| 3478 |
LAUREL PARK AT HENRY MED CTR |
115673 |
1050 HOSPITAL DRIVE |
STOCKBRIDGE |
GA |
30281 |
2019-02-04 |
678 |
J |
1 |
0 |
HHND11 |
**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 for one resident (#4) and failed to accurately document the Advance Directive status for one resident (#12) 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: The facility had an Advance Directives: Georgia policy. The policy statement included that the healthcare center recognizes the right of residents to control decisions related to their medical care. The policy procedure included that prior to, or upon admission, the resident and/or their responsible party will be asked about the existence of any advance directives. The Advance Directive Checklist will be completed. During an interview on [DATE] at 11:10 a.m., Nurse Consultant UUU stated that the facility went live with using an electronic clinical record system on [DATE] and that the staff was trained on the system as the different components came on line. The facility provided an agenda for the staff training for [DATE] through [DATE] and sign in sheets for the training. 1. R#4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. In addition, progress notes documented the resident was status [REDACTED]. A Georgia Advance Directive for Healthcare form and DNR form, were signed by the resident's responsible party on [DATE]. The Georgia Advance Directive for Healthcare form documented that the resident had not executed an Advance Directive and did not wish to discuss Advance Directives further at that time. The DNR form documented that the resident did not have a DNR order or Physician order [REDACTED]. R#4 experienced a change in condition on [DATE]. A nurse's note dated [DATE] at 5:22 a.m., documented that upon entering the resident's room, the resident was unresponsive to verbal and physical stimuli. The note also documented that they were unable to obtain a blood pressure, pulse, respirations or pulse oximetry, and her temperature was 90.3 degrees. The DHS was notified, and a message was left for the on-call physician. There was no evidence that emergency basic life support measures were immediately implemented. The subsequent nurse's note, approximately one hour later, on [DATE] at 6:25 p.m. documented that CPR was started. Further review of nurses' notes entries revealed that EMS personnel were onsite and took over CPR at 6:30 a.m. and continued emergency life support measures, but without success. EMS personnel received a physician's orders [REDACTED]. During an interview on [DATE] at 7:35 a.m., Licensed Practical Nurse (LPN) AA stated that, after finding the resident unresponsive and unable to obtain vital signs, she checked the resident's electronic chart. She stated that she thought she saw DNR on the Advance Directives section of the chart and notified the DHS. However, when she started the paperwork, she could not find DNR information and called the DHS again, who arrived shortly afterward and called 911 and began CPR. LPN AA stated that she would have started CPR immediately, if she had not thought she saw DNR on the electronic chart. During an interview on [DATE] at 4:30 p.m., the DHS confirmed that she received a call from LPN AA the morning of [DATE] regarding resident #4's passing and that the resident was a DNR. The DHS stated while enroute to the facility to pronounce the resident's death, she received another phone call from LPN AA notifying her of that she could not locate DNR information. The DHS stated she arrived shortly afterward, reviewed the chart, and in seeing no Advance Directive status specified, called 911 and initiated CPR. The DHS stated that 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). During an interview on [DATE] at 1:50 p.m., the Administrator stated that she was notified of R#4's death on [DATE]. In response to the incident, she interviewed staff, called a Quality Assurance Plan Improvement (QAPI) meeting (on [DATE]), put a plan in place and began auditing residents' Advance Directive status in the clinical records. A review of the plan revealed that it included the following specifics: The facility identified that all residents had the potential to be affected. [NAME] The DHS and Assistant Director of Health Services (ADHS) would educate all nurses on the Advance Directives policy and procedures. All nurses would also be educated on the facility's electronic clinical record system integration related to Advance Directives. All training was initiated on [DATE] and would be completed by [DATE] with all nurses being educated prior to the start of their next shift. B. The Administrator or designee would complete a daily audit tool to monitor Advance Directives for four weeks. The DHS and ADHS would complete a weekly audit tool to monitor compliance for four weeks. A QAPI committee meeting would be held on [DATE] to ensure the audit was correct and that no other issues were identified. However, despite the facility's implemented interventions to ensure the Advance Directives were integrated into the electronic clinical record, they failed to ensure that the Advance Directives status was accurate with supporting Advance Directive documentation. 2. Review of the Medical record revealed that R#12 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Review of the Physician order [REDACTED].