cms_SC: 4019
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 4019 | PRUITTHEALTH-BLYTHEWOOD | 425400 | 1075 HEATHER GREEN DRIVE | COLUMBIA | SC | 29229 | 2017-09-15 | 155 | J | 1 | 1 | 4HVH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record reviews, interviews, review of the facility policy titled Do Not Resuscitate Policy: [STATE], and review of the [STATE] Code of Laws, TITLE 44. HEALTH, CHAPTER 66. Adult Health Care Consent Act, the facility failed to initiate cardiopulmonary resuscitation (CPR) as required for 2 of 3 sampled residents reviewed for death in the facility. Residents #205 and #210 had advance directives signed by family/responsible party without two physicians' determinations of inability to make health care decisions completed. The facility failed to establish and implement policies and procedures consistent with State law regarding health care decisions/formulation of advance directives. The facility transferred decision-making responsibility to the legal representatives of Residents #205 and #210 without two physicians' determinations of the residents' inability to make health care decisions. It was determined on [DATE] at 11:45 AM that Immediate Jeopardy existed as of [DATE] for Resident #205 and on [DATE] for Resident #210 for F-155 which was identified at a scope and severity level of (J). The findings included: Cross Refer to CFR 4[AGE].25 F-309 Provision of Care and Services was identified at a scope and severity level of (J). The Immediate Jeopardy existed on [DATE] for Resident #205 and on [DATE] for Resident #210 when licensed nursing staff failed to provide the necessary care and services when the residents exhibited absence of vital signs and did not receive cardiopulmonary resuscitation (CPR). Cross Refer CFR 4[AGE].[AGE] F-490 Administration was identified at a scope and severity level of (J). The facility administration failed to ensure appropriate polices and procedures were developed and implemented to identify if Advanced Directives were formulated and proper care and services were provided related to cardiopulmonary resuscitation. The failure of the facility to ensure policies and procedures were established and implemented according to State law regarding Advanced Directives placed all residents at risk for serious harm/death. Cross Refer CFR 4[AGE].[AGE](o)(1) F-520 Quality Assurance was identified at a scope and severity level of (J). The facility failed to ensure the Quality Assurance process was utilized to identify, and implement a plan of action regarding adherence to legally executed Advanced Directives. The facility admitted Resident #205 with past medical history of [REDACTED]. S/he was treated at the hospital for a Subcapital Right Femoral Neck Fracture resulting from a fall at the Assisted Living Facility (ALF) where s/he resided. According to Social Services Progress Notes, the discharge plan was to return to the ALF. Review of the [DATE] Admission and [DATE] 14 Day Minimum Data Set assessments revealed that the resident scored a 0 on the Brief Interview for Mental Status (BI[CONDITION]), indicating severe cognitive impairment. Review of Nurse's Notes at 10:07 AM on [DATE] revealed that Resident #205 was participating in therapy daily. On [DATE] at 8:20 AM, a staff member called the nurse to the resident's room. S/he stated when s/he assisted the patient out of bed to the chair, s/he did not respond to his/her name. At this time, the resident had no blood pressure (BP) and oxygen (O2)saturation (sat) was 82%. Oxygen was administered at 2 liters/minute. The physician was notified and gave orders to hold medication and notify the family. When notified of the resident's decline in condition, the daughter-in-law stated they did not want the resident hospitalized and to just keep him/her comfortable. According to the notes, the family arrived at 9:45 AM and left at 10:00 AM. At 10 AM, O2 sat 87(%). Pulse 37 (beats per minute). Extremities cool to touch. Patient with some upper extremity movement. At 10:50 AM, the Registered Nurse (RN) Weekend Supervisor noted, Called to room by (Licensed Practical Nurse (LPN) #8) stating resident not breathing. Resident found unresponsive, in bed, no respirations, no pulse, no heart or breath sounds auscultated. No code called per advance directives and signed DNR order in chart. Record review at 8:31 AM on [DATE] revealed a red DNR (Do Not Resuscitate) sticker on the face sheet in the front of the medical record. There was also a [DATE] Physician's Interim Order for DNR. Review of the Authorization of Do Not Resuscitate Order Without Decision-Making Capacity revealed it was signed, but not dated, by the physician. There was no second physician signature to indicate that the resident had been assessed for ability to make health care decisions. The form was signed by a family member to indicate consent to the order and witnessed by Social Services. In addition, there was a DNR order on a Florida Department of Health form indicating that Resident #205 had a durable power of attorney. Multiple requests (on [DATE] at 9 AM, 12:45 PM, and 2 PM) were made to the Administrator to review the power of attorney and on [DATE] at 5:30 PM, s/he stated they were unable to locate the document. During an interview at 9:20 AM on [DATE],Social Services #2 stated that advance directives were discussed on admission. If the resident had an advance directive or durable power of attorney for health care, a copy