The Cottages at Garden Grove, A Skilled Nursing Community

Deficiency Details, Complaint Survey, June 1, 2012

PFI: 0657
Regional Office: Central New York Regional Office

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F155 483.10(b)(4): RIGHT TO REFUSE TREATMENT/RESEARCH; FORM ADVANCE DIRECTIVES

Scope: Isolated

Severity: Actual Harm

Corrected Date: August 17, 2012

The resident has the right to refuse treatment, to refuse to participate in experimental research, and to formulate an advance directive as specified in paragraph (8) of this section.

Citation date: June 1, 2012

Based on record review and staff interviews conducted during an abbreviated survey (complaint # NY00116223) it was determined for 3 of 230 residents reviewed for advanced directives, (Residents #1,2 and 5), the facility did not ensure residents' wishes regarding advanced directives were honored. Specifically, Resident #1 was resuscitated in conflict with his MOLST which documented he wanted to be a DNR and Residents #2 and #5 both had physician orders which were in conflict with their MOLST orders. This resulted in actual harm that is not immediate jeopardy.
Findings include:

The facility policy #AD-A-001-002, titled, "Advanced Directives MOLST (medical orders for life sustaining treatment) Documentation" last reviewed April 2010, documented, "MOLST form-a document which translates resident's treatment preferences into physician's orders for care........The original pink MOLST form is intended to travel with the resident from institution to institution and go home with the resident after discharge." A "DNR order is initially written by MD on MOLST Form as previously described. After the completion of the MOLST form, the attending physician must re-write the DNR order on the usual MD order sheets. This confirms the order on the MOLST form, and triggers further steps to identify and track the resident's DNR status."

1) Resident #1 was admitted to the facility on May 11, 2012 with diagnoses of atrial fibrillation, diabetes and failure to thrive.

A hospital discharge summary dated May 11, 2012 documented the resident was a DNI/DNR (Do Not Intubate-Do Not Resuscitate).

The admission History and Physical from the attending physician, dated May 11, 2012, documented the resident was a full code (CPR, cardiopulmonary resuscitation).

The resident's initial nursing admission assessment dated May 11, 2012 documented the resident was a full code. The questions about the MOLST form and Health Care Proxy were left blank. The assessment also documents that the resident is understood by others and clearly comprehends the communication of others.

Undated telephone admission orders, signed by the physician on May 13, 2012, document the resident is a full code.

On May 15, 2012 a MOLST form was completed to document the resident's verbal request to a DNR order. The physician signed the MOLST on May 15, 2012.

The social worker was interviewed on May 30, 2012 at 10:30 AM. She stated that the resident was admitted on Friday, May 11, 2012 and at the time of admission the resident told the nurse he wanted to be a full code. She stated that she approached the resident on Monday, May 14, 2012 but he was sleeping. She stated that on Tuesday May 15, 2012 the resident said he wanted to be a DNR. She talked to the resident and his son and daughter in law on Tuesday, May 15, 2012 and they completed the MOLST paperwork to make the resident a DNR. The social worker stated she left the MOLST paperwork in the physician's notebook for the physician to the sign. The physician comes to the facility three times a week. The resident coded the following morning, May 16, 2012. The physician had signed the MOLST by that time but the MOLST was not filed back into the chart. It was in a separate folder.

Progress notes dated May 16, 2012 at 0516 written by the RN documented the resident was in full arrest without spontaneous respirations or pulse (carotid and radial). CPR was initiated at 0519. EMS was called and the chart was being copied. The chart was checked for a MOLST and none was present. An admission order for a full code was found and subsequent orders did not include a DNR order so CPR was initiated. The RN wrote, "that was this writer's rationale for initiating CPR." EMS arrived at 0524. The resident had a cardiac rhythm and palpable pulse at 0526 but no spontaneous respirations so EMS intubated and transferred the resident to the hospital.

The Transfer Communication Form sent with the resident to the hospital on May 11, 2012 documented that the resident did not have a DNR and did not have a MOLST.

