cms_DE: 50
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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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 50 | WILLOWBROOKE COURT AT COUNTRY HOUSE | 85003 | 4830 KENNETT PIKE | WILMINGTON | DE | 19807 | 2019-07-15 | 678 | J | 1 | 1 | N66611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of clinical records, interviews and review of facility and other documentation as indicated, it was determined that for 1 (R48) out of 1 death record the facility failed to have an effective system to coordinate, document and implement DNR code status. The facility failed to have a process in place that guaranteed a discussion between a medical practitioner and a resident and/or legal representative concerning DNR code status so that an appropriate and timely DNR order was implemented. For R48, the facility failed to ensure that a physician or nurse practitioner discussed DNR code status with the resident and/or the resident's legal representative upon admission to the facility on [DATE]. R48 had an acute medical emergency at the facility on [DATE] and Emergency Medical Services (EMS) personnel responded. The facility failed to show proper DNR code status paperwork when requested by EMS personnel. The facility's failure to coordinate, document and implement R48's DNR code status in accordance with the facility's DNR policy and procedure and Title 16 of the Delaware Code, Chapter 25, was identified as an Immediate Jeopardy (IJ) on [DATE] at 3:44 PM. IJ was abated on [DATE] at 2:30 PM. Additionally, for two (R1 and R14) current residents with DNR orders, the facility failed to ensure the State DMOST form, also indicating the same DNR status, was signed by the physician in accordance with State law and facility policy. Findings include: The facility's policy and procedure entitled Do Not Resuscitate (DNR), last revised on ,[DATE], stated, Policy. Cardiopulmonary resuscitation (CPR) is administered to any resident suffering a cardiac or respiratory arrest, unless that resident has a 'do not resuscitate (DNR)' order. A DNR order is permitted if the resident or his/her legal representative has discussed the ramifications with their physician or nurse practitioner as allowed per state regulations and the physician or nurse practitioner has placed the appropriate order in the resident's medical record. A DNR order does not permit the facility to refrain from sending the resident to the hospital if, in the professional staff's opinion they cannot provide needed care for the resident. PR[NAME]EDURE: .If a resident does not wish to receive CPR, the resident or staff member must inform his/her attending physician or nurse practitioner. .The resident's legal representative can inform the physician or nurse practitioner if the resident is incapacitated or unable to make his/her wishes known. .The attending physician or nurse practitioner must discuss with the resident and/or family and/or legal representative what a DNR order involves. .Any legal representative deciding on a DNR must base the decision on the resident's wishes, including the resident's religious and moral beliefs; or, if the resident wishes are not known, in the resident's best interest. .The attending physician or nurse practitioner must then write a DNR order and a progress note in the resident's medical record. NOTE: the state designated DNR form will suffice as the progress note. .The progress note must state that the DNR was requested and that the physician or nurse practitioner discussed the DNR order with the resident or the resident's legal representative. Review of Title 16 of the Delaware Code, Chapter 25 Health-Care Decisions, stated, . Section 2501 Definitions . (b) 'Agent' shall mean an individual designated in a power of attorney for health care to make a health-care decision for the individual granting the power . (h) 'Health-care decision' shall mean a decision made by an individual or the individual's agent . regarding the individual's health care, including: . (2) Acceptance or refusal of . orders not to resuscitate; . (4) Execution of a DMOST form pursuant to Chapter 25A of this title . Section 2503 Advance health-care directives . (f) An agent shall make a health-care decision to treat, withdraw or withhold treatment on behalf of the patient after consultation with the attending physician . and in accordance with the principal's individual instructions, if any, and other wishes to the extent known to the agent . Section 2508 Obligations of health-care provider (a) Before implementing a health-care decision made for a patient, a supervising