State Findings:
Based on record review and interviews the facility failed to fully ensure residents had the right to formulate advance directives, by not keeping advance directives updated and current for three (#54, #61 and #70) of five residents out of 44 sampled residents.
Specifically, the facility failed to ensure advance directive forms included updated and accurate information.
The facility policy was to use the Colorado medical orders for scope and treatment (MOST) form however, did not abide by its standards of practice.
Resident #70 MOST form did not match their physician order, Resident #54 did not have a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .
Record review
The resuscitation care plan, initiated [DATE] revealed Resident #70 wished to be a Full Code with the primary goal was to prolong life by all medically effective means.
Review of Resident #70’s MOST form revealed Resident #70’s wished to be Full Code, dated [DATE].
Review of Resident #70’s CPO revealed a do not resuscitate order (DNR), dated [DATE].
Review of a binder at the nurse’s station with MOST forms revealed no further MOST form for Resident #70.
Registered nurse (RN) #2 was interviewed on [DATE] at 3:39 p.m. He said staff followed the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . He said the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . He acknowledged the order in the resident’s electronic record did not match the MOST form. He said the resident recently readmitted from the hospital and it was possible the admitting nurse entered the order incorrectly since there was not an updated MOST form in the binder at the nurse’s station. He said he would review advance directives with the resident to ensure they were following his wishes.
The nursing home director (NHA) was interviewed on [DATE] at 5:15 p.m. She said Resident #70 had a new MOST form completed upon return from the hospital. She said she had the resident’s MOST form (which was updated on [DATE] to reflect DNR status) in her office for the physician to sign that week. She acknowledged the facility’s process for ensuring the MOST was available in case of an emergency and for transfer to the hospital would not have been available for staff since it was kept in her office and not in the binder at the nurse’s station.
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...and we want to hear it.
NHAA is here to assist families, residents, and the community by sounding the alarm on issues like those found above. This nursing home and many others across the country are cited for abuse and neglect.
If you have or had a loved one living in this nursing home or any other nursing home where you suspect any form of abuse or neglect, contact us immediately.
We have helped many already and we can help you and your loved one as well by filing a state complaint, hiring a specialized nursing home attorney or helping you find a more suitable location for your loved one.
You can make a difference, even if your loved one has already passed away.
Please give us a call at 1-800-645-5262 or fill out our form detailing your experience.
Personal Note from NHA-Advocates
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