| 46 |
GARDEN ISLE HEALTHCARE AND REHABILITATION CENTER |
125004 |
3-3420 KUHIO HIGHWAY, SUITE 300 |
LIHUE |
HI |
96766 |
2018-07-13 |
578 |
E |
0 |
1 |
2CGJ11 |
Based on electronic medical record (EMR) reviews, interviews and policy review, the facility failed to ensure that for a resident who does not have an advance directive (AD), the resident (R) was informed of his or her right to develop one, provided assistance in doing so or was periodically reassessed in his/her decision making capacity to do such, for 5 of 33 residents (R6, R79, R54, R60 and R73) in the survey sample. Findings Include: 1) An EMR review conducted for R79 on 07/11/18 at 8:21 AM revealed this resident did not have an AD, but only a POLST. On 07/12/18 at 3:47 PM, during an interview with the Social Services staff, they confirmed R79 did not have an AD, but only a POLST. 2) An EMR review conducted for R6 on 07/11/18 at 9:46 AM revealed he did not have an advance directive (AD), nor were there clinical notes showing the resident was informed of his right to develop one or provided assistance in doing so. 3) On 07/11/18 01:03 PM the EMR review for R54 found that the resident had a Designation of Code status acute care form signed by his spouse on 8/20/12; the form designated do not resuscitate, (DNR). On 07/12/18 at 02:00 PM interviewed the resident care manager (RCM) on the Kona unit and she validated that R54 did not have an advanced directive on file. The RCM stated that 54's spouse was coming to the facility and the SW would be discussing AD with her. 4) The EMR review for R73 noted on the physicians orders (PO), DNR. On 07/12/18 at 01:58 PM interviewed the Kona unit RCM who provided a designation of code form that was signed in 12/2012. The RCM stated that the form was a POLST, and not an advanced directive form. 5) The EMR review for R60 found that a POLST was signed on 11/03/15. On 07/12/18 at 2:02 PM validated with the Kona unit resident case manager (RCM) that R60 did not have an advanced directive on file. A review of the facility's policy and procedure (P&P), Advanced Directive (effective date 9/1/2017) stated, . 5. Social Services will check with resident/guest or resident/guest representative to confirm treatment choices at the time of the initial care conference, during quarterly and annual care conferences, or at the time of significant change of condition. The resident/guest has the right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advanced directive. 6. Changes or revocations of a directive, which can be written or oral, must be noted in the resident/guest's medical record. All of the above residents (R79, R6, R54, R60, and R73) did not have documentation in their clinical record about the treatment choices in the formulation of, or refusal of an AD during quarterly and annual care conferences, or at the time of significant change of condition. |
2020-09-01 |