Health inspection·November 16, 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 have the right to request, refuse, and or discontinue treatment and to formulate an advance directive for 1 (Resident #54) of 5 residents whose records were reviewed for Out-of-Hospital Do-Not-Resuscitate Order forms in that: The Facility did not ensure Resident #54's OOH-DNR form was completed fully and correctly. This failure could place residents at risk of not having their wishes met. The findings included: Record review of Resident #54's Face Sheet dated 11/14/23 reflected she was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Relevant diagnosis of acute respiratory failure (a condition where you don't have enough oxygen in the tissues in your body), dependence on respirator, gastrostomy status (placement of a feeding tube through the skin and the stomach wall), hypertension, type 2 diabetes, tracheostomy status (a procedure to help air and oxygen reach the lungs by creating an opening into the trachea (windpipe) from outside the neck). Record review of Resident #54's Quarterly MDS assessment dated [DATE] reflected she had a BIMS of 07 which indicated Resident #54 had moderate cognitive impairment. Record review of Resident #54's Care Plan reflected she had a DNR status. Record review of Resident #54's Physician's Orders reflected an active order dated 09/21/2023 for a code status of DNR. Record review of Resident #54's OOH-DNR form dated 09/13/2023 reflected no physician signature under Physician's Statement, which required Physician's signature, date, license # and printed name nor on the bottom section that indicated all who signed above must sign below did not have attending physician's signature. In an interview on 11/16/2023 at 8:45 a.m., The social worker said he was responsible to assist residents and/or POA (power of attorney) in completing OOH-DNR form if they wished to be a DNR. He said after the form was completed/dated by resident or POA and witnesses he would give the form to medical records. The social worker said medical records personnel were responsible to obtain the physician's signature and to upload OOH-DNR form to PCC. The social worker said he kept a list of residents who were pending physician's signatures on their OOH-DNR form and would review it weekly. He said Page 1 of 3 676414 676414 11/16/2023 Mid Valley Nursing & Rehabilitation 601 N Mile 2 West Mercedes, TX 78570

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few if medical records had not uploaded the completed OOH-DNR form to PCC, he would send an email to medical records (cc DON, Administrator and MDS) to remind them the OOH-DNR form was still pending physician signature and or had not been uploaded to PCC. The Social Worker said the facility kept a binder of all residents with code status of DNR at the nurse's station. In that binder, he said were resident's face sheet and OOH-DNR form. He said medical records personnel was responsible to update the binder as needed. The social worker obtained Resident #54's OOH-DNR form from the binder and said the form did not have physician's signature. He was not able to say why there was no physician's signature. The social worker said he was not able to say of any negative effects on Resident #54 if her OOH-DNR form was not signed by her physician. In an interview on 11/16/2023 at 9:22 a.m., Medical Records LVN said after the social worker forwards her a resident's OOH-DNR form it is her responsibility to obtain physician's signature. She said she would take OOH-DNR form to the physician's office or would wait for them to come to facility to obtain their signature. She said once the physician singed the OOH-DNR form she would upload it to PCC and would notify MDS for code status to be care planned. She said the facility also kept a binder at the nurse's station which contained face sheets and OOH-DNR form for all DNR residents. She said she would check the binder daily to make sure it was updated and all OOH-DNR forms were completed. Medical Records LVN reviewed Resident #54's OOH-DNR form and said there was no physician's signature. She was not able to explain why there was no signature. She said there as long as the resident/POA had signed OOH-DNR form, the resident would still be considered a DNR. In an interview on 11/16/2023 at 10:00 a.m., The DON said if a resident would code, nursing staff would check their code status on PCC under profile and orders to make sure there was an active order in place. She said as long as there was an order and resident/POA and witnesses have signed OOH-DNR form was enough for a resident to be considered DNR. She said in case of a power outage, the facility had a generator, and one printer would be powered by generator and nursing staff had access to PCC. The DON said the facility also kept a binder at the nurse's station which contained face sheets and OOH-DNR form for all DNR residents. She said medical records personnel were responsible to keep binder updated and is only used a resource. The DON said no negative effect on Resident #54 for not having OOH-DNR form signed by physician as the nursing staff only checked for orders and signatures of resident/POA and witnesses on the OOH-DNR form. In an interview on 11/16/23 at 10:10 a.m., LVN A said if a resident would code, she would immediately check their code status on PCC under profile, orders to make sure a physician order was in place and under documents to make sure the OOH-DNR had been uploaded. She said she would check the OOH-DNR form had the resident's name, date, physician signature, family/POA signature. LVN A said if the OOH-DNR form was missing the physician's signature she would check the binder at the nurse's station and if the form in the binder would also be missing physician's signature, she would consider the resident full code. In an interview on 11/16/2023 at 10:20 a.m., LVN B said if a resident would code, she would check coding status on PCC under orders to make sure a physician order was in place and under documents for make sure the OOH-DNR form was signed by resident or POA. She said she would also check the binder located at the nurse's station make sure the OOH-DNR form had resident's/POA and witnesses signature. LVB said if the OOH-DNR form was missing physician's signature she would still consider the resident as a DNR. In an interview on 11/16/2023 at 10:30 a.m., RN C said if a resident would code, nursing staff would check the orders to make sure a physician's order was in place and under documents to review the 676414 Page 2 of 3 676414 11/16/2023 Mid Valley Nursing & Rehabilitation 601 N Mile 2 West Mercedes, TX 78570

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few OOH-DNR form. She said as long as there was an OOH-DNR form with resident's/POA's signature under documents that was enough to consider the resident a DNR. In an interview on 11/16/2023 at 3:35 p.m., LVN E said if a resident would code, she would immediately check for their code status on PCC under their profile and orders to make sure there is an order in place. She there is also a binder that is kept at the nurse's station that contained the resident's face sheet and OOH-DNR form nursing staff can also check. In an interview on 11/16/2023 at 3:47 p.m., LVN F said if a resident would code, she would check PCC under documents to see if there was an OOH-DNR form. She said they would also check the binder located at the nurse's station to make sure the OOH-DNR form had been signed by resident/POA and physician. She said if the OOH-DNR form was missing the physician's signature she would still consider them DNR. Interview on 11/16/2023 at 3:57 p.m., LVN G said if a resident would code, he would immediately check code status on PCC under orders to make sure there was an active order and under documents to verify the OOH-DNR form was signed by the physician. He said if the OOH-DNR form did not have a physician signature, he would still consider the resident as a DNR as long as there was an OOH-DNR form under documents. Record review of facility's Advanced Directives policy implemented on February 2017 and revised on January 2023 reflected: Advanced directive implementation: The IDT will notify the medical provider of the resident's/representative's care decisions made to include expressed advanced directive, such as DNR code status. The nurse should then obtain a physician's order for appropriate care decision in order to initiate and implement the preferred treatment wished expressed. The IDT should honor the care decision expressed and initiate the advance directive by initiating the Out of Hospital Do Not Resuscitate (OOH-DNR) form and should obtain the medical provider/physician's signature as per the OOH-DNR form instructions. The medical record and resident's plan of care should reflect the resident's wishes as well as the physician's order in order to meet the directives described. 676414 Page 3 of 3