cms_SC: 4063
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 4063 | PRUITTHEALTH-BLYTHEWOOD | 425400 | 1075 HEATHER GREEN DRIVE | COLUMBIA | SC | 29229 | 2017-09-15 | 520 | J | 1 | 1 | 4HVH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on full and/or limited record reviews, interviews and review of the facility policies, it was determined on [DATE] at approximately 11:45 AM that Immediate Jeopardy existed at CFR4[AGE].[AGE] F-520 at a scope and severity level of (J) beginning on [DATE]. The facility failed to identify quality deficiencies related to 2 of 3 sampled residents reviewed for death in the facility for whom cardiopulmonary resuscitation (CPR) was not provided as required. The facility failed to implement a plan of action related to Advance Directives for and initiation of CPR. Failure of the Quality Assurance (QA) Committee to identify and implement action plans to ensure residents who exhibited absence of pulse and respirations received CPR when indicated and according to State Law resulted in Immediate Jeopardy for Residents #205 and #210. It was determined that 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). The findings included: Cross Refer to 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. 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. Based on observations made throughout the course of the standard and extended survey process and interviews, the facility failed to identify and implement appropriate plans of action to address issues that resulted in failure to comply with multiple regulatory guidelines that resulted in citations in multiple areas with negative impact on the quality of life or quality of care provided to those residents present in the facility for two of two nursing units. When asked on [DATE] at 8:00 PM if there were any current Quality Assurance action plans in place that addressed any of the numerous concerns identified by the survey team and shared during the survey process that the facility would like to have taken into consideration during the decision making meeting, the Administrator reported that there were areas that they had been addressing; however there were no specific Performance Improvement Plans in place and that what information was available was in the form of notes that s/he would endeavor to locate as soon as possible. There was no further information related to any current Performance Improvement Plans provided to the survey team to review and discuss through the end of both the standard and extended survey process which was concluded on [DATE]. 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 noted to be 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 lowered 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 |