| 2997 |
OMAHA NURSING AND REHABILITATION CENTER |
285240 |
4835 SOUTH 49TH STREET |
OMAHA |
NE |
68117 |
2020-02-25 |
835 |
K |
0 |
1 |
3ZNV11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference No. 1[AGE] NAC ,[DATE].02 Based on Record Review and Interview the Administration failed to utilize resources to ensure facility staff had the correct information regarding CPR status for 4 of 53 Residents, resident 3,30,32,38. The facility staff identified a census of 53. Findings are : D. [DATE] 09:46 AM Record Review of Resident 38 Admission record sheet printed [DATE] , in the section identified as Advance Directive revealed a DNR ( Do Not Resuscitate) or commonly known as a no code. Record review of resident 38 CSP( Code Status Policy) dated [DATE] revealed Resident 38 representative indicated Resident 38 was a Full Code. Further review of Resident 38 CSP sheet revealed Resident 38 Practioner signed the CSP sheet that identified Resident 38 as a Full Code on [DATE]. [DATE] 4:30PM Interview with LPN C ,revealed that to check the code status of facility residents, she would look at electronic records, or she would look in the Code Status Book. If the resident was going to the hospital she would send a copy of the Admission record from either the electronic records or from the Code Status Book. DB [DATE] 1:00PM Record review of all Residents Advance Directives , electronic records, and Facesheets confirmed that 4 of 53 Residents, resident 3,30,32,38, had a discrepancy regarding thier CPR status. A. Record review of undated Code Status Policy (CSP) sheet revealed the following information: -Full Code: -We will initiate basic life support (oxygen therapy, establishing an airway, providing manual respirations and chest compression). In the event of [MEDICAL CONDITION] or [MEDICAL CONDITION] 911 will be notified immediately for transport to the nearest hospital. -No Code: If the death of a resident is inevitable we do not call 911 for transport to the nearest hospital. We do perform all acts that will give comfort such as oxygen if needed, pain management control, suctioning etc. We keep the physician and family updated on any condition change. The resident will remain in the facility with their normal care givers. In the event either family, resident pr physician change their minds about the code status, CPR will be preformed and then be transported to the nearest hospital. B. Record review of Resident 3's Code Status Policy (CSP) sheet with a dated of [DATE] revealed Resident 3's Representative had marked the section on the CSP to indicate Resident 3 was a full Code. Record review of a second CSP dated [DATE] for Resident 3 revealed Resident 3's Representative indicted Resident 3 was a Full Code. Further review of Resident 3's second CPS revealed Resident 3's practitioner signed the CSP that identified Resident 3 as a Full Code on [DATE]. Record review of Resident 3's Admission Record sheet printed on [DATE] in the section identified as Advanced Directive revealed A DNR (Do Not Resuscitate , or commonly known as a no code). On [DATE] at 2:20 PM an interview was conducted with Licensed Practical Nurse (LPN) A. During the interview LPN A reported if a resident codes or goes to the hospital, there is a binder with a code sheet and face sheet (also known as a Admission record sheet). On [DATE] at 2:23 PM an interview was conducted with LPN C. During the interview LPN C reported there is a binder with a code sheet and face sheet and we can use both. On [DATE] at 4:25 PM an interview was conducted with LPN B. During the interview LPN B reported if some one goes to the hospital or codes we use the code sheet and also can use what is in the computer. On [DATE] at 4:39 PM an interview was conducted with Resource Nurse (RN) A. During the interview, review of Resident 3's CSP dated [DATE] and Admission Record sheet were reviewed. During the interview, RN A confirmed Resident 3 CSP and Admission record sheet printed on [DATE] did not match and should have. C. Record review of Resident 32's CSP revealed on [DATE] Resident 32's Representative signed that Resident 32 was a No Code. Further review of Resident 32's CSP signed by Resident 32's Representative on [DATE] revealed Resident 32's practitioner signed the CSP on [DATE]. Record review of Resident 32's Admission Record sheet printed on [DATE] revealed in the section identified as Advance Directive identified Resident 32 as a Full Code. On [DATE] at 4:39 PM an interview was conducted with Resource Nurse (RN) A. During the interview, review of Resident 32's CSP dated [DATE] and Admission Record sheet were reviewed. During the interview, RN A confirmed Resident 3 CSP and Admission record sheet printed on [DATE] did not match and should have. Record review of Resident 30's admission record reveals her advanced directive is listed as Do Not Resuscitate. Record review of the code status policy which is kept in the Code Status/Face Sheet book reveals that the code status for Resident 30 is listed as Full Code. Record review of the physician orders [REDACTED]. An interview with RN- J and LPN-B on [DATE] at 2:30 PM revealed that it depends on where they are when a code is called. If they are way down the hall then they would look at the Electronic medical record on the computer which may, or may not be, correct. F. Based on the information provided on [DATE] to remove the immediacy of the situation, the facility staff provided the following information. Immediate action; 1. For the 5 residents identified, the code status has been verified and updated in the electronic health record ( Advanced Directive, 2.Physcians orders, Face sheet) and in the Code Status Binder. 3. The director of nursing, or the designee will stay in facility and ensure records are correct, with a 100% audit of all residents code status. 4. All nursing staff will be educated on identifying code status preference and where that information is located before leaving this shift. All scheduled staff will be educated before being able to work, until all of nursing staff has been educated. 5. ED or designee will stay to ensure that the aforementioned bullets are completed. Monitoring: 1. Clinical Resources will audit above commitments daily until above audits and education are completed. 2. director of Nursing or designee will audit all new admissions to verify clear identification of code status with 24 hours of admission. 3. Above audits will be documented and brought to QAPI for further review and discussion, X3 months or until substantial compliance is determined.Licensure Refernce Number 1[AGE] NAC ,[DATE].02 [DATE] 11:13 AM Interview with Clinical Resource Nurse (CRN) , D and Administrator in Training E, confirmed, the CRN D and the current Administrator had knowledge of the Sister Facility being sited for not having consistent and clear information for facility residents on CPR status. CRN, D confirmed that an Audit was done at this facility to identify CPR status. CRN D confirmed certain staff members were identified to follow thru with this task and they did not. CRN D confirmed that binders were put in place to include Advance directives, and Face sheets for each resident. CRN D confirmed that new system was not audited to make sure the system was working. Cross Reference F Tag 678. |
2020-09-01 |