cms_WV: 11022
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 11022 | HEARTLAND OF KEYSER | 515122 | 135 SOUTHERN DRIVE | KEYSER | WV | 26726 | 2009-02-05 | 155 | D | 0 | 1 | 53ZE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to assure that residents with capacity were involved in making decisions with respect to the advance directives documented on the Physician order [REDACTED]. Resident identifiers: #92 and #104. Facility census: 121. Findings include: a) Resident #92 A review of the medical record revealed a POST form indicating Resident #92 was to receive cardiopulmonary resuscitation (CPR) and "Limited additional interventions". This form was signed by the resident's medical power of attorney representative (MPOA) on [DATE]. The resident's attending physician determined Resident #92 lacked the capacity to understand and make healthcare decisions on [DATE]. This determination was validated by a second determination made by a psychologist on [DATE]. On [DATE], the resident's attending physician reversed this and determined the resident now had the capacity to formulate healthcare own decisions. However, there was no evidence in the record to indicate the advance directives recorded on the [DATE] POST form had been reviewed with the resident. During an interview at 11:45 a.m. on [DATE], the social worker (Employee #119) was asked if the advance directives noted on the POST form had been reviewed with the resident. The social worker could not remember and, at the time of exit, she had not produced any evidence to indicate the resident had been informed of the decisions made by the MPOA. b) Resident #104 A review of Resident #104's medical record revealed the resident was admitted on [DATE]. On [DATE], the social worker recorded in social services notes that the resident had the capacity to make his own healthcare decisions and he had "Full Code" status. His attending physician also determined, on [DATE], that Resident #104 had the capacity to make healthcare decisions. However, an attached form stated: "It is my desire that (Name) , my (wife) , sign all forms on my behalf to admit me to Heartland of Keyser, as I am presently in a weakened condition and do not wish to sign all of the forms necessary for admission." The resident had several acute hospitalization s, and a social service note on [DATE] indicated his daughter was his health care surrogate and that he was still "full-code status". A new POST form, indicating the resident was not to be resuscitated and was to receive limited additional interventions, was signed by his wife on [DATE], while he was in the hospital. There was no evidence to show the wife had any legal authority to make healthcare decisions for him at that time. The resident was readmitted to the facility on [DATE], and all documentation indicated the resident had the capacity to form his own healthcare decisions. However, there was no evidence he had been involved in his healthcare decisions, including formulating the advance directives recorded on the POST form. In an interview with both social workers (Employees #79 and #119) at 2:40 p.m. on [DATE], they were asked if the resident was aware of his code status. Neither answered, nor was any documentation offered. They both verified the resident was alert, oriented, and able to make his needs known with sign language. . | 2014-09-01 |