| 2888 |
KEYSTONE RIDGE POST ACUTE NURSING AND REHAB |
285238 |
7501 KEYSTONE DRIVE |
OMAHA |
NE |
68134 |
2019-04-22 |
578 |
K |
0 |
1 |
BJ6K11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews; the facility staff failed to ensure the desired code status was documented consistently and correctly throughout the record for 7 (Resident 53, 31, 21, 51, 1, 34, and 309) residents of 30 sampled residents. The findings are: Review of the Policy and Procedure for Code Status Listing dated ,[DATE] revealed a complete list of residents with code status will be kept in a covered paper binder at each nurse's station. [NAME]Record review of Resident 53's medical record revealed an Advanced Directives/Medical Treatment Decisions form dated [DATE] documenting Resident 53's desire to be a DNR (Do Not Resuscitate). Record review of Resident 53's electronic medical record revealed no information regarding Resident 53's code status. Interview conducted with LPN A on [DATE] at 02:15 PM confirmed the code status was not on the electronic medical record. B.Record review of Resident 31's medical record revealed an Advanced Directives/Medical Treatment Decisions form dated [DATE] documenting Resident 31's desire to be a Full Code/CPR. Record review of Resident 31's electronic medical record revealed no information regarding Resident 31's code status. Interview conducted with LPN A on [DATE] at 02:16 PM confirmed the code status was not on the electronic medical record. C.Record review of Resident 21's medical record revealed an Advanced Directives/Medical Treatment Decisions form dated [DATE] documenting Resident 21's desire to be a Full Code/CPR. Record review of Resident 21's electronic medical record revealed no information regarding Resident 21's code status. Interview conducted with LPN A on [DATE] at 02:17 PM confirmed the code status was not on the electronic medical record. D.Record review of Resident 51's medical record revealed an Advanced Directives/Medical Treatment Decisions form dated [DATE] documenting Resident 51's desire to be a DNR. Record review of Resident 51's electronic medical record revealed a Full Code CPR status. Interview conducted on [DATE] at 02:35 PM with RN B confirmed that the Advance Directive documenting Resident 51's code status did not match Resident 51's electronic medical record. E.Record review of Resident 1's medical record revealed an Advanced Directives/Medical Treatment Decisions form dated [DATE] documenting Resident 1's desire to be a DNR. Record review of Resident 1's electronic medical record revealed no information regarding Resident 1's code status. Interview conducted with LPN A on [DATE] at 02:16 PM confirmed the code status was not on the electronic medical record. F.Record Review of Resident 34's medical record revealed and Advanced Directives/Medical Treatment Decisions form dated [DATE] documenting Resident 34's desire to be a Full Code/CPR. Record review of Resident 34's electronic medical record revealed no information regarding Resident 34's code status. Interview conducted with LPN A on [DATE] at 02:16 PM confirmed the code status was not on the electronic medical record. Interview conducted on [DATE] at 02:10 pm with LPN A and CMA C (Certified Medication Aide) revealed the way the staff knows the code status of residents was there are blue stars on the doors that mean the resident is to have CPR and red stars are DNR. LPN A revealed the code status for each resident is in the electronic record. Observation conducted with CMA C of residents' doors revealed there were red stars on residents name plates and no blue stars were present. Interview conducted on [DATE] at 02:35 PM with Clinical Resource Nurse confirmed that facility staff were correcting DNR status of residents in the electronic record as the staff made the list of Code Status requested by surveyors. Review of Code status list provided by the facility staff revealed Resident 51 was listed as full code status. Interview conducted with DON (Director of Nursing) on [DATE] at 02:20 PM revealed that an in-service was conducted with the staff on [DATE] on Code status which instructed the staff that blue stars on the residents doors meant do CPR and the stars were on order and had not been placed on the residents doors. Abatement Statement: Based on the information provided on [DATE] to correct the immediacy of the situation, the facility staff provided the following information to protect residents: 1. A full audit of residents' signed code status reviewed and cross checked with the electronic record Point Click Care to ensure correctness. 2. Binders with each residents' signed Advanced Directives on each unit reviewed for correctness. 3. Blue stars to residents' doors implemented. 4. Managers will review all new admits and orders every day and discharges will be reviewed. 5. Full audit once a week x 4 weeks then bring to Quality Assurance for review and revision as warranted. 6. All staff re-educated on code status and Point Click Care Status. 7. Agency staff orientation checklist updated to reflect identifying code status. 8. All staff notified that they cannot work until education is complete. The Policy and Procedure for Code Status Listing updated [DATE] revealed the following: -Upon admission, residents identified as electing Full Code Status will have a blue star placed by the name card outside their room. -A complete list of residents with code status will be kept in a covered binder at each nurse's station. -Medical Records or designee will be responsible to keep code status list current and updated whenever a change occurs. The immediacy had been removed, however, the deficient practice was not totally corrected. Therefore, the severity was lowered to an F level. G: On [DATE], Record review of Resident 309 the Electronic Health Record (EHR) revealed that the Advance Directive was signed and indicated DNR. On [DATE] ,Record review of the Care Plan and the Medication Administration Record( MAR) did not reveal the code status of Resident 309. On [DATE] 1:25 PM an interview with CNA, U, was conducted , during the interview when asked how to tell the code status of the residents, CNA,U reported if there is a Red heart on the residents door it means , do not resuscitate (DNR). On [DATE] 1:35 PM an interview with CNA, V was conducted, during the interview when asked how to tell the code status of the residents CNA, V reported it was in point click care ( Electronic Health Record). On [DATE] 1:40 PM an interview with CNA, C was conducted , during the interview when asked how to tell the code status of the residents, CNA, C stated I do not know. On [DATE] 1:45 PM an interview CNA,N was conducted,during the interview when asked how to tell the code status of the residents , CNA,N reported , if there is a blue star on the door the resident is a Code ( Do Resuscitate) On [DATE] 1 :50 PM an interview with RN M was conducted, during the interview when asked how to tell the code status,he reported it is on the Demo graphic Sheet and report sheet On [DATE] at 1:55 PM observation of the Med. Center floor there were no blue stars on residents rooms. , |
2020-09-01 |