cms_GA: 64
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 64 | WILLIAM BREMAN JEWISH HOME, THE | 115022 | 3150 HOWELL MILL ROAD N.W. | ATLANTA | GA | 30327 | 2019-02-28 | 578 | D | 0 | 1 | 952S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to accurately document the Advance Directive status for one Resident (R) R#18 from a sample of 17 residents reviewed for Advance Directives. Findings include: Review of the record for R#18 revealed the resident was admitted on [DATE] with the [DIAGNOSES REDACTED]. Review of the resident's most recent Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) was coded as 15, which indicated no cognitive impairment. A review was conducted of the physician orders [REDACTED]. Review of the facility form titled, Order Summary Report for R#18 documented Advanced Directive: CPR, order date [DATE]; order status active and documented active orders as of [DATE]. Review of the resident's care plan, provided by MDS Coordinator A for R#18, documented two Advance Directive (AD) code status determinations. The care plan focus area reflects a code status as Full Code with a date initiated of [DATE], revision on [DATE]. Another care plan focus area reflects a code status as Do not Resuscitate (DNR) with a date initiated of [DATE], revision on [DATE]. Further record review for R#18 revealed a form titled, Physician order [REDACTED]. The POLST was signed by the resident and dated [DATE]. The section for discussion and signatures was blank for the physician's name and signature. The POLST was found at the front of the record in a clear document sleeve with a bright orange DNR sticker positioned at the top of the clear plastic document sleeve. On [DATE] at 10:38 a.m. an interview was conducted with the Social Worker (SW), she explained that the process to obtain Advance Directive information for a resident begins in admission; they work with the long-term care and rehab residents. Those residents receive an admission packet that starts with an Advance Directive checklist where residents can choose options. If they can sign for themselves, they must have a good BIMS score, meaning no impairment cognitively. If they have a Power of Attorney or a Living Will, that will be requested. The SW stated that it is the Social Worker's responsibility to discuss those options on the form with the resident and family. The SW further stated that the Unit Secretary will scan and upload the forms into the electronic record and place a copy of the original in the hard copy medical record. On [DATE] at 9:30 a.m. an interview was conducted with MDS Coordinator A in the MDS office with MDS Coordinator B and the Director of Nursing (DON) present. A review and confirmation of the quarterly and annual MDS was conducted. A printed copy of the resident's quarterly care plan was provided, dated [DATE]. When MDS Coordinator A was asked where the nursing staff would look for the Advance Directive information and preference, she stated that in an emergency they run to the hard copy chart to find the code status located at the front of the chart. After review of the provided documents with the MDS Coordinators with the DON present, the MDS Coordinators stated that the POLST form signed by the resident on [DATE] is an error. They revealed that the POLST forms have not been officially initiated in the facility yet; they confirmed the POLST form located in the front of the resident's record that is signed by the resident, is not signed by the Physician, and should not have been in the record. They confirmed the care plan indicating a DNR code status is in error. The DON explained that the POLST has not been initiated yet, because another Social Worker that is planning to initiate the POLST form for all residents that choose a DNR determination has been on maternity leave. No documentation was found in the record from the Social Worker regarding a change in the resident's Advance Directive status. In addition, the MDS Coordinator A and the DON explained that once an order is received by the Physician, the nursing staff will have the Unit Secretary scan in the AD into the electronic system and the original copy is placed in the hard copy record. The DON stated the plan now was to get a hold of the Physician's Nurse Practitioner, the resident and family to sort out the wishes of the resident, then get an order if there is a change. On [DATE] at 4:00 p.m. the DON provided a copy of a monthly follow-up visit conducted by the Nurse Practitioner for R#18, dated [DATE]. The note documents: POLST is reviewed with resident on day of exam. No acute changes or concerns per staff. On the bottom of page 5 of the follow-up exam, there is a hand-written note dated [DATE] and signed by the Nurse Practitioner that documents: reviewed POLST election and resident continues to desire elections charted on POLST form ,[DATE]. The DON also provided a printed copy of the original POLST form with the Physician's signature added and dated [DATE]. The DON confirmed that the POLST form is the form the facility has decided to use but confirmed that it has not been initiated yet. | 2020-09-01 |