health-care provider, if possible, shall promptly communicate to the patient the decision made and the identity of the person making the decision. The decision of an agent .does not apply if the patient objects to the decision to remove life-sustaining treatment, providing that the objection is (1) by a signed writing or (2) in any manner that communicates in the presence of 2 competent persons, 1 of whom is a physician .Chapter 25A Delaware Medical Orders for Scope of Treatment Act . (c) . (DMOST) means a clinical process to facilitate communication between healthcare professionals and patients . The process encourages shared, informed medical decision-making. The result is a DMOST form, which contains portable medical orders that respect the patient's goals for care in regard to the use of CPR and other medical interventions . (e) .(1) Is used on a voluntary basis . (3) Is not valid unless it meets the requirements for a completed DMOST form as set forth in this chapter . (4) Is intended to provide direction to emergency care personnel regarding the use of emergency care and to health-care providers regarding the use of life-sustaining treatment by indicating the patient's preference concerning the scope of treatment, the use of specified interventions . (7) Must be signed by a health-care practitioner . The Delaware Basic Life Support Protocols, Guidelines and Standing Orders for Prehospital and Interfacility Patients by the Delaware Office of Emergency Medical Services (EMS) and the Delaware Health and Social Services Division of Public Health, effective [DATE], stated, .Current guidelines for do not resuscitate orders .Do Not Resuscitate Order (DNR) .Delaware Medical Orders for Life Sustaining Treatment (DMOST). A DMOST form is a medical order sheet based on the person's current medical condition and wishes .The DMOST form will clearly indicate the patient's wishes concerning life-sustaining treatment and CPR .Section B: . (CPR) . Section E: Review of Orders with Patient. Documents that orders were reviewed with patient or their representative .Section F: Signatures. EMS provider must review this section to ensure it is signed by the patient (or their authorized representative) and healthcare provider . 1. Review of R48's clinical record revealed the following: [DATE] - A copy of R48's advance directive was in the clinical record. The advance directive stated, .I designate the following individual as my Agent to make health care decisions for me: . F2 (Spouse of R48) .I hereby designate additional or successor Agent: . F3 (Family Member of R48) . Qualifying Conditions: Terminally Ill - (selected) Option 3: Do not Prolong Life . Serious Illness or Frailty - (also selected) Option 1: My Agent will make decisions on my behalf: In the event I have a serious Illness or frailty and I am unable to understand, make or communicate my wishes, I direct that my Agent make all medical decisions on my behalf . [DATE] at 10:25 AM - The hospital Discharge Summary stated, .Condition at Discharge stable . [DATE] at 12:45 PM - R48 was admitted to the facility for rehabilitation and intravenous (IV) antibiotic therapy status [REDACTED]. [DATE] at 11:45 AM - A Social Service note, written by E17 (SW), stated, Meeting with resident's spouse, (name) who with resident's permission is signing admission paperwork. Spouse feels resident 'is not herself'. All paperwork completed .He/she has POA (Power of Attorney) with (other family member name) as back up PO[NAME] Code status discussed. Spouse states resident wants DNR status, reported to nursing. D/C (discharge) goal uncertain with current medical conditioning and physical functioning level .Spouse is at bedside most of day. [DATE] at 1:19 PM - A verbal physician's orders [REDACTED]. By entering the verbal physician's orders [REDACTED]. [DATE] at 1:36 PM - A History & Physical (H&P) was completed by E5 (Physician). The H&P did not address R48's code status. [DATE] at 5:31 AM - The EMS Prehospital Care Report revealed that BLS (Basic Life Support) personnel arrived at the patient (R48) on [DATE] at 5:31 AM. The report stated, .Upon arrival of ALS (Advanced Life Support) and BLS crews Pt (patient) was unresponsive pulse less (sic) and apnic (sic) (not breathing) laying supine (on back) on the floor .Pt was found on floor this morning by Facility staff and pt was unresponsive so they called 911 .Facility advised BLS crew that Pt has a DNR however Facility did not have proper DNR paperwork on hand for BLS crew. Pt's (spouse) wished for resuscitation efforts to be initiated by BLS crew. No bystander CPR was being preformed (sic) prior to BLS arrival . [DATE] at 9:11 AM - A late entry nurse's note, written by E19 (RN) stated, Nurse checked on pt at (midnight) .PT WAS SLEEPING soundly, no s/s (signs/symptoms) distress noted . Visual observation on hall way during the night pt sleeping and no s/s distress. Another rounds (sic) done at 3:50 AM and pt was on his/her bed with [MEDICAL CONDITION] on. At 4:56 AM upon entering pt room he/she was found on the floor, pt did not respond to verbal commands but had positive faint carotid (neck) pulse/resp. pt respond (sic) lethargically to sternal rub. immediately contacted .911, md, and spouse. 