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F0578
G

Failure to Honor Resident's Advance Directives

Lock Haven, Pennsylvania Survey Completed on 01-09-2025

Penalty

Fine: $22,356
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to establish clear and consistent resident wishes regarding advance directives for a resident, resulting in actual harm. The resident had a Durable Health Care Power of Attorney and Living Will appointing his sister as his health care agent, but she was deceased, and no new agent was appointed. Despite the resident being cognitively intact with a BIMS score of 15, there was no evidence that the resident was involved in decisions regarding his advance directives or that he had appointed another individual to act on his behalf. The resident had a POLST indicating a wish to receive CPR, signed by both the resident and a nurse practitioner. However, physician orders later indicated a DNR status, with no evidence of a discussion with the resident or a new document signed by the resident indicating a change in his wishes. The facility's records showed inconsistencies in the resident's code status, with a DNR order being carried over during a change in electronic records, but no documentation of the resident's involvement in these decisions. The resident experienced a change in condition and was sent to the emergency department, where he expired. The facility's records indicated the resident was a DNR/DNI, but there was no evidence that the resident had decided to change his code status from the previously signed POLST. The lack of documentation and involvement of the resident in these critical decisions led to a deficiency in honoring the resident's right to make informed decisions about his care.

Plan Of Correction

1. Corrective action cannot be achieved for resident CR1. 2. All residents have the potential to be affected. Facility altered "code status" form to address the residents' ability to make decisions regarding health care and documentation with resident or family and space designated to document with whom it was discussed. Advance directive/code status was reviewed with residents who have been determined to be capable of making their own health care decisions. Resident representatives have been contacted to review advanced directives/code status for those residents who are not capable of making their own health care decisions. All residents with changes needed to code status were referred to physician for further discussion and physician order changes. 3. Education will be provided to medical providers and nursing staff using a program developed by a well-established center of geriatric health service education, and will include a review of all the federal regulations cited along with a review of the accompanying guidelines for F-0587, and any changes to facility policies and procedures. 4. DON or designee will audit 10 resident code status for accuracy and documentation weekly x 4 then monthly x 3. Results of the audits will be reviewed with QAPI process and meetings.

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