#12 was to be a Do Not Resuscitate (DNR). However, review of the electronic medical record revealed there were no supporting documents to validate the resident's DNR status. Review of the Resident Progress Notes dated [DATE] at 3:00 p.m. revealed that at 2:40 p.m. the nurse was notified by a family member that the resident was unresponsive to all stimuli. The note further documented that the resident was assessed by two nurses and found to be without any vital signs. At 2:45 p.m. the funeral home was notified and was awaiting arrival of the funeral home personnel. The resident had an pronouncement of death by RN CC on [DATE] at 2:45 p.m. During an interview with Licensed Practical Nurse (LPN) BB on [DATE] at 11:35 a.m., she stated that the resident's daughter had reported to her the resident was not responding. She stated that she went and got Registered Nurse (RN) CC who got the crash cart and when they entered the room the resident's son told them the resident was a DNR. She stated when she checked the face sheet she saw where the resident was a DNR and they did not do Cardiopulmonary Resuscitation (CPR). During an interview with RN CC on [DATE] at 12:03 p.m., she stated that LPN BB came to her and said the resident was nonresponsive. She grabbed the crash cart while LPN BB got the electronic record to check the resident's code status. As they were entering the room, LPN BB stated the resident was a DNR. She also stated that as they were entering the resident's room, the son asked them what they were doing with the crash cart since his mother was a DNR. She stated she went in the room to assess the resident who did not have a pulse, no respirations, and her pupils were fixed and dilated. She stated that she was the nurse who pronounced the resident's death. During an interview with Nurse Consultant UUU on [DATE] at 10:30 a.m., she provided a copy of the resident's Advanced Health Care Directive which was faxed from the hospital. However, the fax date was [DATE] at 9:22 a.m. She stated that the facility did not have a copy of the Advanced Directive until after surveyor inquiry on [DATE], 25 days after the resident's admitted . She also stated that the family told the facility they would bring a copy of the Advanced Directive on the following Monday, the seventh. She stated the resident should have been a full code until they had a copy of the Advanced Directive. The facility implemented the following actions to remove the Immediate Jeopardy: Personnel will provide basic life support including CPR to a Resident requiring such emergency care before the arrival of emergency medical personnel and subject to related physicians order and Residents Advanced Directive. Root Cause Analysis Nursing staff did not provide CPR on Resident #4 and Resident #12. This Immediate Jeopardy was abated on [DATE], at which time the facility completed the following actions: 1) Clinical Competency Coordinator or designee will ensure all staff know how to confirm the Residents Advanced Directives. 2) All staff were educated on [DATE]. As of [DATE] we 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%) by the Director of Health Services and the Clinical Competency Coordinator to verify code status via Resident chart. Staff that have not been trained as of [DATE] will be trained prior to working their next shift. All new hires will be trained on during orientation on basic life support including CPR. Director of Health Services and Administrator completed an audit with all staff on [DATE] to ensure the staff know how to confirm the Residents medical record. 3) The facilities policy has been reviewed and is current. The policy was reviewed on [DATE]. 4) Clinical Competency Coordinator or Director of Health Services will randomly audit 10% of all staff weekly to ensure staff knows how to confirm residents code status by return demonstration. Administrator or designee will audit Advanced Directives in the electronic medical record daily x2 months or until substantial compliance is complete. 5) Findings will be communicated by the Director of Health Services at Quality Assurance Performance Improvement monthly x3 months. The State Survey Agency (SSA) validated the facility's Credible Allegation of Immediate Jeopardy Removal as follows: 1. An interview with Registered Nurse CC (Clinical Care Coordinator) on [DATE] at 12:33 p.m. revealed that staff were in-serviced on [DATE] and any remaining staff were in-serviced before starting their next shift at the facility. 2. The following interviews revealed that all of the staff were able to describe the in-service training for the Advance Directives, Code Status and care planning for Code Status. They stated they have had three to four classes on the topics and then a refresher was done every day where the management would come ask them questions and some had to do a return demonstration to make sure they understood. They were able to describe where to find the resident's Code Status, the banner and in resident electronic documents. They also stated if there was no Code Status on the banner or the documents that the resident would be full code and they would have to start CPR. They stated the resident would be a full code until the proper documents were provided. They also discussed the care plans, where the Code Status would also be included. The following interviews were conducted on [DATE] with Licensed Practical Nurses (LPN) confirming they have attended in-services on [DATE] related to 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: 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 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 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 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 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: 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. 3. The Advanced Directive Policy was reviewed and signed by the Administrator on [DATE] and verified with an interview on [DATE] at 2:32 p.m. with the Administrator. 4. Verified via interview [DATE] at 12:33 p.m. with CCC CC, interview [DATE] at 1:15 p.m. with the DHS and review of audit documentation and completed Advance Directive checklists. Also verified via interview [DATE] at 2:32 p.m. with the Administrator who stated she had actually been auditing the lists twice daily. 5. Verified via interview [DATE] at 1:15 p.m. with the DHS confirming that the audit findings will be communicated at the QAPI meetings monthly. |
2020-09-01 |