The hospital admission note from the emergency room physician documented that "while at the nursing home the resident was assisted to the bathroom by an aide, become unresponsive. CPR was started and EMS was called. When EMS arrived, they tried to determine the resident's code status. The nursing home staff indicated that the resident did not have a code status, therefore, was a full code. The patient was intubated and CPR was initiated. The resident soon had a pulse. When the resident arrived to the emergency room, he was found to be hypotensive. While in the emergency room we reviewed his records and found he was a DNR/DNI. The emergency room physician contacted the nursing home and they confirmed that they finally did find the paperwork indicating that he is a DNR/DNI, and they faxed us the paperwork. The family was then contacted and confirmed he is a DNR/DNI. The patient was kept comfortable and he expired."

The Director of Nursing was interviewed on May 30, 2012 at 9:30 AM. She confirmed the resident was wearing two bracelets at the time he arrested at the nursing home on May 16, 2012. She stated he was wearing a DNR bracelet from a prior hospitalization and he was wearing a full code bracelet from the nursing home.

The nursing home physician was interviewed on June 1, 2012 at 4:30 PM. He stated that when he signed Resident #1's MOLST it was in a separate folder and not in the resident's chart. He stated he didn't write a separate order regarding the change in the resident's code status from full code to DNR because the nurses always write the order for him. The physician was asked why he doesn't just write the order himself at the time he signs the MOLST. He stated "that's not the system."

In summary, the facility did not honor the resident's right to be a DNR and he was resuscitated against his wishes when his MOLST was not executed properly.

2) Resident #2 was admitted to the facility on May 10, 2012 with diagnoses including respiratory failure, pneumonia and obesity.

The undated telephone admission orders, signed by the physician on May 13, 2012, documented the resident was a full code.

The nursing admission assessment, dated May 11, 2012, documented the resident was a full code. The questions regarding the MOLST and Health Care Proxy were left blank. The assessment also documented the resident understood others and was understood by others.

On May 14, 2012 the social worker completed a MOLST form documenting that the resident wanted a DNR order. The resident signed the MOLST on May 14, 2012 and the physician signed the following day, May 15, 2012.

On May 30, 2012 a verbal order was taken at 1430 to change the resident's code status to DNR because of the MOLST initiated on May 15, 2012.

In summary, from May 14, 2012 to May 30, 2012, when DOH was present in the facility, the resident's orders did not include an order regarding his desire to change his code status from full code to DNR.

3) Resident #5 was re-admitted to the facility on February 2, 2012 with diagnoses including congestive heart failure, anemia and hemiplegia.

The admission form, from the resident's original admission dated March 9, 2010, documented the resident was a full code.

On February 10, 2012 the resident completed a MOLST form which documented she wanted to be a DNR. The physician signed the MOLST on February 10, 2012.

A review of physician orders from February 10, 2012 to May 29, 2012 revealed no orders relative to the resident's code status.

On May 30, 2012 the physician called in a verbal order to have the resident's code status at DNR/DNI consistent with her MOLST.

In summary, from February 10, 2012 to May 30, 2012, when DOH was onsite at the nursing home, the resident's orders did not include an order regarding her desire to change her code status from full code to DNR.

NYCRR 415.3(e)(1)(ii)

F520 483.75(o)(1): FACILITY MAINTAINS QA COMMITTEE

Scope: Isolated

Severity: Potential for more than Minimal Harm

Corrected Date: August 17, 2012

A facility must maintain a quality assessment and assurance committee consisting of the director of nursing services; a physician designated by the facility; and at least 3 other members of the facility's staff. The quality assessment and assurance committee meets at least quarterly to identify issues with respect to which quality assessment and assurance activities are necessary; and develops and implements appropriate plans of action to correct identified quality deficiencies. A State or the Secretary may not require disclosure of the records of such committee except insofar as such disclosure is related to the compliance of such committee with the requirements of this section. Good faith attempts by the committee to identify and correct quality deficiencies will not be used as a basis for sanctions.

