cms_GA: 3476
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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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 3476 | LAUREL PARK AT HENRY MED CTR | 115673 | 1050 HOSPITAL DRIVE | STOCKBRIDGE | GA | 30281 | 2019-02-04 | 655 | J | 1 | 0 | HHND11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and record review, the facility failed to develop a baseline care plan for the advance directive status for one resident (#4) from a total sample of 30 residents. An Abbreviated/Partial Extended Survey investigating complaints GA 836, GA 960, GA 577, GA 661 and GA 672 was initiated on (MONTH) 2, 2019 and concluded on (MONTH) 3, 2019. Complaints GA 836, GA 960, GA 577, and GA 661 were unsubstantiated. After review by the State Survey Agency, further investigation was needed for complaint GA 672, and a re-entry was initiated on (MONTH) 28, 2019 and concluded on (MONTH) 4, 2019. An additional complaint, GA 099 was also investigated. Complaint GA 672 was substantiated with deficiencies. Complaint GA 099 was partially substantiated with deficiencies. As indicated on the facility's Form CMS-672, Resident Census and Conditions of Resident Form, the facility's census on (MONTH) 3, 2019 was 83. On (MONTH) 29, 2019, 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, Nurse Consultant UUU, and Area Vice President were informed of the Immediate Jeopardy on (MONTH) 29, 2019 at 4:15 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on (MONTH) 19, (YEAR). The Immediate Jeopardy continued through (MONTH) 29, 2019 and was removed on (MONTH) 30, 2019. The Immediate Jeopardy is outlined as follows: 1. Resident (R) #4 had not executed an Advance Directive. On (MONTH) 19, (YEAR), R#4 was found in bed, unresponsive, with no vital signs. The resident's Advance Directive status was initially inaccurately assessed by licensed nursing staff as Do Not Resuscitate (DNR) in the electronic record, therefore, no emergency basic life support was immediately provided. The Physician and the Director of Health Services (DHS) were notified. While documenting the incident on a Situation, Background, Assessment, Recommendation (SBAR) form in the resident's clinical record the Licensed staff discovered that the resident had a full code status rather than a DNR status. Licensed nursing staff identified the error of the incorrect Advance Directive status approximately one hour after initially finding the resident unresponsive, at which time, the DHS initiated Cardiopulmonary Resuscitation (CPR) and Emergency Medical Services (EMS) were notified. EMS arrived and continued to provide additional emergency support. However, basic life support measures were not successful, and the DHS pronounced R#4's death on (MONTH) 19, (YEAR) at 6:53 a.m. 2. R#12 experienced a change in condition on (MONTH) 5, 2019. The resident was found in bed, unresponsive to all stimuli and without vital signs. The resident's Advance Directive status was listed in the electronic clinical record as DNR, therefore, licensed nursing staff did not provide emergency basic life support measures and R#12's death was pronounced at the facility on (MONTH) 5, 2019 at 2:45 p.m. However, the DNR status in the clinical record was inaccurate. There was no supporting physician's orders [REDACTED]. Immediate Jeopardy was identified on (MONTH) 29, 2019 and determined to exist on (MONTH) 19, (YEAR) in the areas of 42 CFR 483.21 Comprehensive Resident Centered Care Plans, F655; 42 CFR: 483.21 (v)(3)(i) Services Provided Meet Professional Standards, F658; 42 CFR: 483.24 (a)(3) Cardio-Pulmonary Resuscitation (CPR), F678; 42 CFR 483.70 Administration, F835; 42 CFR: 483.20 (f)(5), 483.70 (i)(1)-(5) Resident Records-Identifiable Information, F842; 42 CFR 483.75(d) Quality Assurance and Performance Improvement Activities, F867, all at a Scope and Severity (S/S) of a [NAME] Additionally, Substandard Quality of Care was identified at 42 CFR: 483.24 (a)(3) Cardio-Pulmonary Resuscitation (CPR), F678. A Credible Allegation of Compliance was received on (MONTH) 29, 2019. Based on interviews, record reviews, and review of facility 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 (MONTH) 29, 2019. 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. Findings include: R#4 was admitted to the facility on [DATE]. A review of the Georgia Advance Directive for Healthcare and DNR forms, signed by the resident's responsible party on [DATE] revealed that the resident had not executed an Advance Directive and did not have a DNR order. A base line care plan was developed that included problems with dates of [DATE] and [DATE] and [DATE]. However, the care plan did not include the resident's Advance Directive status. During an interview on [DATE] at 4:30 p.m., the DHS stated that the Advance Directive/Code Status is verified in the electronic clinical record at the top of the computer screen, on the banner. If there is no Advance Directive/Code Status listed there, you assume the resident is a full code (not a DNR). She stated that there is no need to scroll down to the Advance Directive section of the chart because whatever is checked in that section will appear on the banner (at the top of the screen). The DHS confirmed that the Advanced Directive status was not included on the Baseline Care Plan for R#4 which should have been completed by the admitting nurse and was not completed. Cross refer to F678 The facility implemented the following actions to remove the Immediate Jeopardy: Each Resident must have a Resident centered baseline care plan, followed by a comprehensive care plan developed following completion of the Minimum Data Set and Care Area assessment portion of the comprehensive assessment according to the Resident Assessment Instrument manual and the Resident's choice. Root Cause Analysis The facility failed to develop a Baseline Care Plan to reflect current code status for Resident #4. This Immediate Jeopardy was abated on [DATE], at which time the facility completed the following actions: 1) MDS Nurses, Senior Nurse Consultant Completed an audit of all resident care plans to ensure correct code status on care plan on [DATE]. MDS Nurse completed an audit of resident care plans on [DATE] for residents with DNR and Full Code Advance Directives. 