cms_GA: 1252
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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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1252 | PRUITTHEALTH - EASTSIDE | 115391 | 2795 FINNEY CIRCLE | MACON | GA | 31217 | 2018-08-17 | 656 | J | 1 | 0 | RM0M11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and record review, the facility failed to develop a care plan for the advance directive status for four residents (A, #2, #3, and #15) 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. 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, 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: 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. However, the resident's Advance Directive status was not included in his care plan. 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. 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. However, there was no evidence in the clinical record that a care plan was developed to include the resident's Advance Directive status on admission or during the care plan updated on [DATE]. During an interview on [DATE] at 11:30 a.m., the Minimum Data Set (MDS) Coordinator stated that prior to [DATE] that only the DNR Advance Directive Status had been added to residents' care plans but now all residents have their advance directive status (Full code or DNR) included in the care plan. She confirmed that R A care plan did not include the Advance Directive Status. Cross refer to F678 2. R #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, there was no evidence in the clinical record that a care plan was developed to include the resident's initial Advance Directive status on admission or new advance directive status of DNR in (MONTH) (YEAR). Cross refer to F678 3. R #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, there was no evidence in the clinical record that a care plan was developed to include the resident's initial advance directive status or new advance directive of DNR in (MONTH) (YEAR). Cross refer to F678 4. R#15 was admitted to the facility on [DATE]. A Physician order [REDACTED]. A review of the clinical record revealed no evidence that the resident's DNR status had been included in the care plan. 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: 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. The facility conducted an Advance Directive audit on [DATE] of all residents' Advance Directives information. The audit included reviewing the care plan for the inclusion of DNR status. A review of the audit tool dated [DATE] revealed that R#15 was identified as not having a care plan in place for the DNR status. However, there was no evidence in the clinical record that a care plan was developed to address R#15's DNR status, until after surveyor inquiry on [DATE]. During an interview on [DATE] at 12:16 p.m., the DHS confirmed that a care plan for R#15's Advance Directive status had not been developed until after surveyor inquiry on [DATE]. 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 related to Advanced Directive care plans: 1. MDS Nurse, DHS and 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 Advance Directives. 2. Any care plans identified were corrected and placed on the chart. Two (2) Residents with no care plan for DNR Advanced Directive care plan. Those care plans were printed and placed on the chart on [DATE]. All Active residents will have a care plan indicating Advanced Directive/Code Status. (sic) 3. Care Plan Coordinator/MDS Nurse educated by CCC on [DATE] to initiate Advanced Directives/DNR Care Plan once an order is received. 4. The DHS and or Unit Manager will monitor this process in clinical stand-up by reviewing all new orders and assuring any DNR orders are carried through to the care plan. This process will be documented on the Advance Directives Checklist by the DHS or Unit Manager. 5. Findings will be reported in QAPI by the DHS or Unit manager x3 months, The State Survey Agency (SSA) validated the corrective actions taken by the facility as of [DATE] as follows: 1. An interview with the DHS on [DATE] at 1:45 p.m. and the MDS Coordinator at revealed they had audited all resident care plans to ensure correct code status. Record review of audit list/spread for all resident's care plan was reviewed and completed. 2. Review of the resident's care plans were reviewed to ensure the correct Advanced Directives were in place utilizing audit/spread sheet. An interview with the MDS Coordinator on [DATE] at 11:30 a.m. verified the process of audit has been completed. 3. Record review of in-service sign in sheet verified the MDS Coordinator had been in-serviced on developing an Advanced Directive care plan once a physician's orders [REDACTED]. 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 [REDACTED]. This process was confirmed by the RN FF. 5. Review of the QAPI process revealed that the Audit findings will be presented to the QAPI meeting monthly by either the DHS or Unit Manager, RN FF. This process was confirmed by interview with the DHS and Unit Manager, RN FF on the dates and times listed in #4. An interview on [DATE] at 1:45 p.m. with the DHS revealed that she had participated in in-services related to Advance Directives and having the correct information on each resident's care plan and updating as changes are made by residents or the responsible party. She is overseeing that the MDS Coordinator has reviewed all care plans against the Advance Directives for each resident and that any changes to the Advance Directive is updated timely. 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 they had all participated in in-services regarding care planning of Advanced Directives and were knowledgeable of the process. 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 they had participated in in-services related to care plans for Advanced Directives. | 2020-09-01 |