cms_SC: 5497
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 5497 | FAITH HEALTHCARE CENTER | 425009 | 617 WEST MARION STREET | FLORENCE | SC | 29501 | 2015-01-23 | 155 | D | 0 | 1 | 1EGB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and review of the facility policy entitled Advance Directives, the facility failed to afford 1 of 19 sampled residents reviewed for advanced directives the right to formulate his/her own advanced directive. Although Resident #12 was able to make her/his own health care decisions, the spouse signed the advance directive. In addition, the facility failed to clarify the Code status of Resident #72, 1 of 1 resident with a request to make a change in an advance directive. The findings included: The facility admitted Resident #12 with [DIAGNOSES REDACTED]. Review of the [DATE] through [DATE] Physician's Cumulative Orders on [DATE] at approximately 12:00 PM revealed an order for [REDACTED].#12 had been examined by the physician and was competent to make health care decisions. Review of the Request Concerning Life-Prolonging Procedures for Resident #12 revealed the resident's spouse had signed the form on [DATE] requesting no .Cardiopulmonary Resuscitation (CPR), Use of respirators or ventilators, Blood transfusion, Administration of medications other than those necessary to prevent infection, provide comfort or alleviate pain, and Transfer to an acute care hospital. During an interview on [DATE] at approximately 4:30 PM, Licensed Practical Nurse #2 reviewed the record and confirmed the above finding. S/he stated, Social Services assists the family in these matters. During an interview on [DATE] at approximately 12:05 PM, Social Service Staff #1 reviewed the record and confirmed that Resident #12 had not signed the Request for Life-Prolonging Procedures although the physician had deemed him/her capable of making his/her own health care decisions. The facility admitted Resident #72 with [DIAGNOSES REDACTED]. Record review on [DATE] at approximately 3:30 PM revealed the ,[DATE] Physician's Order Recapitulation that noted the resident as a Full Code. Further review of the resident's medical record revealed [REDACTED].#72 was a Full Code. Record review on [DATE] at approximately 4:00 PM revealed a Nurses Note that Resident #72 had expired. The following was noted in Resident #72's Nurses Notes: [DATE] 5:05 PM Resident's condition remains unchanged. Wife at bedside. Both pupils in eyes are fixed .Doctor comes in facility and made aware of resident condition and wife wanting to make resident a DNR (Do Not Resuscitate) Code Status. [DATE] 6:15 PM Code Status DNR, new order [MEDICATION NAME] . [DATE] 7:50 PM Called into room via nurse. Witness resident taking last 2 breaths faint pulse noted, carotid pulse present faint. [DATE] 7:52 PM Call to resident room by Nurse, assess resident for pulse, no pulse, assess b/p (blood pressure) no b/p, look for rise and fall of chest for 1 min(ute) no movement. Auscultate lung, no sound, used stimuli, no response. Assess pupils no reaction fixed and dilated. [DATE] 8:15 PM Medical Director (MD) made aware. Review of the Advanced Directives Notification and worksheet signed and dated on [DATE] stated I do not want CPR: Do Not Attempt Resuscitation (Allow Natural Death). Review of the Resident's Durable Power of Attorney did not include health care decision making. Record review on [DATE] at approximately 4:45 PM revealed that staff had failed to record the Physician's Telephone Order for the change from a Full Code to DNR status for Resident #72. During an interview on [DATE] at approximately 5:23 PM, Licensed Practical Nurse (LPN) #4 stated that the resident's spouse came to them crying and stating s/he wanted Resident #72 to be a DNR because of her/his condition. LPN #4 stated s/he paged the resident's attending physician. However, s/he never responded. S/he notified another physician in the building and the resident's spouse told the physician that s/he wanted Resident #72 to be a DNR. LPN #4 stated s/he could not remember if a physician's order was signed at the time. During an interview on [DATE] at approximately 9:11 AM, the Medical Director confirmed there was no DNR order in the resident's medical record. The Medical Director stated, The resident should not have been resuscitated as a verbal order. However, the nurse did fail to document and write a DNR order for the physician to sign. The MD further stated that the nurse did not follow through with his/her responsibility in writing the order. The Director of Nursing needs to talk with nurses and discuss the importance, but I feel the nurse did her job by not resuscitating the resident. , Review of the policy entitled Initiation of Cardio-Pulmonary Resuscitation stated: The nursing home acknowledges its responsibility to provide basic life support, including initiation of Cardio-Pulmonary Resuscitation (CPR), to a resident who experiences [MEDICAL CONDITION] (cessation of respirations and/or pulse) in accordance with that resident's advance directives, or in the absence of advance directives or a DNR order. Section 3 Procedures: B.CPR shall be initiated by qualified staff to a resident or patient that has experienced [MEDICAL CONDITION] unless: 1.) a valid DNR order is in place . | 2018-11-01 |