Effective Date: 7/30/2019
End Date: 9/25/2019
Reference Number: CO19391
Allegation: Failed to assure resident rights
Description: If a resident through an advance directive declines treatment the resident may not be treated against her/his wishes. The ability of a dying person to control decisions about medical care and daily routines has been identified as one of the key elements of quality care at the end of life.On 7/24/19 During the current Nursing Facility Complaint survey (event id SZD411) an Immediate Jeopardy (IJ) situation was found related to the facility failing to ensure residents had the right to refuse treatment.Resident 5 had a POLST (Physician Orders for Life SustainingTreatment) which indicated a Do Not Resuscitate (DNR) status. On 5/16/19 between 9:00 PM and 10:30 PM Resident 5s family provided the facility, specifically, Staff 12, with the POLST form. On 5/17/19 Resident 5 had a cardiac event, staff were unable to locate the code status or POLST form so performed CPR (cardiopulmonary resuscitation) per policy. After the fire department arrived the family was called twice. The first call to verify Resident 5 was a DNR status. The second call to request the family send a photo of the POLST so they could stop CPR. The fire department stopped the CPR after the POLST was texted to the facility.Based on the violations above, DHS concludes that Respondents acts or omissions create a situation that necessitates DHS to issue a license condition. DHS finds that the residents of the facility are at risk of immediate jeopardy. That is because the facilitys failure to comply with DHS rules has caused or is likely to cause serious injury, serious harm, serious impairment, or death to a resident or residents. DHS further concludes that this finding of immediate jeopardy is likely to present an immediate jeopardy to future residents upon admission. As a result, DHS is authorized to impose a condition restricting admissions to the facility.
Rule(s) Violated: 411-085-0310(5)
411-086-0060(2)(h)
411-086-0140(2)(b)
Findings: Failed to Receive Needed Services
Sanction: NFCD19-011