was requested at that time and placed in the medical record. When asked to describe the process for obtaining an advance directive such as a DNR, s/he stated that Social Work would discuss it with the resident and responsible party, get the forms signed and put them in the doctor's box for his/her signature upon next visit. If the resident was able to make his/her own decisions, the resident would sign the Authorization of Do Not Resuscitate Order With Decision Making Capacity form. If the resident was unable to make health care decisions, the family/responsible party would sign the Authorization of Do Not Resuscitate Order Without Decision-Making Capacity form. The forms were then put into the doctor's box. Social Services #2 reviewed Resident #205's Authorization of Do Not Resuscitate Order Without Decision-Making Capacity form and verified that there was only 1 physician's signature determining the resident's inability to make health care decisions. The surveyor asked, In this case, if the resident had been found without vital signs, should s/he have been resuscitated? Social Services #2 stated,Yes. During an interview at 9:45 AM on [DATE], the attending physician/Medical Director confirmed that a second physician needed to assess a cognitively impaired resident and sign that s/he was unable to make health care decisions before the resident could be considered a DNR and the next of kin could make the advance directive decision for him/her. The physician verified his/her signature on the form and confirmed there was no second physician's signature. S/he stated,They (the facility) used to fax or take the form to (physician) to review and sign as the second physician. I don't know what has happened to that. During an interview on [DATE] at 11:08 AM, the Director of Nurses (DON) reviewed the medical record. When asked how the nurse knew what to do in the event the resident was found without vital signs, the DON stated,They have the DNR sticker. Nurses don't go by the sticker. They go by the doctor's order. After reviewing the record, s/he further stated, They needed the second doctor's signature before the order was written and put on the chart. S/he confirmed that, in these circumstances, CPR should have been initiated. During an interview at 11:38 AM on [DATE], LPN #8 stated s/he could not recall all the details of the incident. S/he reviewed and confirmed the entries in the record. At 1:15 PM, when asked how s/he determined when to initiate CPR, LPN #8 stated s/he would look for the physician's order in the chart. Review of the Care Plan at 1:28 PM on [DATE] revealed no reference to advance directives being in place or resident/family participation in the plan of care. During an interview at approximately 2 PM, with the Administrator present, a corporate representative stated s/he thought advance directives were portable from state to state. The facility admitted Resident #210 with [DIAGNOSES REDACTED]. Closed record review at 9:22 AM on [DATE] revealed that the resident was initially admitted on [DATE], was hospitalized for [REDACTED]. Review of Skilled Daily Nurse's Notes at 11:17 AM revealed that at 11:20 AM on [DATE], Resident #210 was alert (with) confusion.denied pain/discomfort.has been OOB (out of bed) -> (to) chair. The next note at 5 AM on [DATE] stated, Resident in bed resting with eyes closed. No complaints of pain or discomfort. No signs of distress noted. At 6:50 AM, the Certified Nursing Assistant (CNA) requested the nurse to come to the resident's room. The LPN noted, There was no movement at this time. There was no pulse, respiration. The RN on duty noted no vital signs and no response to tactile stimuli. Resident is DNR, Resident expired at present time. Closed record review at approximately 9:30 AM revealed a red DNR (Do Not Resuscitate) sticker on a [DATE] Physician's Interim Do Not Resuscitate Order in the front of the medical record. Review of the Authorization of Do Not Resuscitate Order Without Decision-Making Capacity revealed it was signed by one physician on [DATE]. There was no second physician signature to indicate that the resident had been assessed for ability to make health care decisions. The form was signed by a family member to indicate consent to the order. The [DATE] Multidisciplinary Care Conference Meeting form noted: DNR signed during meeting. Review of the ,[DATE] cumulative monthly Physician's Orders at 11:06 AM revealed that they also included a DNR order. Review of the Care Plan at 10:50 AM on [DATE] revealed no reference to advance directives being in place or resident/family participation in the plan of care. During an interview at 10:30 AM on [DATE], the Administrator reviewed the medical record. S/he verified that, although the family had signed for a DNR order, and a physician's order had been written, there was only one physician's signature determining the resident's inability to make health care decisions. The [STATE] Code of Laws, TITLE 44. HEALTH, CHAPTER 66. Adult Health Care Consent Act notes persons who may make health care decisions for a patient who is unable to consent in order of priority. SECTION [DATE]. Definitions states: (8) Unable to consent means unable to appreciate the nature and implications of the patient's condition and proposed health care, to make a reasoned decision concerning the proposed health care, or to communicate that decision in an unambiguous manner. A patient's inability to consent must be