cms_WV: 5860
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 5860 | HILLCREST HEALTH CARE CENTER | 515117 | 462 KENMORE DRIVE | DANVILLE | WV | 25053 | 2014-11-17 | 155 | D | 0 | 1 | LO0C11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, staff interview, and policy review, the facility failed to allow one (1) of four (4) Stage 2 residents reviewed for the care area of choices, the right to formulate an advanced directive related to cardiopulmonary resuscitation (CPR). After Resident #89 regained the capacity to make her own healthcare decisions, the facility failed to provide the resident the right to choose whether or not she wanted to receive CPR should it be necessary. Resident identifier: #89. Facility census: 87. Findings Include: a) Resident #89 Review of the resident's medical record at 10:08 a.m. on [DATE], revealed she was admitted to the facility on [DATE], at which time she lacked capacity to make healthcare decisions. Her son was appointed as her health care surrogate (HCS). The medical record contained a physician's orders [REDACTED]. The POST form indicated Resident #89 was to receive CPR in the event she would need it. Additional review of the medical record revealed a physician's determination of capacity completed by Resident #89's attending physician on [DATE]. This form indicated Resident #89 demonstrated capacity to make medical decisions. There was no evidence in the medical record to indicate the facility had ever discussed with Resident #89 her wishes in regards to CPR after she regained her capacity to make health care decisions on [DATE]. In an interview with Resident #89 at 11:27 a.m. on [DATE], she was asked if any one at the facility had ever discussed with her what her choices in regards to CPR would be. Resident #89 replied, No honey, they have never talked to me about that. I would want it because I want to live as long as possible, wouldn't you? An interview with the Social Service Supervisor (SSS), at 1:08 p.m. on [DATE], revealed if a resident was incapacitated upon admission to the facility, but then regained capacity at a later date, a new POST form should be completed with the resident to reflect his/her choice, not the choices of the health care decision maker. The SSS was asked if Resident #89 was afforded the right to complete a new POST form when she regained capacity on [DATE]. The SSS reviewed the medical record and indicted there was never a new POST form completed with Resident #89 and she would have to go speak with the resident and complete a new form. The SSS stated, they discussed CPR in the quarterly care plan meetings, but they never completed a new post form with Resident #89. The facility's advance directive operations policy was reviewed at 12:30 p.m. on [DATE]. The policy contained the following statements in regards to advance directives, .10. At least annually and following any changes or revocations to the documents, the Interdisciplinary Team (IDT) will review his/her advance directives with the patient to ensure that such directives are still the wishes of the patient. Such reviews will be recorded in the patients clinical record. The IDT shall be responsible to ensure that the patient's current plan of care reflects the patient's expressed directives for treatment. Review of the care plan meeting notes for Resident #89 for the previous year revealed no mention of Resident #89's wishes in regards to CPR. The facility was unable to provide any evidence from Resident #89's clinical record to indicate the facility had reviewed the POST form with Resident #89 since she regained capacity on [DATE]. | 2018-07-01 |