cms_AK: 21
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| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 21 | KETCHIKAN MED CTR NEW HORIZONS TRANSITIONAL CARE | 25010 | 3100 TONGASS AVENUE | KETCHIKAN | AK | 99901 | 2019-08-23 | 550 | D | 1 | 1 | 0OWF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, document review, interview, and state statute review, the facility failed to ensure that the rights of a resident with a guardian were exercised to the extent provided by state law. Specifically, the facility failed ensure 1 resident (#1) out of 4 residents reviewed, code status accurately reflected his/her wishes to be comfortable at the end of his/her life and conflicting views were resolved prior to the resident's death. This failed practice placed the resident at risk for pain and suffering from futile traumatic medical treatment. Findings: Record review 8/22-23/19 revealed Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. Review of Resident #1's most recent MDS (Minimum Data Set- A federally mandated nursing assessment) dated 5/20/19 revealed Resident #1 had a BIMS (Brief Interview for Mental Status) of 15, which indicated no impairment to Resident #1's attentiveness, orientation to person, place, time and situation, and ability to recall events. Record review of POLST (Physicians Orders for Life Sustaining Treatment) dated 3/7/18 revealed that Resident #1 was made a DNR (do not resuscitate). The document was signed by a public guardian. Resident #1 did not sign the document. Review of ethicist note dated 6/5/19 revealed, (Physician #1) spoke to me about the patient's disposition and Code Status. (Resident #1) . admitted to our LTCU (long term care unit) .with multiple medical and behavioral challenges which necessitated the state of Alaska appointing a public guardian through the office of Public Advocacy. (Resident #1's) guardian has the right and responsibility to ensure (his/her) financial, legal, and medical concerns are addressed, and while the courts have declared (him/her) no longer capable of making these decisions, a guardians role is to ensure the patient's wishes are taken into consideration. There has been considerable confusion regarding Code Status based on a POLST document completed in Washington and Alaska that identified DNR/DNI (do not resuscitate/do not intervene). (Physician #1) spoke with (Resident #1) at length about advance care planning and the patient clearly articulated (his/her) desires to remain Full Code. (Physician #1) will speak with the patient guardian to confirm this conversation and obtain assent on the patients request for Full Code. Review of a physician note dated 6/5/19 revealed, Lengthy discussion with (Resident #1) regarding diagnosis, medical management, and plan of care .I stressed that we are doing everything medically to make (him/her) comfortable and prolong (his/her) life. (He/she) admits to refusing care and stopping transfusion early saying that (he/she) gets 'confused' and doesn't want to be a 'pill head'. (He/she) also said that (he/she) did not want a 'bandaid'. (His/her) mortality and code status are brought up on a regular basis by providers and staff in the LTC and (he/she) becomes very anxious. I asked (him/her) when (he/she) is dying does (he/she) want to be comfortable or suffer. (He/she) stated to me that (he/she) wants to be full code until I get to the end, then I will be ready to take what makes me comfortable .(Resident) has state appointed guardian .(Resident #1) does not have decision making capacity. It is not appropriate to ask (him/her) to make medical decisions when (he/she) does not have legal authority to make these decision. Confronting (Resident #1) with (his/her) medical condition and re clarifying code status is not beneficial and I feel it is actually harmful to this patient . Recommendations Code Status-full code until pt is dying, the 2 physicians feel that ACLS (advanced life support) would be non beneficial futile care. When pt is actively dying-change code status to comfort and provide her with comfort measures only, pt understands this is the plan. Document review of the court Order Appointing Full Guardian With Powers of Conservator is dated as 6/6/19 with an unreadable note next to the judge's signature indicating a date of 7/6/19. Review of a Patient Care Coordination note dated 6/8/19 revealed, Pt (patient) has been disenrolled living permanently in SNF (skilled nursing facility) on 6/4/18. Record review of IP (Inpatient) Palliative Care note dated 8/9/19 revealed that Resident #1 was on palliative care. Random review of nursing notes from 6/1/19 through 8/1/19 revealed Resident #1 frequently declined medications, food and water. He/she would take pain medications and other ordered items on occasion. Review of a nursing note dated 8/9/19 revealed, Resident stood up from beside commode unaided without calling for assistance, fell to floor, sustained tibia/fibula (lower leg) fractures. See by hospitalist, awaiting ortho consult. Witnessed by PT (physical therapy) volunteer. Resident said knees gave way and fell . Resident does not use call light. Immobilizer on . Review of nursing notes dated 8/12/19 revealed: 0533- At this time CNA (certified nurse assistant) summoned this nurse to resident's bedside to assess her because residents condition had changed. This nurse immediately went to bedside to assess Residents. Upon entering the room the resident was found to have a pulse and to have agonal breathing (abnormal breathing pattern but short, sporadic gasps of air, common before death). 