cms_SC: 3840
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 3840 | COMPASS POST ACUTE REHABILITATION | 425391 | 2320 HIGHWAY 378 | CONWAY | SC | 29527 | 2017-02-17 | 155 | D | 0 | 1 | FLED11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, review of facility policies, and review of the South [NAME]ina Adult Health Care Consent Act, the facility failed to ensure residents were afforded the opportunity to exercise choices for 2 of 22 residents reviewed for advance directives. Resident #101 and Resident #86 were not afforded the opportunity to formulate their own advance directives. The findings included: The facility admitted Resident #101 with [DIAGNOSES REDACTED]. Review of the medical record revealed an Emergency Medical Services Do Not Resuscitate Order form dated 10/27/16 signed by the physician and Resident #101's representative. The medical record did not contain documentation signed by 2 physician's indicating that Resident #101 lacked the capacity to make his/her own healthcare decisions. The medical record contained no further documentation related to the resident's advance directives except for an order dated 10/27/16 which indicated the resident was a Full Code. During an interview on 2/15/17, the surveyor asked the Assistant Director of Nursing (ADON) for more documentation related to Resident #101's advance directives, information related to the resident's healthcare decision-making capacity, and informed the ADON the surveyor was unable to locate any physician's orders [REDACTED]. The ADON provided a copy of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. During an interview on 2/16/17 at approximately 9:15 AM, the ADON informed the surveyor that 1 physician had signed the paperwork related to Resident #101's decision-making capacity, and the second physician would sign the paperwork today. On 2/16/17 at approximately 4:00 PM, the ADON provided the surveyor with a copy of a Do Not Resuscitate order signed by the resident's physician dated 2/16/17. The ADON also provided a copy of a form entitled Authorization for Allow Natural Death Patient WITHOUT Ability to Consent signed by Resident #101's representative and 2 physicians related to the resident being incapable to making his/her own medical decisions. Review of the South [NAME]ina Adult Health Care Consent Act, Section 44-66-20 indicates in section (8), .A patient's inability to consent must be certified by two licensed physicians, each of whom has examined the patient .If a patient unable to consent is being admitted to hospice care pursuant to a physician certification of a terminal illness required by Medicare, that certification meets the certification requirements of this item. The facility admitted Resident #101 with [DIAGNOSES REDACTED]. Review on 2/17/2017 at approximately 8:03 AM of the medical record for Resident #101 revealed a physician's orders [REDACTED]. No documentation could be found in the medical record to ensure the code status had been discussed with the resident nor his/her responsible party of a possible DNR status. During further review of the medical record on 2/17/2017 at approximately 8:03 AM revealed no 2 physician signatures to determine that Resident #101 was unable to make his/her own health care decisions. Review on 2/17/2017 at approximately 9:20 AM of the facility policy titled, Code Status Listing, under Resident Rights states, It is the policy of this facility to assure that advanced directives are honored as written. Number one under procedures states, All residents will be informed of their opportunity to file advanced directives upon admission and at least annually. | 2020-09-01 |