cms_GA: 1257
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rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
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1257 | PRUITTHEALTH - EASTSIDE | 115391 | 2795 FINNEY CIRCLE | MACON | GA | 31217 | 2018-08-17 | 868 | J | 1 | 0 | RM0M11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review, and review of the Quality Assurance and Performance Improvement policy, the facility failed to utilize the Quality Assurance and Performance Improvement (QAPI) system to oversee the Advance Directive system and 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 to 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 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 orders [REDACTED]. 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 (QAPI), 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: Review of the facility Quality Assurance and Performance Improvement policy, which was in place, revealed that the policy documented that the purpose of the QAPI program was to continually take a proactive approach to assure and improve the way the facility provided care and engaged with patients, partners, and other stakeholders so that the facility may fully realize their vision, mission, and commitment to caring pledge. The facility's QAPI committee included the Administrator, Medical Director, Director of Health Services (DHS), Clinical Competency Coordinator (CCC), West Wing Unit Manager, Therapy, Admissions, East Wing Unit Manager, Social Services Director (SSD), Activities Director, Business Manager, Maintenance Director, Medical Records Director, Skin Integrity Registerd Nurse (RN), Minimum Data Set (MDS) Coordinator, Dietary Services, Environmental Services and Central Supply/Transportation. The QAPI committee met monthly, at the end of the month. The facility had a system 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 through the QAPI process, to ensure that it was accurately and consistently implemented. Review of the facility Cardiopulmonary Resuscitation (CPR), one-person policy, which was in place, 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 through the QAPI process, to ensure that, in an emergency situation, nursing staff could respond and implement the policy appropriately. 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. 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 entries 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. 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 orders [REDACTED]. 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 [REDACTED]. 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 QAPI monthly for three months or until substantial compliance is obtained for three months. A telephone interview with the Administrator, Regional V.P., and the DHS on [DATE] at 11:00 a.m., during review of the A[NAME] with the State Survey Agency 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. 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. He further revealed that he had not been involved in developing the facility's self-imposed IJ plan but was involved and approved the facility's A[NAME] plan. The facility implemented the following actions to remove the Immediate Jeopardy per the A[NAME] dated [DATE] related to QAPI: Facility failed to educate all licensed staff according to the self-imposed plan of correction initiated on [DATE]. Facility failed to audit the Advance Directive system for compliance using the Advanced Directive clinical system checklist. 1. On [DATE] the Administrator, DHS, Area Vice President (AVP), Senior Nurse Consultant (SNC) and Senior Vice President of Clinical Services (SVPCS) met via telephone conference for an ad hoc QAPI meeting to establish interventions for the cited incident. The Medical Director was also called by the DHS on [DATE] and communicated the interventions included in this Allegation of Compliance (A[NAME]). The Medical Director concurred with interventions listed in the A[NAME]. 2. Review of active staff listing was completed to ensure accuracy. Terminated employees will be removed and/or identified on the active staff listing. 3. Newly hired licensed and certified staff will be provided with the education prescribed in the self-imposed plan of correction ([DATE]) will be completed with all licensed and certified staff prior to working, by the CCC or DHS. Completion percentages are noted in each section of the A[NAME]. 4. Newly hired licensed and certified staff will be provided with the education prescribed in the self-imposed plan of correction upon orientation. 5. DHS and Senior Nurse consultant completed and audit of all active resident records on [DATE] and [DATE] utilizing the Advance Directive facility checklist. 6. 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). 7. Education compliance related to F580, F656, F726, F835 and F868 will be reported to QAPI by the CCC monthly for three months and quarterly thereafter as needed. The Administrator is specified as the staff person responsible for implementing the acceptable plan of correction. The State Survey Agency validated removal of the Immediate Jeopardy as follows: 1. During an interview and record review with the Administrator on [DATE] at 12:46 p.m. confirmed by reviewing emails and meeting signatures dated [DATE] which included the Medical Director's signature that he had approved the A[NAME]. 2. On [DATE] review of the revised active list of employees to verify the correct number of RNs, Licensed Practical Nurses (LPNs) and CNAs have been educated on the new policies and procedures for verifying Advanced Directives and updating with any change in Physician Order, Code process and procedure, use of the Automated External Defibrillator (AED), and care planning. 3. Review of the in-service sign in sheets with the CCC on [DATE] at 1:20 p.m. revealed that as of [DATE] that RNs, LPNs, and CNAs had been in-serviced on the new policy and procedures to verify code status of residents via the resident's chart. 4. An interview with the CCC on [DATE] at 12:01 p.m. and the DHS on [DATE] at 1:45 p.m. revealed that both had been educated by the SNC regarding MD notification policy for change of condition on [DATE] and on [DATE]. Review of the sign in sheets confirm the in-services. Verification of sign in sheets for Licensed Nurses confirmed that on [DATE], 20 licensed nursed had completed the in-service on Change of Condition with one nurse on [DATE]. 5. Record review and an interview with the DHS on [DATE] at 1:45 p.m. of the Advance Directives facility checklist dated [DATE] and [DATE] confirmed that all active resident's records had been reviewed to ensure that their Advance Directives were correct. 6. An interview with the DHS on [DATE] at 1:45 p.m. revealed that she currently responsible for updating any new admissions or residents with a change in their Advanced Directives until the new Social Worker (SSD) is hired and educated on the process. 7. Review of the in-service sign in sheets with the CCC on [DATE] at 1:20 p.m. revealed that as of [DATE] that RNs (87.5%), LPNs (100%), and CNAs (88%) had been in-serviced on the new policy and procedures to verify code status of residents via the resident's chart, care plan updates, new resident or change in condition reporting, new Advance Directive Policy, responsibilities during a code and use of the Automated External Defibrillator (AED). 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 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 |