911 arrived, spouse and .(family member) present. Police officer onsite .Medics MD pronounced pt without signs of life . [DATE] at 10:12 AM - E6 (NP) electronically signed the verbal physician's orders [REDACTED]. [DATE] - The facility's investigation of R48's death on [DATE] failed to identify that R48 had an incomplete DNR code status at the time of the acute medical emergency. The facility failed to identify that R48's incomplete DNR code status was not completed in accordance with the facility's DNR policy and procedure and Title 16 of the Delaware Code, Chapter 25. [DATE] at 7:37 AM - During an interview, E19 (RN) stated that at 4:56 AM, he/she entered R48's room with IV antibiotic medication to administer. E19 stated that R48's right side upper body was leaning against the bed and R48's lower body was on the floor with all the bed linens/blankets underneath him/her. E19 stated that he/she called for help, performed a sternal rub, and checked R48's pulse which was faint. E19 stated R48 was lethargic. E19 stated that he/she lowered R48 to the floor, stepped out of the room and asked E20 (CNA) to stay with R48. E19 stated that he/she called 911, F2 (R48's spouse), E2 (DON) and the on-call physician. E19 stated, And before I even called 911, F2 asked me 'Is somebody coming? Is somebody coming?' E19 stated, Yeah, help is on the way, help is on the way. Because I had to put papers together. I assigned the other nurse and the cna to be there in that room. E19 stated that F2 came immediately and phoned F3 (R48's family member) from R48's room. E19 stated that upon arrival, EMS personnel asked to see the document to make sure R48 was a DNR. E19 stated that he/she told them verbally. E19 stated that he/she printed everything and showed them the eMAR and eTAR, which stated DNR. E19 stated that EMS personnel were given a bunch of documents to show them proof that R48 had the status of a DNR. E19 stated that the documents were: plan of care, face sheet, doctor's H&P, eMAR and eTAR. E19 stated that the EMS personnel asked F2 (R48's spouse) if he/she wanted CPR as F2 was present in the room. E19 stated that F2 said yes. E19 stated that EMS personnel proceeded to give R48 CPR and then a short while later they pronounced him/her. E19 stated that he/she knew R48 was a DNR because he/she reviewed the eMAR/eTAR when the resident was admitted to the facility. E19 stated that was the first thing he/she looked at because you never know, anything could happen. [DATE] at 12:56 PM - During an interview, E6 (NP) confirmed that he/she gave the verbal physician's orders [REDACTED]. When asked if he/she wrote any progress notes in R48's clinical record, E6 stated no after reviewing the electronic clinical record. When asked if he/she had any discussion about code status with R48 and/or R48's family, E6 stated no. [DATE] at 8:38 AM - During an interview, E17 (SW) confirmed that he/she had a code status discussion with F2 (Spouse). E17 stated that F2 (Spouse) wanted a DNR code status for R48. E17 stated he/she could not remember who he/she told, probably the nursing supervisor. E17 stated that nursing passes the information on to the Physician/NP. When asked what the procedure was for DNR code status, E17 stated that the Physician/NP meets with the resident/family and has a conversation and then documents the code status in the clinical record and enters a physician order. [DATE] at 9:26 AM - During an interview, E5 (Physician) stated that R48's spouse (F2) was not present during the History & Physical on [DATE]. E5 stated that he/she did not want to have the code status discussion since the family was not present and he/she left R48's code status section blank on the [DATE] History & Physical. [DATE] at 2:10 PM - During a telephone interview, E22 (RN) stated that between 5 and 5:30 AM he/she went into R48's room to see what was happening. E22 stated that no one else was in the room. E22 stated that he/she did not see R48 on the bed and went further into the room and saw R48 on the floor in between