2) Resident #4 and Resident #12's Care Plan was updated to reflect their Advanced Directives. Director of Health Services and Administrator completed an audit of all active resident records on [DATE] to ensure the residents care plans were accurate. There were no other Residents identified during the audit with inaccurate Care Plans. 3) Care Plan Coordinator/MDS Nurse educated by Senior Nurse Consultant on [DATE] to initiate Advanced Directives/Do Not Resuscitate/Full Code Care Plan once an order is received. As of [DATE] we have trained ,[DATE] activity (100%), ,[DATE] Maintenance (100%), Administration ,[DATE] (100%), Housekeeping & Laundry ,[DATE] (100%), Dietary ,[DATE] (70%), Certified Nursing Assistant ,[DATE] (81%), Licensed Practical Nurses ,[DATE] (88%), Registered Nurses ,[DATE] (100%), Therapist ,[DATE] (75%). Staff that have not been trained as of [DATE] will be trained prior to working their next shift. All new hires will be trained during orientation on baseline care plans for an Advanced Directive. The Director of Health Services and/or Unit Manager will monitor this process in clinical stand-up by reviewing all new orders and ensuring any Do Not Resuscitate or Full Code orders are carried through to the care plan. This process will be documented on the Advance Directives Checklist by the Director of Health Services or Unit Manager. 4) The facilities policy has been reviewed and is current. The policy was reviewed on [DATE]. 5) Findings will be reported in Quality Assurance Performance Improvement Committee by the Director of Health Services or Unit manager x3 months. The State Survey Agency (SSA) validated the facility's Credible Allegation of Immediate Jeopardy Removal as follows: 1. An interview and record review with the Minimum Data Set (MDS) Coordinator on [DATE] at 12:45 p.m. revealed that chart audits have been completed daily for Advance Directives and corresponding care plans from [DATE] through [DATE]. She further stated that as of [DATE] the audits include that the correct Code Status and that the corresponding paper work is included in the resident's record. 2. Review and verification of the facility's audit documents, care plans and Advance Directive documentation for residents with a DNR is specified in the resident's chart. 3. The following interviews were conducted on [DATE] with Licensed Practical Nurses (LPN) confirming they have attended in-services on [DATE] related to developing a Base Line Care Plan for Code Status: LPN HH at 12:27 p.m., LPN PP, Unit Manager, at 12:39 p.m., LPN RR at 12:47 p.m. and LPN WW at 1:00 p.m. The following Registered Nurses (RN) were interviewed on [DATE] confirming attending in-services regarding the development of Base Line Care Plans for Code Status on [DATE]: RN KK at 12:29 p.m., RN DD at 12:34 p.m., RN SS at 12:51 p.m., RN VV (Assistant Director of Health Services-ADHS) at 12:53 p.m., RN ZZ at 1:04 p.m., RN HHH (DHS) at 1:21 p.m., RN III at 1:25 p.m. and RN CC at 12:33 p.m. The following Certified Nursing Assistants (CNA) were interviewed on [DATE], confirming they had attended in-services on [DATE] related to developing a Base Line Care Plan for Code Status and their role in the process: CNA II at 12:27 p.m., CNA JJ at 12:29 p.m., CNA MM and CNA NN at 12:36 p.m., CNA OO at 12:39 p.m., CNA QQ at 12:47 p.m., CNA TT and CNA SS at 12:51 p.m., CNA UU at 12:53 p.m., CNA YY at 1:04 p.m., CNA AAA and CNA BBB at 1:09 p.m., CNA CCC at 1:12 p.m. and CNA GGG at 12:21 p.m. The following interviews were conducted on [DATE] related to in-services on [DATE] confirming they had attended in-services on Advanced Directives Policy, responsibilities for maintaining the resident's record and confirming the Code Status in the electronic record and to confirm the accuracy of the resident's code status: Admission Coordinator LL at 12:34 p.m., Activity Director XX at 1:00 p.m., Social Worker DDD at 1:12 p.m., Front office staff EEE and FFF at 1:18 p.m., Maintenance staff JJJ and KKK at 1:34 p.m., Dietary Aides LLL and MMM at 1:40 p.m., Cooks NNN and OOO at 1:43 p.m., Housekeeping Staff PPP and QQQ at 1:48 p.m. and Housekeeping staff RRR and SSS at 1:50 p.m. and Laundry staff TTT at 1:54 p.m. 4. Per interview and review of the Care Plan Policy, confirmed that the facility Baseline Care Plan Policy was reviewed and approved on [DATE] with input from the Medical Director and Nursing. The policy was signed by the Administrator on [DATE]. 5. Record review and interviews with the Administrator and DHS on [DATE] at 1:15 p.m. and 2:32 p.m. which confirmed that a QA meeting was held on [DATE] after the death of R#4 to put a plan into place which included an audit of all resident's records for Advanced Directive Status. Additionally, a QA meeting was held on [DATE], which included the Medical Director (via telephone) to update the plan to address the Advance Directive error and review the affected policies of the facility, which included Base Line and Comprehensive Care Plans. | 2020-09-01 |