Failure to Ensure Advance Directives for Residents
Penalty
Summary
Bryn Mawr Village was found to be non-compliant with the requirements of 42 CFR part 483, Subpart B, and the 28 PA Code related to the health portion of the survey process. The facility failed to ensure that advance directives were in place for two residents, Resident R149 and Resident R26, as evidenced by clinical record reviews and staff interviews. Resident R149, admitted with a diagnosis of Chronic Obstructive Pulmonary Disease, had no advance directives indicated on the face sheet, nor was there documented evidence of discussions regarding advance directives. Similarly, Resident R26, admitted with Acute Respiratory Failure with Hypoxia and Multiple Sclerosis, also lacked advance directives on the face sheet and documentation of related discussions. Interviews with Unit Manager Employee E3 confirmed the absence of advance directives for both residents. Additionally, there were no physician orders for advance directives for either resident. The facility's policy on advance directives, last revised in 2016, mandates that residents be provided with written information about their rights to accept or refuse treatment and to formulate an advance directive upon admission. The policy also requires that information about advance directives be prominently displayed in the medical record and that the plan of care aligns with the resident's documented treatment preferences.
Plan Of Correction
(1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Residents R26 and R149 are discharged from the facility. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: An audit of the clinical records of current residents will be conducted to ensure that a code status is included, a physician order for code status is included, and the resident's family member is given an advance directive or clarification of the hospital code status to implement the residents wishes after admission to the facility. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: Education will be provided by the DON/ and or designee to nursing staff and Social Services regarding the components of this regulation and how to properly document this regulation. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: Random audits will be conducted weekly by the DON/ or designee of five clinical records to ensure that they include a code status, a physician order for code status and that the family was involved in the wishes. Audits will be conducted weekly x for four weeks and then monthly for six months. Results of these audits will be reported to the monthly Quality Assurance Performance Improvement Committee until monthly and/or substantial compliance is met. Adjustments to the plan of corrections will be made by the Interdisciplinary team as needed.