certified by two licensed physicians, each of whom has examined the patient. Review of the facility policy titled Do Not Resuscitate Policy: [STATE] and the [STATE] Code of Laws, TITLE 44. HEALTH, CHAPTER 66. Adult Health Care Consent Act revealed the policy was not in conformance with State law. The [DATE] policy stated: Definitions: 4. Decision Making Capacity.Every adult is presumed to have decision making capacity unless determined otherwise by a physician in writing.Procedure: I. Receiving a DNR Order from Another Healthcare Provider: A. Any written order issued by any attending physician using the term 'do not resuscitate', 'DNR',.or substantially similar language, and that is contained in the patient's medical record shall constitute a sufficient order.C. If an adult patient/resident does not have decision-making capacity and is a candidate for non-resuscitation a physician may issue a DNR with the consent of the patient/resident's representative. Based on full and/or limited record reviews, interviews, and review of the facility policies, it was determined on [DATE] at 11:45 AM that Immediate Jeopardy and/or Substandard Quality of Care existed in the following areas: CFR 4[AGE].10(b)(4) F-155 Right to Formulate an Advance Directive was identified at a scope and severity level of (J). The facility transferred decision-making responsibility to the representatives of Residents #205 and #210 without two physicians' determinations of the residents' inability to make health care decisions. This failure resulted in staff not initiating cardiopulmonary resuscitation (CPR) as required. The facility Administrator was informed of the Immediate Jeopardy on [DATE] at 12:40 PM. The facility provided an Allegation of Compliance (AOC) that was acceptable and implemented on [DATE]. The Immediate Jeopardy at F-155, F-309, F-490, and F-520 was removed on [DATE] but the citations remained at a lower scope and severity of D. The AOC included the following: (1) The residents with the alleged deficient practice are no longer residing in the facility. (2) The Director of Health Services will complete a review of all residents in the facility to ensure that do not resuscitate orders have been obtained per policy and state regulations. The Social Worker will also ensure where appropriate two physician signatures have been obtained. (3) All new residents' code status will be included on the 24 hour chart check daily and then reviewed during the daily morning meeting for compliance. (4) The DNR policy is as follows: Prior to, or upon Admission, the patient/resident and/or their responsible party will be asked about the existence of any advance directives. The Advance Directives Checklist, which is in the South Carolina Admission Packet, will be completed. Should the patient/resident indicate on the Advance Directive Checklist that he/she has issued advanced directives about his/her treatment, the healthcare center will require that copies of such advance directives be given to the healthcare center for inclusion in the patient/resident's medical record. A copy of the advance directive shall become a permanent part of the patient/resident medical record. The Director of Health Services will notify the attending physician of advance directives and document such notification in the medical record. Should the patient/resident indicate on the Advance Directive Checklist that he/she does not currently have an advance directive, but would like further information on advance directives; the patient/resident shall be provided with legal forms located on the [STATE]'s Office on Aging website. If upon admission, or any time thereafter a patient/resident or his Representative requests a DNR order, the Social Worker/Case Mix Director or Director of Health Services shall be responsible for completing the process. If an adult patient/resident HAS decision making capacity, he/she may consent to an order not to resuscitate. If an adult patient/resident does not have decision making capacity and is a candidate for non- resuscitation and the attending physician may decide to withhold life-prolonging measures or discontinue life prolonging measures by initiating a without decision making capacity form and having a concurring physician signature along with the authorized person signature. All resident will be a full code until this procedure is complete (5) The facility Admission Director will review advance directive checklist with resident and or responsible party. If there resident is confused and BI[CONDITION] (Brief Interview for Mental Status) score is 9 or below, a decision making capacity form will be completed with two physician signatures. The BI[CONDITION] score will be completed on the day of admission for all new residents. (6) Social service was educated on the process for obtaining Advance Directive upon admission and change of condition per policy and by regulation, by the Regional Nurse Consultant. All future hires for the department will be trained during the orientation and all of the Social Workers in the facility will be reeducated annually with their evaluation. (7) The Regional Nurse Consultant has educated both physicians at the facility on the DNR and requirements for the second signature. (8) The Clinical Competency Coordinator will educate all of the licensed nursing personnel on the DNR orders and requirements for DNR orders to be valid before the start of their next work shift. | 2020-09-01 |