cms_AZ: 41
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 41 | HANDMAKER HOME FOR THE AGING | 35016 | 2221 NORTH ROSEMONT BOULEVARD | TUCSON | AZ | 85712 | 2019-01-08 | 578 | D | 0 | 1 | ZWO111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, staff interviews and policy review, the facility failed to have documentation of advanced directives for one resident (#10) and obtain physician orders once obtained, and failed to obtain physician orders in accordance with the advance directive for one resident (#171). Findings include: -Resident #10 was admitted to the facility on (MONTH) 30, (YEAR) and readmitted to the facility on (MONTH) 10, (YEAR), with [DIAGNOSES REDACTED]. An admission Minimum Data Set (MDS) assessment dated (MONTH) 8, (YEAR) revealed the resident had a Brief Interview for Mental Status score of 3, which indicated severe cognitive impairment. Review of the clinical record on (MONTH) 5, 2019 revealed no documentation regarding advance directives for resident #10. There were also no physician orders for any advance directives. An interview was conducted with two licensed practical nurses (LPN/staff #52/staff #53) on (MONTH) 6, 2019 at 2:50 p.m. The nurses stated that they were unable to locate advance directive information for resident #10. Staff #52 stated that the nurses usually get a new order when a resident returns from the hospital, because the directive could change at anytime. Staff #52 stated that she would need to have the responsible party for the resident sign the form and that she would contact the responsible party right away. Review of the clinical record on (MONTH) 7, 2019 revealed advance directives had been obtained for resident #10. The advance directives were obtained from the resident's responsible party by telephone on (MONTH) 6, 2019 and included for a Do Not Resuscitate (DNR) status. Further review of the physician orders on (MONTH) 7, 2019 revealed there was no physician order for [REDACTED].>-Resident #171 was admitted to the facility on (MONTH) 31, (YEAR), with [DIAGNOSES REDACTED]. A review of the clinical record revealed an Advanced Directive form indicating the resident was a DNR status, which was signed by the resident's power of attorney on (MONTH) 2, 2019. However, review of the physician orders on (MONTH) 7, 2019 revealed there were no orders for a DNR status. An interview was conducted with two licensed practical nurses present (LPN/staff #52/staff #53) on (MONTH) 6, 2019 at 2:50 p.m. Staff #52 stated that there is an Advance Directive for a DNR on the paper chart which was signed on (MONTH) 2, 2019, but there is no physician's order at present. An interview was conducted on (MONTH) 8, 2019 at 12:17 p.m. with the Director of Nursing (DON/staff #160). She stated that Social Services interview residents or responsible parties and obtains advance directives on admission, or shortly after admission. Staff #160 stated if the resident desires a DNR status, Social Services will inform nursing so they can contact the provider to get an order in place and obtain the orange card (Prehospital Medical Care Directive). She also stated there should be a physician's order for a DNR. Review of the facility's policy regarding Advance Directives revealed the facility will respect advance directives in accordance with state law and facility policy and that the Director of Nursing or designee will notify the attending physician of advance directives. so that appropriate orders can be documented in the resident's medical record and plan of care. | 2020-09-01 |