Citation date: June 1, 2012

Based on staff interviews, record review, and a review of the policies and procedures conducted during an abbreviated survey (Complaint # NY00116223) it was determined the facility failed to provide a quality assessment and assurance program (QA) that readily and effectively identified issues with the potential to cause serious harm to the health and safety of residents for 3 sampled residents (Residents #1, 2, and 5) reviewed for advanced directives, in a facility with a census of 230 residents. Specifically, the QA committee failed to ensure that effective systems were in place to identify problems with the accuracy of the residents' advance directive status. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.
Findings include:

The facility policy #AD-A-001-002, titled, "Advanced Directives MOLST (medical orders for life sustaining treatment) Documentation" last reviewed April 2010, documented, "MOLST form-a document which translates resident's treatment preferences into physician's orders for care........The original pink MOLST form is intended to travel with the resident from institution to institution and go home with the resident after discharge." A "DNR order is initially written by MD on MOLST Form as previously described. After the completion of the MOLST form, the attending physician must re-write the DNR order on the usual MD order sheets. This confirms the order on the MOLST form, and triggers further steps to identify and track the resident's DNR status."

1) Resident #1 was admitted to the facility on May 11, 2012 with diagnoses of atrial fibrillation, diabetes and failure to thrive.

A hospital discharge summary dated May 11, 2012 documented the resident was a DNI/DNR (Do Not Intubate-Do Not Resuscitate).

The admission History and Physical from the attending physician, dated May 11, 2012, documented the resident was a full code (CPR, cardiopulmonary resuscitation).

Undated telephone admission orders, signed by the physician on May 13, 2012, document the resident is a full code.

The resident's initial nursing admission assessment dated May 11, 2012 documented the resident was a full code. The questions about the MOLST form and Health Care Proxy were not answered. The assessment also documents that the resident is understood by others and clearly comprehends the communication of others.

On May 15, 2012 a MOLST form was completed to document the resident's verbal request to a DNR order. The physician signed the MOLST on May 15, 2012.

The social worker was interviewed on May 30, 2012 at 10:30 AM. She stated that the resident was admitted on Friday, May 11, 2012 and at the time of admission the resident told the nurse he wanted to be a full code. She stated that she approached the resident on Monday, may 14, 2012 but he was sleeping. She stated that on Tuesday May 15, 2012 the resident said he wanted to be a DNR. She talked to the resident and his son and daughter in law on Tuesday, May 15, 2012 and they completed the MOLST paperwork to make the resident a DNR. The social worker stated she left the MOLST paperwork in the physician's notebook for the physician to the sign. The physician comes to the facility three times a week. The resident coded the following morning, May 16, 2012. The physician had signed the MOLST by that time but the MOLST was not filed back into the chart. It was in a separate folder.

Progress notes dated May 16, 2012 at 0516 written by the RN documented the resident was in full arrest without spontaneous respirations or pulse (carotid and radial). CPR was initiated at 0519. EMS was called and the chart was being copied. The chart was checked for the MOLST none was present. An admission order for a full code was found and subsequent orders did not include a DNR order so CPR was initiated. The RN wrote, "that was this writer's rationale for initiating CPR." EMS arrived at 0524. The resident had a cardiac rhythm and palpable pulse at 0526 but no spontaneous respirations so EMS intubated.

The Transfer Communication Form sent with the resident to the hospital on May 11, 2012 documented that the resident did not have a DNR and did not have a MOLST.

The hospital admission note from the emergency room physician documented that while at the nursing home the resident was assisted to the bathroom by an aide and become unresponsive. CPR was started and EMS was called. When EMS arrived, they tried to determine the resident's code status. The nursing home staff indicated the resident did not have a code status, so he was a full code. The resident was intubated and CPR was initiated. The patient soon had a pulse. While in the emergency room we reviewed his records and found he was a DNR/DNI. The emergency room physician contacted the nursing home and confirmed they finally did find the paperwork indicating he is a DNR/DNI, and they faxed us the paperwork. The family was then contacted and confirmed he is a DNR/DNI. The patient was kept comfortable and he expired.

