The guardian for Resident E discovered the deception only during a care plan meeting she demanded after learning her father's toe had turned black and developed an odor. By then, staff at Countryside Meadows had already changed his treatment goals from full care to palliative care without her knowledge or consent.
The June incident began when the nurse practitioner called the guardian on June 14 to report that Resident E had stopped eating and drinking and was sleeping more than usual. The NP attributed the decline to his dementia and asked about changing his code status from full code to DNR.
The guardian told the NP she wanted her brother to visit Resident E before making any decisions. Her brother went on June 16 and found the resident awake, alert, and able to eat and drink when assisted. The family asked staff to sit with Resident E during meals due to his dementia.
The guardian heard nothing more until June 26, when the NP called to report that Resident E's right big toe had turned black with an odor, indicating dead tissue. The NP said she had referred him to a vascular surgeon and ordered a doppler ultrasound, but the specialist couldn't see him for two to four weeks.
"That was unacceptable," the guardian told inspectors.
She called back the next day demanding both a doctor's appointment and care plan meeting. During that June 27 meeting, she learned that her brother had been asked to sign a DNR form and that staff had changed Resident E's overall treatment plan to palliative care.
"No one was authorized to sign off, and/or make treatment changes or decisions about Resident E's care," she said.
Court documents from December 2020 granted the guardian "the authority to administer the permanent guardianship of the Person and Estate" of Resident E under Indiana law.
The son told inspectors he signed the DNR because the nurse practitioner presented it as already approved by his sister. "The form was presented to him as already approved by the guardian," according to the inspection report.
He said staff told him his father's dementia had worsened and "he was at the end of his life, basically, he was getting ready to pass."
Medical records show the sequence of events differently. On June 17, a social services note documented that Resident E's legal guardian "requested the resident remain a full code."
The next day, June 18, a nurse practitioner note at 1:43 p.m. stated: "Daughter called to discuss resident declining condition with poor PO intakes and labs. Daughter states that her father was previously a DNR with comfort care."
But the guardian told inspectors she never said this.
The same note continued: "Son in building. Reviewed POST form and signed DNR comfort measures." The nurse practitioner then ordered morphine and lorazepam as needed and discontinued IV fluids.
A Physician's Order for Scope of Treatment form dated June 18 changed Resident E's status from full code to DNR with comfort measures, signed by the son and nurse practitioner.
Resident E had diagnoses including Parkinson's disease, Alzheimer's disease, peripheral vascular disease, and atherosclerosis. He lived on the secured memory care unit.
The doppler ultrasound performed June 18 showed arterial stenosis and recommended additional imaging. But with the switch to palliative care, further diagnostic testing was discontinued.
Inspectors also found that staff failed to update a care plan for another resident with new skin breakdown. Resident D developed a pressure ulcer on his tailbone measuring one centimeter in each dimension on July 17, but his care plan dated June 14 was never revised.
The Director of Nursing Services told inspectors that care plans should be updated within seven days of any significant event. Facility policy required care plan problems and interventions to be "reviewed and revised by the interdisciplinary team periodically and following completion of each MDS assessment."
A third violation involved failing to notify family of an acute condition change for Resident F, though details of that incident were not provided in the inspection report.
The August 1 inspection followed complaints filed with state regulators. All violations were classified as causing minimal harm or potential for actual harm.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Countryside Meadows from 2024-08-01 including all violations, facility responses, and corrective action plans.