Health inspection·February 1, 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 verify code status, failed to follow up on advanced directives, and failed to have the current paperwork on advanced directives for one (R1) of three residents reviewed for advanced directives in a sample of seven. Findings include: R1's medical record documents R1 is a full code as of [DATE]. R1's medical record, dated [DATE] by V18 APRN/Advanced Practice Registered Nurse, documents Recommend hospice and DNR/Do Not Resuscitate. R1's Medical Record documents R1 was admitted to hospice on [DATE] due to her diagnosis of End Stage Multiple Sclerosis and was not cognitively intact. R1's nurses note, dated [DATE] by V6 LPN/Licensed Practical Nurse, documents Packet filled out and forwarded to state guardian for (R1). Guardian called and noted sections left blank. Forwarded packet to hospice to be filled out by MD/Medical Doctor and forwarded back to the facility to be forwarded to (R1's) state guardian. Packet is consent to change from full code to DNR status. (R1) remains full code at this time. R1's medical record has no documentation of the information sent to R1's OSG/Office of State Guardian. R1's nurses notes, dated [DATE] at 4:00am by V13 RN/Registered Nurse, documents This nurse called to bedside by CNA/Certified Nurse Aid at 1:25am; resident without pulse, respiration and cool to touch; second RN called to pronounce at 1:30am; hospice notified at 1:40am; coroner called at 1:42am; funeral home notified at 2:05am; and body released to funeral home at 3:40am. R1's medical record has no documentation CPR/Cardiopulmonary Resuscitation was performed on R1. On [DATE] at 10:56am, V15 RN Administrator of Hospice stated I thought (R1's) DNR form filled out and filed with (R1's) OSG made her a DNR but she was a full code because it was not signed by the judge. We were working on a document with the guardian, but the guardian was not able to take it to court prior to the resident's death. My hospice nurse got the call (R1) had passed, my hospice nurse called me for clarification on her code status, and she was a full code. I looked thru (R1's) form, she was a full code, and I told the nursing home to do CPR. The nursing home did not have the Page 1 of 3 145646 145646 02/01/2024 Loft Rehab of East Peoria, The 900 Centennial Drive East Peoria, IL 61611

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few paperwork for the OSG, we had at our office which is why the hospice nurse did not know her code status and had to call me. When the hospice nurse got to the facility she was told they had (R1) listed as a full code, (R1's) guardian would not make her a DNR without a Judge's order so the hospice nurse called me for clarification. R1's OSG DNR paperwork, filled out on [DATE] by the physician, and provided to this state department by V15 RN Administrator of Hospice has no documentation of R1's OSG consent for DNR or withdrawal of treatment. On [DATE] at 12:25pm, V13 RN stated (R1) was hospice but was a full code. She was not changed to a DNR by the judge. I missed it and did not do CPR. We have a yellow notebook at the nurse's station that has the code status forms in case the power goes out. (R1's) code status was in the computer under her name and in the computer in the miscellaneous part of (our charting system). I called the hospice nurse when (R1) passed. (R1's) DNR paperwork was filled out for the OSG but not signed by the Judge. Hospice called her supervisor for clarification since she had the paperwork with her, we did not have it here. On [DATE] at 12:40pm, V2 DON/Director of Nursing stated (V13 RN) did not perform CPR on (R1) and was disciplined with a final written reprimand. (V13) had never been disciplined before. (V13) assumed (R1) was a DNR because she was hospice and did not follow the full code orders. We sent the paperwork to the OSG on [DATE]th, 2023, but (R1) died before it could go before the judge and get the DNR. Usually, it takes less than one week for the judges signature and the code status is done. We did not have time to follow up on her form with the holidays. (R1) was a full code when you pulled the electronic face sheet on (R1). (R1) could not talk for herself at the time of her death which is why she had an OSG. V13's employee file, dated [DATE], documents Disciplinary Action Form 3rd/final written reprimand- did not follow nursing guidelines, failed to verify a resident code status, and no prior discussion or warnings. Employee educated and stated she missed verifying (R1's) code status. Facility Residents' Rights Regarding Treatment and Advanced Directives, revised [DATE], documents It is the policy of this facility to support and facilitate a resident's right to request, refuse, and/or discontinue medical or surgical treatment and to formulate an advanced directive. The advance directive will be added to Physician Orders. The copy of the form will be scanned into the resident record. 145646 Page 2 of 3 145646 02/01/2024 Loft Rehab of East Peoria, The 900 Centennial Drive East Peoria, IL 61611

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to obtain an order for catheter care upon admission for one (R3) of two residents reviewed for indwelling urinary catheters in a sample of seven. Findings include: R3's medical record documents R3 was admitted to the facility on [DATE] with a diagnosis of traumatic L4 compression fracture and urinary retention. R3's medical record documents R3 was at the facility for pain management, indwelling urinary catheter care, and weakness. R3's medical record has no documentation R3 received catheter care from 12/23/23 through 12/28/23. R3's Physician's orders, dated 12/28/23, documents R3's catheter care was to be conducted every day shift, to start on 12/29/23, and discontinued on 1/10/24. R3's Treatment Administration Record/TAR, dated December 2023, documents catheter care was started on 12/29/23. On 1/31/24 at 3:00 PM, V2 DON/Director of Nursing stated R3's physician order for catheter care was not obtained until 12/28/23 due to R3 being admitted on a weekend and the holiday followed. V2 verbally agreed catheter cares were not documented as completed until 12/29/23 and did not know why the admitting nurse did not put in orders upon R1's admission for catheter care. Facility Catheter Care policy, dated 1/24/23, documents The facility will ensure that residents with indwelling catheters receive appropriate catheter care per standard of care. 145646 Page 3 of 3