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
491630 A. BUILDING __________
B. WING ______________ 		09/24/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
AMEDISYS OF BLACKSTONE 920 S MAIN STREET STE C & D, BLACKSTONE, VA, 23824
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)
L0505      
27661 Based on interviews and a review of clinical records it was determined the agency's staff failed to respect the patient's wish to exercise their rights related to not being resuscitated for one (1) of six (6) patients in the survey sample (patient #3). The findings were: The clinical records were reviewed offsite as a virtual review in read-only mode from 9/21/2020 through 9/24/2020. The clinical record for patient #3 contained Do Not Resuscitate order signed by the patient on 7/24/2020. The initial nursing assessment dated 7/24/2020 contained a section related to, was the patient or responsible party asked about their preference for the use of CPR (cardiopulmonary resuscitation) and life- sustaining treatments. The response to both questions was answered with yes, and discussion occurred. No explanation was provided in the note about what the discussion entailed. The social workers (SW) initial assessment dated 9/28/2020 contained an intervention section with one intervention stating in part, "evaluate for problems related to lack of resolution regarding DNR (do not resuscitate) status". The note failed to contain further clarification as to whether or not there was a problem with the DNR status. An on-call note after hours by the triage nurse on 7/30/2020 at 7:47 PM revealed the patient had died and a nurse was to make a visit. The nurse who made a visit on 7/30/2020 documented in a nurseing visit note dated 7/30/2020 at 10:13 PM revealed when the nurse arrived to make a visit ; the patient had already been transported to the emergency department by EMS (emergency medical services). The note stated, EMS performed CPR because no visible DNR was present in home. It further stated, the patient was transported to the hospital after EMS got a pulse but then lost the pulse again during transport and the patient was pronounced at 8:32 PM at the hospital. The nurse documented in the note the DNR was in the office waiting to be signed by the physician. The record failed to contain documented evidence the DNR was ever delivered to the home. An interview with a patient family member on 9/23/2020 at 12:10 PM revealed the caregiver in the home at the time the patient died thought they were to call 911 to pronounce the patient's death. The caregiver called 911 and the hospice agency. The family member remembers being taught about calling hospice but did not realize that the hospice nurse could pronounce the patient and was not aware that calling 911 would cause so much problem with the DNR not in the home. The family member reports knowing the patient had signed the DNR on admission and it was taken to the office for the physician to sign. A phone interview with the Regional Director of Clinical Operations on 9/23/2020 at 12:10 PM revealed the staff should be documenting in the narrative section of the visit note when the signed DNR is delivered to the home. A phone interview with the Regional Director of Clinical Operations on 9/24/2020 at 11:25 AM revealed the questions on the nursing assessment related to patient preference on CPR and life sustaining measures are part of the hospice item set and the nurse has three options to document. The nurse would document in the narrative section if there were any problems. The SW section related to lack of resolution of the DNR status is a required yes/no question on all assessments. If the SW determined it was a problem, they would add the care plan to the patient's list of problems. A phone interview with the Director of Operations (DOO) on 9/24/2020 at 11:38 AM revealed the Medical Director is responsible for signing the DNR. The DOO acknowledged there was a breakdown on the agency's part in getting the signed copy of the DNR back to the home for patient #3. The patient signed it on 7/24/2020 and the physician signed it late on Monday 7/27/2020. The DOO acknowledged there were multiple visits and opportunities for the DNR to be delivered to the home prior to the patient's death on 7/30/2020. The findings were reviewed with the Director of Operations, Regional Director of Clinical Operations and other members of leadership during the exit conference on 9/24/2020 at 12:05 PM.
L0556      
27661 Based on interviews and a review of clinical records, it was determined the agency failed to ensure ongoing sharing of information between all disciplines providing care/services for three (3) of six (6) patients in the survey sample (patients #2, 3, and 6). Specifically, the agency's staff failed to coordinate and document the delivery of the signed DNR (Do Not Resuscitate) to the patient's home prior to the patient's death. The findings were: The clinical records were reviewed offsite as a virtual review in read-only mode from 9/21/2020 through 9/24/2020. A phone interview with the Regional Director of Clinical Operations on 9/23/2020 at 12:10 PM revealed the staff should be documenting in the narrative section of the visit note when the signed DNR is delivered to the home. A review of the clinical record for patient #2 revealed the patient/patient representative signed a DNR on 9/02/2020 as documented in a nursing note for that date. The record failed to contain documentation of when the DNR had been signed by the physician and delivered to the patient's home. A review of the clinical record for patient #3 revealed the patient signed the DNR on the date of admission, 7/24/2020. The DNR was taken to the office for the physicians signature and there was no documentation in the record that it was ever returned to the patient's home. It was later determined through chart review and interviews that the DNR was never returned to the patient's home. Clinical notes revealed that on 7/30/2020 the patient died and the caregiver called 911 thinking the EMS (emergency medical services) had to be notified. EMS responded and performed CPR on the patient due to no DNR paperwork being in the home. The patient subsequently was pronounced dead at the hospital later that night. A review of the clinical record for patient #6 revealed the patient/patient representative signed a DNR on 7/17/2020. The record failed to contain documentation of when the DNR had been signed by the physician and delivered to the patient's home. An email interview with the Regional Director of Clinical Operations on 9/24/2020 at 10:12 AM revealed the DNRs on patients #2 and #6 were signed and delivered to the patients home however; the documentation was done internally and not visible in the client record. A follow-up phone call with the Regional Director on 9/24/2020 at 11:25 AM revealed the internal documentation was done by email and not documented in the clinical record. A phone interview the Director of Operations (DOO) on 9/24/2020 at 11:38 AM revealed the Medical Director is responsible for signing the DNR. The DOO acknowledged there was a breakdown on the agency's part in getting the signed copy of the DNR back to the home of patient #3. The patient signed it on Friday 7/24/2020 and the physician signed it on Monday 7/27/2020. The DOO acknowledged there were multiple visits and opportunities for the DNR to be delivered to the home prior to the patient's death on 7/30/2020. The findings were reviewed with the Director of Operations, Regional Director of Clinical Operations and other members of leadership during the exit conference on 9/24/2020 at 12:05 PM.