cms_SC: 6232
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 6232 | PRESBYTERIAN COMMUNITIES OF SOUTH CAROLINA- CLINTO | 425393 | 801 MUSGROVE STREET | CLINTON | SC | 29325 | 2015-02-19 | 155 | D | 0 | 1 | UWQF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and a review of the facility policy entitled Advance Directives, the facility failed to provide 1 of 6 sampled residents the opportunity to formulate his/her own advance directive. A Do Not Resuscitate (DNR) order was written for Resident #30 at the direction of the resident's Responsible Party (RP) without documentation that 2 physicians had determined the resident was unable to make healthcare decisions or that this was the resident's wishes. The findings included: The facility admitted Resident #30 with [DIAGNOSES REDACTED]. Record review on [DATE] at 4:10 PM revealed a [DATE] Physician order for [REDACTED]. Further review revealed the resident's RP had signed a request on [DATE] for Resident #30 to not have CPR performed under any circumstances. The RP had signed this request in the space designated for the Power of Attorney/RP for a resident certified as unable to sign. The space designated for a competent resident to sign had been left blank. Review of the facility form Attachment F, Certification of Patient's Inability to Consent to Health Care Decisions, revealed the following: According to the South Carolina Adult Health Care Consent Act, Section [DATE], a patient's inability to consent must be certified by two licensed physicians . According to the document, 2 physicians were to verify that a patient was considered unable to consent to healthcare procedures. The form contained only 1 physician signature dated [DATE]. A review of Progress Notes revealed a Social Services note dated [DATE] at 8:43 AM which documented the resident was a DNR with durable Power of Attorney (POA) for healthcare provisions. During an interview on [DATE] at 4:38 PM, when asked about the resident's code status, Licensed Practical Nurse (LPN) #1 reviewed the chart and stated the resident was a DNR. LPN #1 verified the documentation that the resident's RP had signed for the DNR status and that only 1 physician had signed the inability to consent form. The nurse thought that a copy of the form was in the physician's folder awaiting his/her signature as the 2nd physician. According to the nurse, the 2nd physician did not come to the facility as often as the attending physician did. During an interview on [DATE] at approximately 4:45 PM, the Director of Health Services (DHS) verified the Physician Orders conflicted with the resident's code status of DNR. The DHS stated that when the resident had been in Assisted Living, s/he had been a full code. During an interview on [DATE] at 5:01 PM, the Social Services Director (SSD) stated Resident #30 would not be coded if his/her heart stopped based on the RP's wishes for the DNR status. According to the SSD, s/he had attempted to speak with the resident about his/her code status but the resident did not or was not able to give a response. A review of the policy provided by the facility on [DATE] at 7:55 AM entitled Advance Directives revised [DATE], revealed that Advance directives will be respected in accordance with state law and facility policy .8. If a resident or health care designee chooses to have a DNR order, the resident or health care designee will sign the appropriate documents. The resident will always sign his or her DNR sheet unless they have been determined unable to make health care decisions by two physicians. | 2018-05-01 |