advance Directive documentation in the clinical record via the Do Not Resuscitate Policy: Georgia and Advance Directive: Georgia policy. However, there was no evidence that this system was routinely monitored by the Administrator, to ensure that it was accurately and consistently implemented. Review of the facility policy which was in place for Cardiopulmonary Resuscitation (CPR), one-person policy revealed that 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. However, there was no evidence that this system was routinely monitored by the administrator, to ensure that, in an emergency situation, nursing staff could response and implement the policy appropriately. Record review for Resident (R) A revealed the resident 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. 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] per 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, the note documented that the resident returned to his bed then returned to the bathroom and again turned on the call light. 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 Medication Administration Record (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., Emergency Management Services (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., 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. A telephone interview with the Administrator, Regional Vice President (VP), and the DHS on [DATE] at 11:00 a.m., during review of the A[NAME] with the State Survey Agency (SSA) Regional Director, revealed that the Medical Director had not been involved in the development of the self-imposed IJ plan of action and that a full QAPI committee meeting had not taken place. Additionally, the facility had not reviewed the current Advanced Directive Policy and Procedures as part of the self-imposed IJ action nor had in-services included the CNAs, rather only the licensed nurses had been in-serviced. Therefore, the self-imposed IJ action plan did not remove the I[NAME] Cross refer to F678 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 and 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 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], nor had a full QAPI meeting taken place prior to the survey entrance to investigate the complaint. 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 ensuring the accuracy of Advanced Directives and the Administrator's oversight of this process: 1. The DHS and Senior Nurse Consultant completed an audit of all active resident records on [DATE] and [DATE] utilizing the Advance Directives facility checklist. 2. Review of the Do Not Resuscitate Policy: Georgia by the Area Vice President (AVP) and Senior Vice President of Clinical Services (SVPCS) completed on [DATE]. Policy revision 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. The policy was revised and published on [DATE] to include removal of the above referenced section. 3. The Social Worker (SSD) was terminated on [DATE] for failing to ensure accuracy of DNR list per policy. 4. The Advance Directive Clinical system checklist will be updated upon each new admission or change in advance directive orders by the DHS, Unit Manager or Social Worker (SSD). 5. The Administrator will review the Advance Directive clinical checklist in the QAPI meetings monthly for three months and quarterly thereafter. 6. The Administrator was educated on [DATE] by the AVP on the Administrator job description and responsibilities. The State Survey Agency validated removal of the Immediate Jeopardy as follows: 1. Record review of audit list dated [DATE] and [DATE] confirmed that all active residents medical record were audited utilizing the Advanced Directives facility check list. 2. 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. 3. Review of the personnel records for the SSD confirmed separation notice dated [DATE]. 4. A interview with the DHS on [DATE] at 1:45 p.m. and the Unit Manager, RN FF on [DATE] at 3:45 p.m. revealed the DHS provided evidence that new Physician's Orders and that new admission orders [REDACTED]. Review of the Advanced Directives Clinical system checklist was reviewed on [DATE]. 5. An interview and review of the Advanced Directive Checklist on [DATE] at 12:46 p.m. revealed the Administrator is responsible for review of the checklist and to present the findings to the QAPI meeting monthly for three months then quarterly thereafter. 6. Review of the description with acknowledgment page for the Administrator signed and dated [DATE]. An interview with the AVP on [DATE] at 12:46 p.m. confirmed that he had reviewed the Administrator's job description and responsibilities with the Administrator on [DATE]. An interview with the Administrator on [DATE] at 12:46 p.m. revealed that the DNR policy was reviewed and revised by an ad hoc QAPI committee which including the Medical Director. She confirmed that the Area Vice President (AVP) had reviewed and in-serviced the Administrator on her job description and duties. The Administrator will oversee the A[NAME] plan. She confirmed the SSD and that Licensed Practical Nurse (LPN) OO have been terminated. |
2020-09-01 |