Health inspection·September 24, 2024

F 0578 Level of Harm - Minimal harm or potential for actual harm Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. Based on record review and interview, the facility failed to have accurate Advance Directive information on the medical chart for 2 of 4 residents sampled (Resident #19 and #23). Residents Affected - Few The findings include: Resident #19: Resident #19 was observed to have a No Code sticker on the front of the medical chart. However, Resident #19's face sheet listed the resident as a full code dated 8/5/2024. On 5/19/23, the resident had signed a form saying he wished to be DNR (Do Not Resuscitate). On 09/23/24 at 04:50 PM, during an interview with Staff B, a registered nurse (RN), she was asked what No Code means. Staff B stated that the resident has chosen not to be resuscitated. When asked how new staff would find out the resident's advance directives, Staff B stated they were always instructed to look at the face sheet in the medical chart. On 09/24/24 at 12:21 PM, an interview with the facilities Minimum Data Set (MDS) coordinator was held. When asked about Resident #19's advance directives, the MDS coordinator stated this resident was a DNR. When shown that the record contained conflicting information, the MDS coordinator stated that was done in error. She explained the pharmacy prints out the face sheets and the facility had forgotten to update the pharmacy, so it was showing inaccurate information. The DON was present and was asked how staff would know the advance directives, the DON stated they go by the sticker. She also stated they would correct the discrepancy right away. Resident #23: The chart for Resident #23 had a sticker stating NO CODE. A Do Not Resuscitate (DNR) form was not found in the chart of Resident #23. The medication administration record (MAR) code status however indicated, FULL CODE. A review of the advance directives for Resident #23 revealed a document signed on 3/21/24 by the legal representative for Resident #23 which indicated the desire for no resuscitative measures to be taken. On 09/24/24 at approximately 12:25 PM, during an interview with Staff A, the Minimum Data Set coordinator (MDS) stated that Resident 23 was a DNR, NO CODE. She indicated that the FULL CODE printed on the MAR was an error. She stated that the facility had not communicated the correct code status (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 4 Event ID: 106055 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 106055 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northwest Florida Community Hospital (Snu) 1360 Brickyard Rd Chipley, FL 32428 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)