FF15 483.10(c)(6)(8)(g)(12)(i)-(v):REQUEST/REFUSE/DSCNTNUE TRMNT;FORMLTE ADV DIR
REGULATION: §
483. 10(c)(6) The right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
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483. 10(c)(8) Nothing in this paragraph should be construed as the right of the resident to receive the provision of medical treatment or medical services deemed medically unnecessary or inappropriate.
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483. 10(g)(12) The facility must comply with the requirements specified in 42 CFR part 489, subpart I (Advance Directives).
(i) These requirements include provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive.
(ii) This includes a written description of the facility's policies to implement advance directives and applicable State law.
(iii) Facilities are permitted to contract with other entities to furnish this information but are still legally responsible for ensuring that the requirements of this section are met.
(iv) If an adult individual is incapacitated at the time of admission and is unable to receive information or articulate whether or not he or she has executed an advance directive, the facility may give advance directive information to the individual's resident representative in accordance with State law.
(v) The facility is not relieved of its obligation to provide this information to the individual once he or she is able to receive such information. Follow-up procedures must be in place to provide the information to the individual directly at the appropriate time.
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 2, 2025
Corrected date: January 24, 2025
Citation Details None | Plan of Correction: ApprovedJanuary 10, 2025 FoltsBrook Center for Nursing and Rehabilitation is committed to ensuring that advance directive wishes are honored. 1. Resident #1 was discharged from the facility. The RN Supervisor was terminated. 2. All residents are at risk of this deficient practice. An audit was conducted on all residents' Advance Directives. No further issues were identified. 3. The facility's Advance Directives Policy and Procedure was reviewed. An audit will be conducted to ensure resident's code status is accurate across the indicators (Order and MOLST). This audit will be conducted monthly x's 3 months. The audit results will be reviewed during the facility's monthly QA meeting. The frequency and duration of the audit will be re-evaluated at the end of the 3-month period. Also, Code Blue drills will be implemented monthly x's 3 months. Those drills will be reviewed during the facility's monthly QA meeting. The frequency and duration of the drills will be re-evaluated at the end of the 3-month period. - 4. All nursing staff will be educated on the Advanced Directives Policy and Procedure including the difference between CPR and DNR; and indicators for resident's code status (Order and MOLST). 5. Director of Nursing |