Health inspection·May 7, 2024

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure resident's advance directives and physician's orders reflected resident's wishes for 2 of 3 residents (R41 and R58) reviewed for advance directives in a sample of 25. Findings include: 1. R41's Face Sheet, with original admission date of [DATE], documents R41 has diagnoses of but not limited to chronic combined systolic (congestive) and diastolic (congestive) heart failure, chronic obstructive pulmonary disease with (acute) lower respiratory infection, atherosclerotic heart disease, and chronic atrial fibrillation. R41's Minimum Data Set (MDS), dated [DATE], documents R41 is severely cognitively impaired with a Brief Interview for Mental Status (BIMS) of 06 out of 15 and she is dependent on staff for most of her activities of daily living (ADLs). R41's Care Plan, not dated, documents Resident desires CPR be initiated in the event of cardiac arrest, resident wishes will be honored thru next review, Full Code/CPR, In the event of cardiac arrest, CPR will be initiated, and continue until EMS arrival to take over compressions, and/or physician gives order to stop compressions, if not effective, Provide information regarding Advance Directives upon admission. R41's Physician's Order, dated [DATE], documents R41 was a Full Code, and the order was discontinued and R41 was made a Do Not Resuscitate (DNR) on [DATE]. R41's Practitioner Order for Life-Sustaining Treatment (POLST), dated [DATE], documents R41's wishes are to be a DNR. R41's Updated Care Plan, print date of [DATE], documents R41 desires no life-prolonging measures in the event of cardiac or respiratory arrest as evidenced by advance directives/POLST form. 2. R58's Face Sheet, with original admission date of [DATE], documents R58 has diagnoses of but not limited to Parkinson's disease and dementia. R58's MDS, dated [DATE], documents R58's is severely cognitively impaired and is dependent on staff for most of his ADLs. Page 1 of 2 145367 145367 05/07/2024 Gillespie Health & Rehab Ctr 7588 Staunton Road Gillespie, IL 62033

F 0578 R58's Care Plan, with admission date of [DATE], has no documentation of his advanced directive wishes. Level of Harm - Minimal harm or potential for actual harm R58's Physician's Orders, dated [DATE], documents Full Code See POLST for medical interventions. R58's POLST, dated [DATE], documents R58 wishes to be a DNR. Residents Affected - Few [DATE] 12:40 PM V1, Administrator stated the resident's physician's orders will document they are a full code until the doctor signs the POLST and then V13, Social Services will notify the nurse so the nurse can change it in the computer and then the nurse will pass it on to the V4, MDS coordinator so she can update the care plan. She said they must not have notified anyone of the updated POLST so they could change them in the computer, and they would get them changed right away. The facility's Advanced Directives policy, issue date of [DATE], documents Purpose: To provide guidance to staff on the expectation of respecting residents wishes with regards to Advance Directives and compliance with state and federal regulations. Policy: Advance directives will be respected in accordance with state law and facility policy. Responsibility: It is the responsibility of the Social Service department/Administrator to know the regulations/policies and ensure all appropriate staff are aware. Procedure: 1. Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. If further documents 7. Information about whether or not the resident has executed an advance directive shall be prominently in the medical record. It also states 10. The Plan of Care for each resident will be consistent with his or her documented treatment preferences and/or advance directives. It further states 20. The Director of Nursing Services or designee will notify the Attending Physician of advance directives so that appropriate orders can be documented in the resident's medical records and plan of care. 145367 Page 2 of 2