cms_SC: 2080
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 |
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2080 | OAKBROOK HEALTH AND REHABILITATION CENTER | 425156 | 920 TRAVELERS BOULEVARD | SUMMERVILLE | SC | 29485 | 2017-06-29 | 155 | D | 0 | 1 | 4QY511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to ensure accuracy of medical records for Code Status and the Advance Directives Notification Worksheet in the medical record for 1 of 21 residents reviewed. Resident #141's Advance Directive was not complete in the clinical record and was in conflict with the record maintained by Social Services. The findings included: Resident #141 was admitted on [DATE] with [DIAGNOSES REDACTED]. On [DATE] at 9:09 AM a review of the Advance Directives Section of the Medical Record kept on the nursing unit revealed that the form titled; Advance Directives Notification and Work Sheet was signed by Resident #141 and no date completed. On the same form, the section that states: Please Choose One: ___I do want CPR: Attempt Cardio [MEDICAL CONDITION] Resuscitation (CPR) Choosing CPR means that all medical treatments will be done to prolong life when the heart stops or breathing stops. ___I do not want CPR: Do not Attempt Resuscitation (Allow Natural Death) This means no attempts will be made to restart the heart or breathing if either stops allowing for a natural death. No election was made for CPR as there was no election checked by the resident. The form shows a signature on the Social Service line and dated [DATE]. [DATE] at 2:43 PM, LPN#1 verified that no selection was checked on the Advance Directives Notification Worksheet located in the medical record kept on the nursing unit. On [DATE] at 2:53 PM, Social Worker #2 verified that the date should have been included beside the Resident #141's signature and form should have had an election made for CPR. On [DATE] at 3:30PM Social Worker #2 presented a copy of the Advance Directives Notification Worksheet that h/she keeps in a file in his/her office that has checkmark by I do not want CPR and stated: I keep the original copy in a file in my office. On [DATE] 9:44AM the Administrator verified that the copy of Advance Directives Notification Worksheet in Resident #141's medical record does not match the copy that Social Worker #2 keeps in her office. The Policy and Procedure titled: Social Services Policies and Procedures, Subject: Advance Directives states, Procedures: 4. B. Once it has been determined that the patient/resident wishes to be a DNR patient/resident, the following procedures must be followed IN ADDITION to those outlined in the Policies of Practice for Advance Directives 1) The patient/resident's decision must be CLEARLY AND CONCISELY documented in their chart AND on the patient's/resident's care plan .2) The properly executed Do Not Resuscitate consent from must be provided to the attending physician AND a Do Not Resuscitate order must be provided in the current orders the patient's/resident's medical record. | 2020-09-01 |