cms_ND: 73
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 |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
73 | MINOT HEALTH AND REHAB, LLC | 355031 | 600 S MAIN ST | MINOT | ND | 58701 | 2018-08-16 | 578 | D | 0 | 1 | B0I611 | Based on record review, facility policy, and staff interview, the facility failed to ensure the medical record for 1 of 16 sampled residents (Resident #38) accurately reflected the resident's Advanced Directive regarding code status. Failure to ensure the resident's medical record accurately reflected her wishes may prevent emergency personnel from knowing the resident's choices in the event of a medical emergency. Findings include: Review of the facility policy titled Code Status occurred on 08/16/18. This undated policy, stated, . Every resident or responsible party signs a consent for full code or no code upon admission . Red sheet of paper with DNR (do not resuscitate)/No Code is placed in the front of the chart with consent choice sheet signed right behind it. Green sheet of paper with Full Code is placed in the front of the chart with the consent choice sheet signed right behind it. The full code or no code order is noted on physician orders. Review of Resident #38's medical record occurred all days of survey. A Living Will form signed and dated on 06/25/14 by Resident #38, indicated DNR status. A physician's order, dated 10/04/17, indicated Full Code status. A green sheet of paper for Full Code was placed in the front of Resident #38's medical record with a copy of the signed physician's order attached. During an interview on the morning of 08/16/18, an administrative staff member (#16) indicated nursing staff asks the resident on admission and/or readmission what he/she would like their code to be. The facility failed to ensure the code level status was consistent in all areas of the medical record and accurately reflected the residents' current wishes. | 2020-09-01 |