| 21 |
KENTMERE REHABILITATION AND HEALTHCARE CENTER |
85001 |
1900 LOVERING AVENUE |
WILMINGTON |
DE |
19806 |
2018-12-06 |
678 |
K |
1 |
1 |
H65F11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record reviews, interviews and review of other facility documentation as indicated, the facility failed to ensure that the residents' code status (advanced directives) listed on the individually printed Resident Face Sheets, kept in binders in the ground floor reception area and the second floor nurses station, matched the electronic medical record (physician orders [REDACTED]. For 6 (R7, R20, R54, R73, R83, and R96) out of 97 sampled residents, the Resident Face Sheets were inconsistent with the electronic medical records (EMR). For 2 residents (R54 and R96), their electronic medical documents failed to match the Emergency Face Sheets binder located in the ground floor reception area. For 4 residents (R7, R20, R73, and R83), their EMR's failed to match the 2nd Floor Face Sheets binder located in the second floor nurses station. The facility no longer uses charts. Furthermore, interviews with multiple staff revealed inconsistencies regarding where to find the backup information on each resident's code status in the event of an EMR system failure. The facility failed to have a system in place for staff to obtain the residents' accurate code status in the event of an EMR system failure which placed these residents in an immediate jeopardy situation. The IJ was identified on [DATE] at 10:55 AM and was abated on [DATE] at 3:30 PM. Findings include: The facility's Advance Directives policy (undated) stated, Every resident has the right to accept or refuse medical care. Advance Directives communicate your choices of care in the event that you become physically or mentally unable to communicate yourself . specific types of Advance Directives include: 1. Do Not Resuscitate (DNR) which means that if a resident is found not breathing or non-responsive, measures would not be taken to try to start the heart pumping again. 2. Cardio-Pulmonary resuscitation (CPR) is the act of applying force to the chest with the hand, compressing the heart, and breathing into the resident's mouth, filling the lungs with air in an attempt to restart the heart beating again. The facility's Consent Form Code Status policy (undated) stated, At some point . a catastrophic event may occur (for example, the resident's heart or breathing may stop). At that point, the question of whether to begin extraordinary measures to attempt resuscitation arises (for example, cardiopulmonary resuscitation (CPR) attempts, electric shock potentially leading to chest surgery, artificial breathing machines .) Without written instructions to the contrary, these invasive procedures must be attempted . some residents decide either independently or through their substitute Decision maker that they do not wish for resuscitation measures in cases of heart or breathing failure. In those cases the doctor will write a DO NOT RESUSCITATE or 'DNR' order. Once that order is written, no measures will be taken to restart the heart or respirations (no CPR or mechanical ventilation . 1. Review of R7's clinical record revealed: During the initial pool record review, a code status form (scanned into the EMR), dated [DATE], stated that R7 was a no code or DNR and there was a current physician order [REDACTED]. The emergency book in the reception area listed R7's code status as DNR. R7 resided on the 2nd floor. In contrast to the code status form, physician order [REDACTED]. 2. Review of R20's clinical record revealed: During the initial pool record review, a code status form, dated [DATE], stated that R20 was a DNR and there was a current physician order [REDACTED]. The emergency book in the reception area listed R20's code status as DNR. R20 resided on the 2nd floor. In contrast to the code status form, the physician order [REDACTED]. The remainder of resident's were identified when code status' were checked for all residents that did not have record reviews during the initial pool. 3. Review of R73's clinical record revealed: Review of R73's code status form, dated [DATE], stated that R73 was a DNR and there was a physician order, dated [DATE], for DNR in the EMR. The emergency book in the reception area listed R73's code status as DNR. R73 resided on the 2nd floor. In contrast to the code status form, the physician order [REDACTED]. 4. Review of R83's clinical record revealed: Review of R83's code status form, dated [DATE], stated that R83 was a full code and there was a current physician order, dated [DATE] for full code in the EMR. The emergency book in the reception area listed R73's code status as full code. R83 resided on the 2nd floor. In contrast to the code status form, the physician order [REDACTED]. 5. Review of R54's clinical record revealed: Review of R54's code status form, dated [DATE], stated that R54 was a no code or DNR. There was a current physician order [REDACTED]. R54 resided on the 3rd floor of the facility. In contrast to the code status form and the physician's orders [REDACTED]. 6. Review of R96's clinical record revealed: Review of R96's code status form, dated [DATE], stated that R96 was a no code or DNR. There was a current physician order [REDACTED]. The 2nd floor face sheet binder listed R96's code status as DNR. R96 resided on the 2nd floor. In contrast to the code status form and the physician's orders [REDACTED]. [DATE] 9:16 AM - E2 (DON) was interviewed on the 2nd floor. E2 stated that resident code status was in the EMR. When asked how staff would obtain a resident's code status if the EMR was down, E2 stated staff would call the ground floor receptionist office where a book was kept with everyone's face sheet and code status. E2 stated there was someone in the reception area 24 hours a day. E2 stated there was not a code book on the 2nd floor. [DATE] 9:50 AM - E20 (reception clerk) was interviewed. E20 stated that someone was at the reception desk from 8 AM to 8 PM, however, the office was not locked when there was no one at the desk. [DATE] 11:45 AM - E13 (LPN on 2nd floor) was interviewed. When E13 was asked how she would obtain a resident's code status if the EMR was down, E13 stated that when the receptionist was there, she'd call the receptionist (on the ground floor) to obtain a resident's code status (have binder of all resident's face sheets listing code status' in the receptionist office). E13 stated on night shift, staff use the 2nd floor Face Sheets binder that's kept in the 2nd floor nurses station. The emergency book in the reception area contained face sheets for each resident. [DATE] 4:47 PM - E19 (LPN) was interviewed on the third floor. When asked how she would obtain a resident's code status if the EMR was down, E19 stated she would ask someone who was familiar with the resident for the code status. E19 stated there was no code status binder on the third floor. [DATE] 10:55 AM - Findings were reviewed with E1 (NHA) and E2 (DON) and they were advised that an IJ was identified when 6 current residents were found to have inconsistent advance directives related to their code status'. [DATE] 3:15 PM - Review of the 2nd floor binder and the Emergency book at the receptionist office verified that the incorrect code status' for the 6 residents were corrected. Additionally, the survey team interviewed 2 nurses from the ,[DATE] shift for each floor and confirmed they were aware of where and how to obtain current code status' for residents. [DATE] 3:30 PM - At this time, we also received an approved plan of correction that included: correction of code status' on identified residents after a whole facility audit of consent forms, orders and face sheets, the facility policy on code status was updated, all new residents and residents with code status changes are to be discussed at High Risk Meetings Monday- Fridays, in-services are to be done including: use of Unit Book/Front office book to verify code status in event of power outage, on hire, a competency verification regarding code status and contingency plan will include nurses, activity, admissions, social service and rehabilitation staff, and annual training will be updated to include review of the policy and process. Additionally, shift report will include communication related to new and/or changes in code status and monitoring will be done on the above measures. The IJ was abated at this time. The facility failed to maintain consistent documentation of residents' code status leading to the possibility that the incorrect code status could be implemented during an emergency event resulting in immediate jeopardy to the residents. |
2020-09-01 |