0535- This nurse immediately called code blue and proceeded to get the crash cart to the resident's room .Supervisor was the first to arrive to the unit to assist with the code. As I attempted to get the pads off the crash cart to place on resident, the Rapid Response Team arrived on unit and at bedside. (Physician #1) was with this group. (Physician #1) proceeded to tell staff not to code the resident. He/she said very loudly a minimum of three times 'nothing is to be done'. This nurse nor the house supervisor was aware that the residents code status had changed. It (code status) was still listed on the computer as full code. (Physician #1) proceeded to inform the staff of the conversations that the care team had with the patient prior to the incident. 0540- (Physician #1) called the time of demise at this time .Supervisor stated for me not to call the family and that he/she would ask Physician #1 to do so. House Supervisor will handle paperwork and proper notifications. Review of physician #1's note dated 8/12/19 revealed, Code blue was called for (patient) who was found without a pulse. When I arrived (he/she) had no pulse and was not breathing. Due to prior conversations with (Resident #1's) MPOA (medical power of attorney), PCP (primary care provider), and ethics committee it was previously determined that (patient) has irreversible, progressive terminal illness/multiorgan failure and given (his/her) decision to refuse care including medications and blood draw and blood [MEDICAL CONDITION] despite severe [MEDICAL CONDITION], that attempting ACLS (Advanced Cardiovascular Life Support) at the time of the (patient's) death would be futile care. Two physicians have concluded that attempting to code (patient) would be futile. (Physician #2) and myself. This plan was discussed with (patient) and (his/her) MPOA, please see note from 6/5/19. (Public Guardian) (Resident's) medical decision maker agreed with plan of care. (Patient's) code status was changed to DNR (do not resuscitate) and a code was not performed. During an interview on 8/23/19 at 3:58 pm the Medical Director (MD) stated that when a Resident lacks capacity for medical decision making, the decisions were deferred to the court appointed decision makers with documentation by two physicians. The MD was unaware if the process was different between the hospital and long term care. The MD was unaware if there was a policy to address these types of issues. During an interview on 8/23/19 at 4:00 pm, request made for policy related to Resident choice on end of life care. No policy was provided prior to exit. During an interview on 9/3/19 at 10:00 am, the Ethicist (ETH) stated that the facility did not have a process or ethics review committees. Staff had met with the Resident and other legal parties to discuss medical issues. The ETH stated there was no hospital directive in regards to Resident #1's case. The ETH was aware that a Public Guardian was unable to make a decision regarding code status but could not reject the medical doctor's recommendation. The ETH further stated that there could have been a different outcome if a different doctor had responded to the code blue. The ETH stated that he/she was aware that Resident #1 wished to remain full code and not to be DNR (do not resuscitate). Review of Alaska Statute 13.26.150(e) states that a guardian may not do the following things: A guardian may not consent on behalf of the ward to the withholding of lifesaving medical procedures. However, a guardian is not required to oppose the withholding of lifesaving medical procedures under certain circumstances where the procedures would only serve to prolong the dying process, unless the ward has clearly stated that life saving medical procedures not be withheld. Review of the facility policy Medically Non-Benefical Treatment (MNBT), reviewed 12/19/18, revealed Patient/Family Conference. If agreement is not reached between the primary treating physician, and the patient or the legally authorized decision-maker, a patient/family family conference facilitated by the Network Director of Mission and Ethics or designee, should be organized .If disagreement persists the Network Director of Mission and Ethics, or designee documents in the patient medical record the underlying conflict(s) and facilitate the conflict guidelines below. 3. Second Physician Review .a second medical opinion from a physician not currently treating the patient who has personally examined the patient and signed a note documenting the findings in the chart .If the second physician confirmed the intervention in question is MNBT then the case is refereed to the ethics committee. . | 2020-09-01 |