Health inspection·August 14, 2025

REGULATION VIOLATION(S) § 483.10(a)(1)(2)(b)(1)(2) Resident Rights (a) The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section. (c) The resident has the right to be informed of, and participate in, his or her treatment, including: (6) The right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. § 483.10(c)(6)(8)(g)(12)(i)-(v) Resident Rights (c) The resident has the right to be informed of, and participate in, his or her treatment, including: (6) The right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. (8) Nothing in this paragraph should be construed as the right of the resident to receive the provision of medical treatment or medical services deemed medically unnecessary or inappropriate. (g) (12) The facility must comply with the requirements specified in 42 CFR part 489, subpart I (Advance Directives). (i) These requirements include provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive. (ii) This includes a written description of the facility's policies to implement advance directives and applicable State law. (iii) Facilities are permitted to contract with other entities to furnish this information but are still legally responsible for ensuring that the requirements of this section are met. (iv) If an adult individual is incapacitated at the time of admission and is unable to receive information or articulate whether or not he or she has executed an advance directive, the facility may give advance directive information to the individual's resident representative in accordance with State law. (v) The facility is not relieved of its obligation to provide this information to the individual once he or she is able to receive such information. Follow-up procedures must be in place to provide the information to the individual directly at the appropriate time. § 483.24(a)(3) Quality of Life (a)(3) Personnel provide basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advance directives. § 72311(a)(2) Nursing Service-General (a) Nursing service shall include, but not be limited to, the following: (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. § 72313(a)(2), Nursing Service-Administration of Medications and Treatments (a) Medications and treatments shall be administered as follows: (2) Medications and treatments shall be administered as prescribed. § 72523(a), Patient Care Policies and Procedures (a) Written patient care and policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. § 72527(a)(4), Patients' Rights (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (4) To consent to or to refuse any treatment or procedure or participation in experimental research. Findings: On 1/27/25 at 9:30 a.m., an unannounced visit was conducted at the facility to investigate a complaint regarding patient rights. The department determined the facility failed to provide patient-centered care to one patient (Patient 1) of four sampled patients when Licensed Nurses (LN) administered Cardiopulmonary Resuscitation (CPR, an emergency procedure consisting of chest compressions combined with artificial breathing in an effort to manually preserve brain function to restore blood circulation and breathing in a person whose heart unexpectedly stops beating) against Patient 1's decision not to be resuscitated (rescued). This failure resulted in psychosocial (involving both psychological and social aspects), and financial harm to Patient 1 after she had survived the medical emergency. The facility further failed to provide adequate training and oversight to its employees to ensure LNs checked a non-responsive patient's Physician Orders for Life Sustaining Treatment (POLST, a portable medical order that documents a person's decisions regarding end-of-life care) before administering CPR. These failures further constitute a failure by the facility to ensure its staff follow its policies and procedures. A review of Patient 1's admission record indicated an initial admission to the facility on 2/9/24. The admission record also indicated Patient 1 was her own responsible party (a person in charge of making healthcare decisions). A review of Patient 1's Physician Orders for Life Sustaining Treatment (POLST, a portable medical order that document's a person's decisions regarding end-of-life care), prepared on 2/9/24 indicated, "...First follow these orders, then contact Physician...A copy of the signed POLST form is a legally valid physician order...Cardiopulmonary Resuscitation (CPR): If patient has no pulse and is not breathing...[check marked as choice] Do Not Attempt Resuscitation/DNR (Allow for Natural Death)...Medical Interventions: If patient is found with a pulse and/or is breathing...[check marked as choice] Comfort-Focused Treatment- primary goal of maximizing comfort. Relieve pain and suffering with medication by any route as needed; use oxygen, suctioning, and manual treatment of airway obstruction. Do not use treatments listed in Full and Selective Treatment unless consistent with comfort goal. Request transfer to hospital only if comfort needs cannot be met in current location...Information and Signatures: Discussed with...[check marked as choice] Patient (Patient has Capacity)... [check marked as choice] No Advanced Directive...Signature of Physician...My signature below indicates to the best of my knowledge that these orders are consisted with the patient's medical condition and preferences [signed by Physician on]...2/12/24...Signature of Patient...I am aware that this form is voluntary. By signing this form, the legally recognized decisionmaker acknowledges that this request regarding resuscitative measures is consistent with the known desires of, and with the best interest of, the individual who is the subject of this form...