cms_WV: 3307
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 3307 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2018-04-05 | 842 | D | 0 | 1 | NWDF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, electronic record review, hard copy (paper) medical record review, and staff interview, the facility failed to ensure the accuracy of a resident's code status, and to ensure it was readily available, consistent, and communicated to staff. Staff were unable to locate Resident #18 code status in the electronic medical record. In addition, staff found conflicting code statuses when reviewing the hard copy of the medical record. This failed practice was true for one (1) of sixteen (16) residents reviewed for code status. Resident identifier: #18. Facility census: 46. Findings included: a) Resident #18 On 04/02/18 at 3:00 PM, a review of the electronic medical record (EMR) for Resident #18 revealed a DO NOT RESUSCITATE (DNR) order. An additional review of the hard copy (paper) medical record conflicting orders were found on 04/3/18 for Resident #18's code status. The hard copy medical record was labeled to read FULL CODE. Continuing review of the both the EMR and hard copy medical record found the following: - State of West Virginia Medical Power of Attorney (MPOA) stated FULL CODE dated 08/14/1998 - the Physician order [REDACTED]. - the Face Sheet dated admitted : 08/27/13 (latest return) and 06/01/12 Current as a DNR; - admission orders [REDACTED] - physician's orders [REDACTED]. - physician's orders [REDACTED]. - admission orders [REDACTED] - Advanced Directives and code Status Report dated 4/2/18 stated DNR. During an interview on 04/04/18 at 2:00 PM, Nursing Aides (NAs) #46 and #84, and Licensed Practical Nurse (LPN) #72 were asked to demonstrate how to find a resident code status. The NAs and LPN stated that staff were not informed of the code status during shift change, but were sure it was in the computer in the hallway. After searching for about 15 minutes, the NAs and LPN had to be shown were to find a resident's code status on the computer system. When asked to show the code status for Resident #18, they pointed to the screen for Resident #18 that showed DNR. During an interview on 04/04/18 at 2:40 PM, when asked how she knew the code status of a resident, LPN #72 replied, We don't exchange that in report unless there was a change in status because they all know their residents. When asked to show the code status for Resident #18, LPN #72 pointed to the computer screen which displayed DNR. On 04/04/18 at 3:20 PM, Registered Nurse (RN) #44 looked on the hard copy medical record for Resident #18 and stated that she was a full code. Further review of the hard copy medical record with RN #44 found evidence of both DNR and FULL CODE status. RN #44 looked on the Desk Top Computer and found the code status for Resident 18 was DNR. During an interview on 04/04/18 at 4:00 PM, the Director of Nursing (DoN) stated that Social Worker (SW) #3 had found a POST form that the Resident #18 signed in 2004 requesting to be a full code, but the MPOA had changed the code status to a DNR. The DoN stated that she felt like the MPOA changed the code status without the consent of Resident #18. The DoN stated that she was not aware that the chart had conflicting code status orders and that the electronic chart code status was incorrect. The DON agreed this was confusing for the staff and the charts both electronic and the hard copy were wrong. | 2020-09-01 |