Survey Report for 261603

DEPARTMENT OF HEALTH AND HUMAN SERVICES		FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES		OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION	(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER	(X2) MULTIPLE CONSTRUCTION	(X3) DATE SURVEY COMPLETED
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION	261603	A. BUILDING __________ B. WING ______________	12/10/2020
NAME OF PROVIDER OR SUPPLIER	STREET ADDRESS, CITY, STATE, ZIP
PREFERRED HOSPICE OF MISSOURI	423 BUSINESS HIGHWAY 60 WEST BOX 99, DEXTER, MO, 63841
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
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 reverse for further 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
(X4) ID PREFIX TAG	SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY SHOULD BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION)
L0671
L0671	15697 Based on the Patient Self-Determination act, clinical record review, and interview, the hospice failed to ensure the registered nurse (RN) accurately and completely documented a patient assessment in the electronic medical record (EMR), in but not limited to, one (Record/Patient #1) of three records reviewed related to patient's self determination - Do Not Resuscitate (DNR- medical order written by a doctor. It instructs health care providers not to perform cardiopulmonary resuscitation (CPR) if a patient's breathing stops or if the patient's heart stops beating). The deficient practice has the potential to affect all patients on service with the hospice provider. Findings included: Patient Self Determination Act of 1990 - Amends Titles XVIII (Medicare) and XIX (Medicaid) of the Social Security Act to require home health agencies to (1) inform patients of their rights under State law to make decisions concerning their medical care; (2) periodically inquire as to whether a patient executed an advanced directive and document the patient's wishes regarding medical care. PATIENT/RECORD #1: Review of the clinical record showed Admission Orders dated 10/02/2020 at 12:16. Review of the order section of this document showed an order for DO NOT RESUSCITATE (DNR). The document was signed by the RN on 10/02/2020 and signed by the physician on 10/06/2020. Review of the initial assessment dated 10/02/2020 performed by the RN showed "Patient continues to be a full code and may choose to return to hospital. Will decide at the time". Review of the patient's profile dated 10/02/2020 showed Advanced Directive - Patient a Full Code (Advanced Cardiac Life support), patient wants chest compression and respiratory support in the event that the patient is no longer breathing and/or patient's heart stops. Review of the DNR form provided to the patient and/or patient's care giver on admission failed to contain a signature of consent. Review of the interdisciplinary group meetings (IDG), that updated the patient's assessment and plan of care showed on 10/06/2020, patient a full code, and the document was signed by the physician 10/06/2020. The IDG meetings 10/20, and 11/03 showed no change in code status. Patient remained a full code and patient was discharged on 11/12/2020 to a facility closer to his/her home. During an online interview on 12/08/2020 at 4:40 PM, the director of clinical services stated that the facility's standing admission order stated DNR and that the order wasn't changed before sending to the physician for signature. The nurse failed to change the wording when the patient chose to be a full code.