| 6 |
SANTA FE CARE CENTER |
325030 |
635 HARKLE ROAD |
SANTA FE |
NM |
87505 |
2019-07-19 |
578 |
E |
0 |
1 |
W7WU11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that the Advanced Directives were filled out completely and correctly for 9 (R #3, R #9, R #37, R #88, R #97, R #200, R #299, R #300, & R #302) of 9 (R #3, R #9, R #37, R #88, R #97, R #200, R #299, R #300, & R #302) residents reviewed for Advanced Directives/MOST form (MOST form is a doctor's order that tells emergency medical personnel and other health care providers whether or not to administer cardiopulmonary resuscitation (CPR) in the event of a medical emergency.) This deficient practice could likely result in the resident's wishes not being followed. The findings are: R #3 [NAME] Record review of the medical chart for R #3 revealed that there was no advance directive on file. B. On [DATE] at 11:18 AM, during an interview, the DON confirmed that there was no advance directive on file and he stated We will need to complete another MOST for (name of R #3) R #9 C. Record review of R #9's advanced directive dated [DATE] revealed No Heroic resuscitations efforts was marked, and Full resuscitations was marked just below that on the form. D. On [DATE] at 3:16 PM, during an interview, the DON confirmed that R #9 advanced directive was not clear in whether R #9 want to be resuscitated or not. R #37 E. Record review of the MOST for R #37, dated [DATE], revealed Sections B Medical Intervention, Section C Artificially Administered Hydration/Nutrition, and Section D Discussed With, were all blank. F. On [DATE] at 3:07 PM, during an interview, the Social Worker (SW) stated, I see those sections are blank, the nurses should have gathered that information. R #88 [NAME] Record review of the MOST for R #88 revealed it was signed by physician but not by the resident or her representative. H. On [DATE] at 3:12 PM, during an interview with the SW regarding the Most for R #88, she confirmed, I do not see a signature by the resident or her representative. R #97 I. Record review if R #97's advanced directive dated [DATE] revealed sections B. C. D. were not filled out. [NAME] On [DATE] at 3:16 PM, during an interview with the DON confirmed that the facility had not been filling out the entirety of the advanced directives. R #200 K. Record review of the MOST for R #200 revealed a signature that was not the resident's name and there is no indication on the form that this person is a legal surrogate. L. On [DATE] at 3:09 PM, during an interview, the SW stated, (Name of R #200) is her own decision maker, she should have signed the document. I do not know who the person is who signed the document. R #299 M. Record review of the MOST for R #299, dated [DATE], revealed section B Medical Interventions, Section C Artificially Administered Hydration/Nutrition, and Section D Discussed with were all blank. R #300 N. Record review of the MOST for R #300, dated [DATE], revealed section B Medical Interventions, Section C Artificially Administered Hydration/Nutrition, and Section D Discussed with were all blank. R #302 O. Record review of the MOST for R #302, dated [DATE], revealed section B Medical Interventions, Section C Artificially Administered Hydration/Nutrition, and Section D Discussed with were all blank. P. On [DATE] at 11:17 AM, during an interview, the DON confirmed that the sections were blank and stated, We are completing an audit and we are going to retrain on the completion of the MOST and re-do them all. |
2020-09-01 |