The nursing home physician was interviewed on June 1, 2012 at 4:30 PM. He stated that when he signed resident #1's MOLST it was in a separate folder and not in the resident's chart. He stated he didn't write a separate order regarding the change in the resident's code status from full code to DNR because the nurses always write the order for him. The physician was asked why he doesn't just write the order himself at the time he signs the MOLST. He stated "that's not the system."

An event report dated May 16, 2012 documented that CPR was done on the resident. On May 18, 2012 it was documented in an entry on this form "resident's orders indicated he was a full code-CPR done appropriately." On the back of this form it is documented a root cause analysis was conducted on May 21, 2012, "MOLST was located with dates indicating the resident was a DNR/DNI and social work documentation indicated the resident was a DNR/DNI." It is also documented on this form that no harm occurred and the resident's plan of care was followed. The form is signed by the Director of Nursing and the Administrator.

Attached to the May 16, 2012 event report is a narrative summary of the May 21, 2012 root cause analysis meeting. The conclusions of the meeting included that the performance of CPR on resident #1 was appropriate given the orders written upon admission was that the resident said he wanted to be a full code and that there was a communication issue when he changed his mind. It is documented that the Director of Nursing and Medical Director attended this meeting.

The DON was interviewed on May 30, 2012 at 9:30 AM. She stated the facility had conducted an audit in response to this case but had only looked at the MOLST form itself. They had not compared the MOLST forms to the physician orders and to the bracelets issued to the residents. She stated the facility did not report this matter to DOH because the last physician order was honored.

The Medical Director was interviewed on May 31, 2012 at 9 AM. He indicated the facility had looked at advanced directives due to Resident #1 but they did not realize that some orders and MOLSTs did not match. The Medical Director acknowledged that he had begun to work on advance directives since the DOH investigation began on May 30, 2012.

2) Resident #2 was admitted to the facility on May 10, 2012 with diagnoses including respiratory failure, pneumonia and obesity.

The undated telephone admission orders, signed by the physician on May 13, 2012, documented the resident was a full code.

The nursing admission assessment, dated May 11, 2012, documented the resident was a full code. The questions regarding the MOLST and Health Care Proxy were left blank. The assessment also documented the resident understood others and was understood by others.

On May 14, 2012 the social worker completed a MOLST form documenting that the resident wanted a DNR order. The resident signed the MOLST on May 14, 2012 and the physician signed the following day, May 15, 2012.

On May 30, 2012 a verbal order was taken at 1430 to change the resident's code status to DNR because of the MOLST initiated on May 15, 2012.

3) Resident #5 was re-admitted to the facility on February 2, 2012 with diagnoses including congestive heart failure, anemia and hemiplegia.

The admission form, from the resident's original admission dated March 9, 2010, documented the resident was a full code.

On February 10, 2012 the resident completed a MOLST form which documented she wanted to be a DNR. The physician signed the MOLST on February 10, 2012.

A review of physician orders from February 10, 2012 to May 29, 2012 revealed no orders relative to the resident's code status.

On May 30, 2012 the physician called in a verbal order to have the resident's code status at DNR/DNI consistent with her MOLST.

In summary, the facility did not identify, appropriately report and address the systems issues that lead staff to resuscitate resident #1 in violation of his advance directives. No action was taken until DOH staff were onsite two weeks later. In addition, the facility conducted an audit of resident advance directives but failed to identify systems issues with inconsistency between the MOLST orders and the physician orders on two additional residents ( F155) because they only audited for completion of the MOLST form, and did not look at physician orders. In addition, they failed to recognize the MOLST as containing physician orders.

10 NYCRR 415.27 (a-c)