cms_WV: 5101
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 5101 | RALEIGH CENTER | 515088 | 1631 RITTER DRIVE | DANIELS | WV | 25832 | 2015-04-10 | 155 | D | 0 | 1 | CRGX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, policy review, and resident interview, the facility failed to ensure two (2) of two (2) sample residents, reviewed for the care area of choices during Stage 2 of the survey, were afforded the right to formulate an advanced directive. The facility determined each of the residents had capacity to make health care decisions; however, a family member for each resident signed their Physician order [REDACTED]. Resident Identifies: #32 and #83. Facility Census: 66. Findings Include: a) Resident #32 A review of Resident #32's medical record, at 9:04 a.m. on [DATE], found she was admitted to the facility on [DATE]. Review of the resident's admission information found Resident #32 signed all admission paperwork on [DATE]. Further review of the medical record found a Physician Determination of Capacity completed by Resident #32's attending physician on [DATE]. This form indicated Resident #32 was able to make her own informed medical decisions. The medical record contained a POST form which indicated Resident #32 was not to receive cardiopulmonary resuscitation (CPR). The form also noted she was to receive intravenous fluids and a feeding tube for a defined trail period only. The POST form was signed by Resident #32's daughter on [DATE]. Licensed Practical Nurse (LPN) #36 assisted Resident #32's daughter in completing this form on [DATE], as indicated by the LPN's signature on the back of the POST form. The form went into effect on [DATE], when Resident #32's attending physician signed the form making it a physician's orders [REDACTED].>The medical record contained no evidence indicating Resident #32's wishes for CPR, use of IV fluids, and use of a feeding tube were ever discussed with her. An interview with the Director of Admissions (DOA) #42, at 1:20 p.m. on [DATE], confirmed Resident #32 had capacity to make medical decisions. She stated the POST form should have been completed by Resident #32 and not her daughter. The DOA was unable to provide any information to indicate these decisions were ever discussed with the resident. She stated she would complete a new POST form with Resident #32 as soon as possible. At 3:00 p.m. on [DATE], DOA #42 provided a new POST form completed by Resident #32. This POST form indicated the resident was not to have CPR, was to only have IV fluids for a defined trial period. and was not to have a feeding tube. The resident's wishes in regards to a feeding tube conflicted with the previous POST form completed by her daughter. b) Resident #83 A review of Resident #83's medical record, at 9:14 a.m. on [DATE], found he was admitted to the facility on [DATE]. Review of the resident's admission information found Resident #83 signed all admission paperwork on [DATE]. Further review of the medical record found a Physician Determination of Capacity completed by Resident #83's attending physician on [DATE]. This form indicated Resident #83 was able to make his own informed medical decisions. Resident #83's medical record contained a POST form which indicated he was to receive CPR, and a feeding tube and IV fluids long term if needed. The POST form was signed by Resident #83's daughter on [DATE]. Registered Nurse (RN) #41 assisted Resident #83's daughter in completing this form on [DATE], as indicated by the RN's signature on the back of the form. The form went into effect on [DATE], when Resident #83's attending physician signed the form making it a physician order. The medical record contained no evidence indicating Resident #83's wishes for CPR, use IV fluids, and use of a feeding tube were ever discussed with him. An interview with Resident #83, at 11:30 a.m. on [DATE], revealed facility staff had never spoken with him about his wishes in regards to CPR. He stated, That topic of conversation has never come up with anyone. An interview with DOA #42 and Social Service Director (SSD) #59, at 12:51 p.m. on [DATE], confirmed Resident #83 should have signed his own POST form. SSD #59 stated she had reviewed his code status on his quarterly and admission assessments, but failed to notice Resident #83 had not signed his own POST form. She stated she would have to complete a new POST form with Resident #83. At 4:30 p.m. on [DATE], a POST form dated [DATE] was provided by SSD #59. This form indicated Resident #83 was to receive CPR, and was only to receive IV fluids and a feeding tube for a defined trial period only. His wishes in regards to IV fluids and feeding tube conflicted with the form completed by his daughter. c) Healthcare Decision Making Policy A review of the Facility's Health Care Decision Making policy on [DATE], found the following, .9. Upon admission, quarterly, and with a change in condition, the physician, in collaboration with designated center staff, will meet with the patient or health care decision maker to complete or review advance directives . and define and clarify medical issues . | 2019-03-01 |