cms_GA: 59
Data source: Big Local News · About: big-local-datasette
| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 59 | WILLIAM BREMAN JEWISH HOME, THE | 115022 | 3150 HOWELL MILL ROAD N.W. | ATLANTA | GA | 30327 | 2018-02-08 | 578 | D | 0 | 1 | G4GK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and policy review, the facility failed to determine whether or not the resident wanted to formulate an Advanced Directive, for five residents (R) observed. R# 11, R# 72, R#255, R# 84 and R#254. The sample size was 22 residents. Findings include: 1. Medical Record review revealed that Resident (R) #72 review of the medical record for R#72 revealed that there was not any evidence that an Advance Directive was completed. Further review of the admission file for R#72 revealed that the form, Responsible/Legal Guardian & Advanced Directive Checklist (no date) was incomplete. No response were checked for choice and there was not any evidence that an Advance Directive checklist was documented. 2. Medical Record review for R #255 reveals that there was not any evidence that the resident had an Advance Directive. Further review of the Acknowledgement of Receipt of Admission for Rehabilitation form reveals that there is not a check mark next to the Georgia Advance Directive for Healthcare. 3. Medical Record review for R #84 reveals that there was not any evidence that the resident had an Advance Directive. Further review revealed that R #84 does have a completed Acknowledgement of Receipt of Admission for Rehabilitation Information form in the resident's Admission Folder. 4. Medical Record review for R # 254 revealed that there was not any evidence that the resident had an Advance Directive on their medical record or in their admission folder. Further review of theAcknowledgement of Receipt of Admission for Rehabilitation information form revealed that R#254 does not have a check mark next to Georgia Advance Directive for Healthcare. 5. Medical record review for resident R#11 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 10, which indicated no cognitive impairment. Further review on clinical record on 2/6/18 lacked evidence that the resident had been offered options to formulate an advance Directive. Document titled Responsibility/Legal Guardian & Advanced Directive Information was provided by Social Services Director on 2/6/18. The form revealed that resident was responsible for self, but no other information was documented on the form as to her choice to formulate or not formulate Advanced Directives. Based on interview, record review and policy review, the facility failed to determine whether or not the resident wanted to formulate an advanced directive, for seven residents (R) observed. R# 11, R#76, R# 38, , R# 72, R#255, R# 84 and R#254; out of a sample of 22 Findings include: For all resident's in the sample, a form titled Responsibility/Legal Guardian and Advanced Directive Checklist were missing information regarding resident's response to an offer of formulating an advanced directive. On 2/6/18 11:31 a.m. an interview with Social Services Director (SSD) was able to provide a folder evidencing a form titled Responsibility/Legal Guardian and Advanced Directive Checklist. This document shows where the facility provided information to the resident and/or family member on legal guardianship, and Power of Attorney (POA) along with an advanced directives checklist. The checklist included a decision made by the resident to formulate an advance directive or not. This document did offer a decision. No decision was noted. Further interview by the SSD indicated the facility no longer uses the form as it was becoming confusing for the staff. When asked how does the facility know what the resident's decision was in the event of an emergency, SSD stated they use a form titled Acknowledgement of Receipt of Admission for Rehabilitation information. This document lists the Georgia Advanced Directive for Healthcare. A check by the document name indicates the resident and /or family member received the document. When asked what the time frame is for return of the document SSD stated we asked they return it within 24 hours. When the time frame runs out there is no follow up done. SSD was once again asked what is done if there is no documentation of resident's preference regarding advanced directives. SSD stated if there is no information on the record the resident the resident is considered to be a full code. On 2/7/18 11:23 a.m. an interview with Director of Health Services (DHS) and Administrator revealed that the form titled Responsibility/Legal Guardian & Advanced Directive Checklist is no longer used because their attorney stated it was not a legal document. When asked where is the resident's response to advance directives education documented, DHS stated that it should be in the admission noted or on the dashboard of the Electronic Medical Record (EMR). On 2/7/18 01:06 p.m. further interview with the DHS revealed the facility does not have any documentation as to resident's preference to execute an advance directive. A review of facility policy titled Advance Directives, no date, states information about whether or not the resident has executed an advanced directive, shall be displayed prominently in the medical record. Also, if the resident indicates that he or she has not established advance directive, the facility staff will offer assistance in establishing advance directives. The resident will be given the option to accept or decline the assistance, and care will not be contingent on either decision. Nursing staff will document in the medical record the offer to assist and the resident's decision to accept or decline. | 2020-09-01 |