cms_ID: 52
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 52 | WEISER CARE OF CASCADIA | 135010 | 331 EAST PARK STREET | WEISER | ID | 83672 | 2019-10-04 | 578 | D | 0 | 1 | VWS011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and staff interview, it was determined the facility failed to ensure residents' records included an Advanced Directive or documentation of discussion regarding Advance Directives and their decision not to formulate one. This was true for 2 of 12 residents (#1 and #30) reviewed for Advance Directives. The deficient practice created the potential for harm should residents' wishes regarding end of life care not be honored when they are unable to make or communicate their health care preference. Findings include: The State Operations Manual (SOM) defined an Advance Directive as a written instruction, such as a living will or durable power of attorney for health care, recognized under State law (whether statutory or as recognized by the courts of the State), relating to the provision of health care when the individual is incapacitated. The SOM defined a Physician order [REDACTED]. medical condition into consideration. A POLST [MEDICATION NAME] form is not an advance directive.If an adult individual is incapacitated at the time of admission and is unable to receive information or articulate whether he or she has executed an advance directive or not, the facility may give advance directive information to the individual's resident representative in accordance with State Law. The facility's Advance Directives/Health Care Decisions policy and procedure, dated 10/1/17, documented Residents have the right to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment, and the right to formulate Advance Directives. In states with governance surrounding Advance Directives, facilities are to follow the State's specific requirements. This policy was not followed. 1. Resident #1 was admitted on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #1's record did not include an Advance Directive or documentation Advance Directives were discussed with her. On 10/3/19 at 10:35 AM, the Resident Support Services Manager (RSSM) said within 48-72 hours after admission a conference with a resident and/or a resident's representative was scheduled. She said during the conference the facility reviewed a resident's living will or provided the Idaho Advance Directive information, and if needed, the facility offered Advance Directive completion assistance. The RSSM said if the Advance Directive was not completed at the next conference, the facility reminded the resident and/or resident's representative to complete and provide it to the facility. On 10/3/19 at 10:45 AM and 11:52 AM, the DON confirmed the review process described above was correct and said unless an Advance Directive was scanned into a resident's chart, the resident and/or resident's representative had not provided it. The DON said Resident #1's record did not include an Advance Directive and there was no discussion with Resident #1 and/or her representatives about Advance Directives documented. 2. Resident #30 was admitted to the facility on [DATE] and was readmitted on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #30's record included a Multidisciplinary Care Conference note, dated 9/3/19, which documented Advance Directive - continue. Resident #30's record did not include an Advance Directive or documentation information was discussed with her about Advance Directives. On 10/3/19 at 10:35 AM, the RSSM said within 48-72 hours after residents are admitted , a care conference was scheduled for residents and/or their representatives. The RSSM said Advance Directives were discussed during the care conference, and the resident and/or their representatives were asked to provide a copy of the resident's Advance Directive if they had one. The RSSM said the facility offered to help the resident to complete an Advance Directive if they did not have one. The RSSM also said Advance Directives were reviewed with the residents and/or their representatives quarterly. On 10/3/19 at 11:39 AM, the DON said Advance Directive - continue meant to continue what was on Resident #30's Physician order [REDACTED]. The DON said she was unable to find documentation Advance Directives were discussed with Resident #30. | 2020-09-01 |