cms_GA: 95
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 95 | MILLER NURSING HOME | 115039 | 206 GRACE ST | COLQUITT | GA | 39837 | 2019-11-07 | 578 | E | 0 | 1 | C7SX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, and review of the facility's policy titled, Advance Directives the facility failed to obtain a Physician's signature and a concurring Physician's signature for a Physician order [REDACTED].#55, R#42 and R#117). This deficient practice affected 3 of 7 residents reviewed for Do Not Resuscitate. Findings include: Review of Advance Directives Policy revealed: 2. Prior to or upon admission of a resident, the Social Services Director or designee will inquire of the resident, and/or his/her family members, about the existence of any written advance directives. POLST Additional Guidance for Health Care Professionals III. When a POLST form is signed by an Authorized Person (other than the patient's Health Care Agent) and Attending Physician: I. If Section A indicates Allow Natural Death - Do Not Attempt Resuscitation, this order may be implemented when the patient is a candidate for non-resuscitation as defined in Georgia Code Section 31-39-2(4). A concurring physician signature is Required per Georgia Code Section 31-39-4(c). 1. Review of the medical record for R#55 revealed a POLST with a verbal signature noted for Allow Natural Death with one Physician signature on 9/13/17. There was not any evidence of any documentation that R#55 had a power of attorney for healthcare nor was there a healthcare agent identified. During an interview on 11/5/19 at 4:00 p.m. with the facility's Long-Term Care (LTC) Director revealed that if a resident has a legal next of kin to sign the POLST only one Physician's signature has been gotten and was signed by an authorized person who is not the health care agent. The LTC Director further reported that if there was no legal next of kin two Physician signatures would be needed. The LTC Director reviewed the POLST for R#55 and she confirmed that there was only one Physician signature for R#55. Upon reading the POLST LTC Director acknowledged that a concurring physician's signature was needed when residents do not sign the form and there is not a health care agent. 2. A review of the Quarterly Minimum Data Sets dated 8/20/19 for R#42 revealed that the resident had both long-term and short-term memory problems and was unable to answer the assessment questions. A review of the medical record for R#42 revealed a Physician order [REDACTED]. An interview on 11/6/19 at 10:35 a.m. with the Assistant Director of Nursing confirmed that the resident did not have a healthcare agent and that only one Physician had signed his POLST form. An interview on 11/6/19 at 10:54 a.m. with Social Service CC confirmed that R#42 did not have a healthcare agent on file. Social Service CC brought a POLST in that was signed on 11/6/19 after surveyor inquiry by a second physician. She confirmed that prior to surveyor inquiry that the lack of appropriate signatures for the POLST to be legal had not been identified. 3. A review of the Admission MDS assessment dated [DATE] for R#117 documented both long-term and short-term memory problems with the resident being unable to answer assessment questions. A review of the POLST form dated 4/18/19 for R#117 revealed it was signed by only one Physician, and the responsible party. The resident had no Power of Attorney (POA) or healthcare agent. A review of the Face Sheet identified that R#117 had an Advanced Directive of DNR. An interview on 11/5/19 at 4:06 p.m. with the facility's Long-Term Care (LTC) Director revealed if there was no responsible party or next of kin, we obtain two physician signatures, but if there was a responsible party or a next of kin that they had only been getting one physician signature and the signature of the responsible party. The LTC Director confirmed that based on what was written on the POLST form that there needed to be two concurring Physician signatures if there was no Power of Attorney with a legal healthcare agent. A review of the POLST with the LTC Director for R#117 confirmed that there was the signature of the next of kin and one physician signature and there was no legal healthcare agent for R#117. An interview on 11/6/19 at 11:29 a.m. with the LTC Director again confirmed that R#117 did not have a healthcare agent. | 2020-09-01 |