Commander Nursing Center in Florence, SC, has been cited after state investigators found that the facility “failed to ensure [a resident] had the opportunity to make a health care decision.” In this situation, the facility took a Do Not Resuscitate order signed by a family member without the required signatures from two physicians to determine the resident’s ability to make their own decisions.
The resident’s health changed, requiring cardiopulmonary resuscitation (CPR). The nursing home did not administer CPR, and the resident passed away. The state investigator found a form from South Carolina Emergency Medical Services, signed by a family member, directing medical providers not to intervene in a situation such as this.
The form did not, however, have the signatures from two physicians. The nursing home did not have record of a physician’s order in their electronic records, so multiple staff members looked through their written files for two hours while the state investigator continued to interview nursing home staff. They did not have a physician’s order for Do Not Resuscitate.
This is an essential part of a Do Not Resuscitate order; individuals must be able to make their own health decisions unless they have been reviewed as unable to make their own decisions regarding medical care. A family member may have their loved one’s best interests in mind, but they are not qualified to decide whether or not their loved one can make their own health decisions.
Advance directives, or wishes of an individual regarding their own death, are to be protected and correctly observed. The facility’s policy clearly stated that they should “adhere to residents’ rights to formulate advance directives,” communicating these wishes clearly in every document relevant to a resident’s medical record. Not only were nursing home staff working from an invalid form to care for the resident, but they also struggled to sort through different sources of medical information about the resident. All information in a resident’s medical record should be accurate and consistent between physical and electronic records throughout the nursing home.
The facility also failed to tell the resident’s physician of their change in health. The nursing home called the physician after the resident passed, rather than as their health was failing. The resident’s physician and responsible representatives, such as a family member, should be notified immediately of changes to a resident’s health.
The facility was given a citation code by the state of “immediate jeopardy.” This is a serious level of offense and is often the subject of the citations discussed in this legal blog. The nursing home did submit a correction plan. This plan included a thorough investigation of the records of residents deemed at risk of passing. They would assess the accuracy of these records and notify physicians and resident representatives of the records they had on file.
Commander Nursing Center also created an educational plan for its staff, including the immediate changes the nursing home was making to advance directives and code status. The facility promised to include a review of this policy in their daily morning meeting. The nursing home also planned to monitor the effectiveness of their new measures every week for four weeks and perform a Root Cause Analysis to identify root cause and immediate interventions if a break in policy was identified.
Commander Nursing Center has been cited previously and discussed in a number of our earlier legal blog posts. The facility has been cited for the abuse of a resident in relation to toileting needs, for multiple cases of mishandling instances of abuse, and has been noted as a Special Focus Facility in South Carolina.
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