the two beds. E22 stated that he/she observed R48's lips were blue, hands were cold, able to move his/her fingers, and checked R48's brachial (arm) and carotid (neck) pulses. E22 stated there was no pulse. E22 stated he/she went to look for E19 (RN) and found E19 returning to the room (in conflict with E19's (RN) interview on [DATE] when E19 stated that he/she asked E20 (CNA) to stay with R48 prior to leaving the room to make calls). E22 stated that E19 told him/her that he/she called 911 and F2 (R48's spouse). E22 stated the next thing F2 arrived and E22 was trying to console F2, who was crying. E22 stated that F3 (R48's family member) arrived and was on the floor kissing R48 and crying. E22 stated that it took EMS personnel some time to arrive. E22 stated that EMS personnel asked about code status and E19 told them R48 was a DNR. E22 stated that F2 asked EMS Personnel to revive R48. [DATE] from 3:44 PM to 4:22 PM - A meeting was held with E16 (ED), E1 (NHA), E2 (former DON), E3 (acting DON) and the survey team. The survey team informed the facility that an Immediate Jeopardy was identified and involved R48 and the facility's failure to complete R48's code status in accordance with the facility's DNR policy and procedure and Title 16 of the Delaware Code, Chapter 25. The facility MD/NP failed to have a sit down discussion with R48's spouse (POA) to determine his/her code status wishes for R48, what the selected code status entailed and a written progress note of the code status discussion. [DATE] at 6:41 PM - A meeting was held with E1 (NHA), E2 (former DON), E3 (acting DON) and E6 (NP). The survey team identified 2 additional residents (R1 and R14) currently in the facility that had incomplete code status documentation in their clinical records. The facility also conducted an audit of all the current residents and acknowledged that there were incomplete code status issues with some residents. [DATE] at 7:31 PM - The facility submitted a Plan of Correction to the survey team. The facility's NP, E6, was inserviced on the facility's DNR policy and procedure immediately. E6 then started working on the code status for the 2 residents identified by the survey team as having incomplete code status documentation. The facility started inservicing the nursing staff on the DNR policy and procedure. [DATE] from 7:37 PM to 8 PM - E6 (NP) spoke with either the resident/legal representative/POA to discuss each resident's advance directives. E6 wrote progress notes in each resident's clinical record documenting the discussion, the code status and then entered new physician's orders [REDACTED]. [DATE] at 12:35 PM - E5 (Physician) was inserviced on the facility's DNR policy and procedure as he/she signed and dated a copy of the facility's DNR policy and procedure. [DATE] at 2:30 PM - The facility completed the nursing staff inservices on the facility's DNR policy and procedure. The facility's Immediate Jeopardy was abated at this time. The facility failed to have an effective system to coordinate, document and implement DNR code status for R48 in accordance with the DNR policy and procedure and Title 16 of the Delaware Code, Chapter 25. The facility failed to have a process in place that guaranteed a discussion between a medical practitioner and a resident and/or legal representative concerning DNR code status so that an appropriate and timely DNR order was implemented. [DATE] at 12:30 PM - Findings were reviewed with E1 (NHA), E2 (former DON), E3 (acting DON), E6 (NP) and E16 (ED) during the Exit Conference. [DATE] from 4:30 PM to 5:45 PM - A review of all current residents in the facility, totaling 43, revealed incomplete code status documentation in the following residents' (R1 and R14) clinical records: 2. R14's clinical record revealed a DMOST form signed by R14's POA and dated [DATE]. In Section B, R14's POA selected Do not attempt resuscitation. The DMOST form was not signed by a physician in Section F. While R14 had a physician's orders [REDACTED]. record. [DATE] at 12:30 PM - Findings were reviewed with E1 (NHA), E2 (former DON), E3 (acting DON), E6 (NP) and E16 (ED) during the Exit Conference. 3(-. R1's clinical record revealed a DMOST form signed by R1's POA and a Hospice Nurse on [DATE], which was the same day that R1 elected Hospice benefits. In Section B, R1's POA selected Do not attempt resuscitation. The DMOST form was not signed by a physician in Section F. While R1 had a physician's orders [REDACTED]. record. [DATE] at 12:30 PM - Findings were reviewed with E1 (NHA), E2 (former DON), E3 (acting DON), E6 (NP) and E16 (ED) during the Exit Conference. | 2020-09-01 |