Health inspection·April 11, 2023

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 residents' right to formulate an advance directive for 1 of 1 resident (Resident #1) reviewed for advanced directives, in that: The facility failed to ensure Resident #1, a competent adult, signed his own OOH-DNR and allowed the resident's Medical Power of Attorney (MPOA) to complete the document. This failure could place residents at-risk of having their end of life wishes dishonored. The findings were: Record review of Resident #1's face sheet, dated [DATE], revealed the resident was admitted on [DATE] with diagnoses that included: olecranon bursitis (inflammation of the bursa or fluid filled sacs that reduce friction between moving parts in the body's joints) of left elbow, Parkinson's Disease (progressive nervous system disorder that affects movement), benign neoplasm (abnormal but noncancerous collection of cells) of lower jawbone and neurocognitive disorder with Lewy Bodies (abnormal aggregations of protein that develop inside nerve cells). Further review of Resident #1's face sheet, dated [DATE], revealed under the section ADVANCE DIRECTIVE: DNR Record review of Resident #1's admission MDS, dated [DATE], revealed a BIMS score of 15, which indicated the resident was cognitively intact. Record review of Resident #1's Care Plan, print date [DATE], revealed a focus area, Resident does not want CPR performed. Fully executed OOH DNR in place. Date initiated [DATE] Record review of Resident #1's electronic medical record Order Summary Report, Active Orders as of [DATE], revealed an order dated [DATE] for DNR. Further review revealed an OOH-DNR signed by Resident #1's family member in section C, Declaration by a qualified relative of the adult person who is incompetent or otherwise incapable of communication. The OOH-DNR was signed by the physician and two witnesses, witness #2 was the facility SW. Record review of the INSTRUCTIONS FOR ISSUING AN OOH-DNR ORDER, revised [DATE], by the Texas Department of State Health Services, revealed If an adult person is competent and at least [AGE] years of age, he/she will sign and date the Order in Section A. If the adult person in incompetent or otherwise mentally or physically incapable of communication and does not have a guardian, agent, or proxy, then a qualified relative may execute the OOH-DNR Order by signing and dating it in Section C. Page 1 of 2 676240 676240 04/11/2023 Cibolo Creek 1440 River Rd Boerne, TX 78006

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of the ADVANCE DIRECTIVE ACKNOWLEGMENT form included in the Admissions Agreement, dated [DATE], signed by Resident #1 revealed I DO NOT possess an Advance Directive and DO NOT WISH TO INITIATE A DNR. In a record review and interview with the SW on [DATE] at 2:30 p.m., the SW revealed that when Resident #1 was admitted he had an OOH-DNR that was completed incorrectly and mentioned this to the family member who said because she was Resident #1's MPOA she would sign a new OOH-DNR. The SW revealed Resident #1's family member later came to her office and completed the OOH-DNR that was in Resident #1's electronic record. The SW also revealed she had interviewed Resident #1 and completed a BIMS assessment with him on two occasions, [DATE] and [DATE] in which Resident #1 scored a 15 each time. The SW confirmed a score of 15 indicated the resident to be cognitively intact. The SW was asked if the OOH-DNR was valid with the family member's signature if Resident #1 is competent and the SW stated technically, I guess it's not legal. The SW was asked if a conversation had occurred with Resident #1 regarding his wishes and the SW stated she would need to have that conversation to determine if he wanted to sign a new OOH-DNR. When asked about the potential harm of having someone other than a competent resident sign the OOH-DNR, the SW stated the resident's wishes may not be known or followed. In an interview with the DON on [DATE] at 2:45 p.m., the DON confirmed Resident #1's OOH-DNR to not be valid and revealed she would follow up immediately with the SW to ensure Resident #1's wishes were known, and his code status correct. In an interview with the Administrator on [DATE] at 3:10 p.m., the Administrator revealed the SW had informed her that Resident #1's OOH-DNR was not valid, and the SW was meeting with him to discuss his rights and assist with completing a new OOH-DNR if that was his wishes. Record review of the facility's policy titled, Residents' Rights Regarding Treatment and Advance Directives, undated, 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 advance directive. 676240 Page 2 of 2