cms_SC: 6396
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 6396 | MOUNT PLEASANT MANOR | 425110 | 921 BOWMAN ROAD | MT PLEASANT | SC | 29464 | 2014-06-30 | 155 | D | 0 | 1 | QRXS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record reviews, interviews, and review of the facility policy titled, Do Not Resuscitate , the facility failed to afford 2 of 19 sampled residents reviewed for Code Status the right to formulate their own Advanced Directives. Resident #52 and Resident #76 had not been deemed to lack capacity by 2 Physicians to make their own Advanced Directives/healthcare decisions. The findings included: The facility admitted Resident #52 with [DIAGNOSES REDACTED]. Record review on 06-25-14 at approximately 4:30 PM of the Physician's Telephone Orders dated 04-15-14 revealed the following order, .i.e .Do Not Resuscitate (DNR). Further record review on 06-25-14 of the Medical Decision Capacity for Resident #52 revealed only one Physician had determined Resident #52 to have all medical decisions made by others , not the required 2 Physicians. The resident's daughter had signed the Resuscitation designation form instead of the resident. During an interview on 06-25-14 at approximately 4:37 PM with the Director of Social Services, h/she, after chart review, verified the Medical Decision Capacity for Resident #52 had been signed by 1 Physician, not the required 2 Physicians. Review of the facility policy titled Do Not Resuscitate revealed in Section III. Basic requirements for facility Do Not Resuscitate order policy the following, (f.) Incompetent Patient- An adult who is unable to appreciate the nature and implications of his condition, to make reasoned decisions concerning his care, or to communicate decisions concerning his care. This incapacity must be verified by clinical assessment of the patient by 2 physicians, unless the individual was previously declared legally incompetent by court order. The facility admitted Resident #76 for Short-Term Rehab following hospitalization with [DIAGNOSES REDACTED]. Review of the Advance Directives section of the medical record revealed the resident's daughter signed the Resuscitation Designation form indicating the resident's code status was DNR. The physician had signed this form as well. Review of the Medical Decision Capacity form indicated one physician had signed this form indicating the resident lacked decision-making capacity. The section of the form reserved for a second physician's signature attesting to the resident's capacity contained documentation which stated, See H & P (History and Physical) & D/C (discharge) summary dated 2/18/14. Review of the hospital Discharge Summary indicated that the resident's granddaughter was the Healthcare Power of Attorney. Review of the facility's Social Services Evaluation form upon admission indicated , Resident's daughter is her RP and HCPOA (Healthcare Power of Attorney.) A DNR was signed by daughter and MD. Further record review indicated the resident signed a Durable Power of Attorney prior to admission designating his/her daughter as the Durable Power of Attorney. Review of the document indicated it did not address the right to make health-care decisions for the resident. Additional documentation was requested related to the family member signing the Advance Directive form without two physician's attesting to the resident's capacity to make healthcare decisions. The Director of Nursing reviewed the medical record and confirmed that the record contained only the Durable Power of Attorney. | 2018-03-01 |