[signed by Patient 1] on...2/9/24." A review of Patient 1's Minimum Data Set (MDS, a federally mandated patient assessment tool), dated 2/15/24, indicated a Brief Interview for Mental Status (BIMS) score of 15 which meant her cognition was intact. A review of Patient 1's Care Plan initiated on 2/15/24 indicated, "[Patient 1] has a POLST for DNR Status [with] the goal [that Patient 1's] POLST/DNR status will be followed through [the] target date [of 8/14/24] or till change of order...[interventions staff were expected to implement included] DNR POLST form will be in the medical records at all times...Staff will recognize [Patient 1's] wishes and follow as indicated." A review or Patient 1's Order Summary Report which indicated active orders as of 4/28/24 at 3:50 p.m. indicated, "DNR Code...Active [order as of] 2/12/24...Pt [Patient] has capacity to make healthcare decisions: Yes...Active [order as of] 2/9/24...I have approved these orders for [Patient 1]...[Orders signed by Physician on] 5/1/24." A review of Patient 1's Progress Note dated 5/13/24 at 12:28 p.m. documented by LN A indicated, "Called to patients [sic] room by CNA [Certified Nursing Assistant]. [Patient 1] noted to be slumped over in wheelchair and unresponsive. Pallor [abnormal paleness of the skin] noted, sternal rub [the most common painful stimulus practiced in the field by Emergency Medical Technicians and paramedics] attempted without response, carotid pulse [a wave of blood pressure felt on either side of the neck] absent. Initiated CPR after transfer to bed...Another nurse [LN B] took over CPR. Chart checked and noted to be DNR. [Patient 1] began crying out in pain. Paramedics responded and transferred to ED [Emergency Department]..." A review of Patient 1's Hospital Discharge Summary dated 5/15/24 indicated, "Principle Diagnosis: Syncope [a temporary loss of consciousness that occurs when the brain does not receive enough blood flow]...NSTEMI (non-ST elevated myocardial infarction) [a type of heart attack where involving a partial blockage of one of the coronary arteries, causing reduced flow of oxygen to the heart muscle]...[Patient 1] had a CPR for few minutes at the [facility] when they did not find a pulse over there. [Patient 1] woke up after 5 minutes..." During an interview on 1/27/25 at 12:32 p.m. Patient 1 stated she could not recall going to the hospital. Patient 1 stated she was told her heart stopped beating and was resuscitated by LN A. Patient 1 stated when she came back to the facility, LN A apologized to her for performing CPR when her code was DNR. Patient 1 stated she now must live in an assisted living facility where she has had to pay $6,000 per month just to sit in a wheelchair, unable to do things independently. Patient 1 stated, "I did not wish to live in this situation." During an interview on 1/27/25 at 1:35 p. m. the Director of Nursing (DON), stated it was her expectation for nurses to verify the patient's code status before initiating CPR. The DON stated LN A became aware of Patient 1's DNR code status after she had already provided CPR. During an interview on 1/27/25 at 1:42 p.m. LN B confirmed she went to Patient 1's room and saw LN A performing CPR on Patient 1. LN B stated she assisted LN A with the CPR and took over the chest compressions. LN B stated while she was performing chest compressions on Patient 1, another nurse informed her Patient 1's code status was DNR, so she stopped performing the chest compressions. During an interview on 2/3/25 at 9:58 a.m., Patient 1 stated because she was resuscitated, she is now experiencing a financial burden because she is having to spend her money for people to take care of her since she is physically unable to care for herself. Patient 1 stated she is anxious because she is running out of money, and she is unsure of where she will go when her money runs out. Patient 1 also stated she is depressed and, "...would not wish her current situation on anybody." A review of the facility's policy and procedure titled "Resident Rights," dated 2001, indicated, "Federal and state laws guarantee certain basic rights to all [patients] of the facility. These rights include the [patient's] right to...self-determination...be supported by the facility in exercising his or her rights...participate in, his or her care planning and treatment..." A review of the facility's policy and procedure titled "Do Not Resuscitate Order," dated 2001, indicated, "Our facility will not use cardiopulmonary resuscitation and related emergency measures to maintain life functions on a [patient] when there is a Do Not Resuscitate Order in effect...Do not resuscitate (DNR) orders will remain in effect until the [patient]...provides the facility with a signed and dated request to end the DNR order..." Therefore, the department determined the facility failed to provide patient-centered care to Patient 1 when LNs administered CPR against Patient 1's decision not to be resuscitated. This failure resulted in psychosocial, and financial harm to Patient 1 after she had survived the medical emergency. This violation had a direct or immediate relationship to the health, safety, or security of Patient 1 and further presents either (1) an imminent danger that death or serious harm to the resident of the long-term health care facility would result therefrom, or (2) a substantial probability that death or serious physical harm to residents of the long-term health care facility would result therefrom.