SAINT STEPHEN, SC - Lake Moultrie Nursing Home received an immediate jeopardy citation from federal inspectors after staff failed to properly update resuscitation orders when a mentally competent resident changed his wishes from do-not-resuscitate to full resuscitation status.
Critical Documentation Failure Discovered
The most serious violation occurred when Resident 71, who had been admitted with a DNR (Do Not Resuscitate) order, decided to change his code status to full resuscitation five days after admission. Despite the resident signing a new directive requesting "all possible measures taken to revive me," nursing staff never updated the physician's orders in the electronic medical record system.
This created a dangerous scenario where, in the event of cardiac arrest, emergency responders would have conflicting information about the resident's wishes. The facility's own policy required that "the Director of Nursing Services or designee will notify the Attending Physician of advance directives so that appropriate orders can be documented in the resident's medical record."
Resident 71, who scored 13 out of 15 on cognitive testing indicating mental competence, clearly expressed his wishes during the inspection, stating: "If you can save a life, why not try? If I'm good, they can help me."
System-Wide Documentation Problems
The inspection revealed broader issues with the facility's advance directive management system. Staff were in the process of transitioning to paperless records, but this transition created gaps in communication between signed forms and electronic orders.
When interviewed, Registered Nurse 1 acknowledged the potential consequences of mismatched documentation, stating: "If they don't match, well that wouldn't be good. I would try to find the initial signed order." This response highlighted the confusion among staff about proper protocols when documentation conflicts arose.
The Social Services Director discovered the error only when she found Resident 71's full code request form filed in the business office rather than in his medical chart. The form had been signed in August but never communicated to nursing staff for order updates.
Medical Implications of Documentation Errors
Advance directive documentation serves as the foundation for emergency medical response in nursing homes. When residents experience cardiac or respiratory arrest, staff must make split-second decisions based on available documentation. Conflicting or outdated information can lead to inappropriate treatment - either providing unwanted resuscitation attempts or failing to provide life-saving measures.
The timing factor becomes critical during medical emergencies. Emergency responders typically have only minutes to assess a resident's code status and initiate appropriate care. When documentation systems fail, valuable time gets lost while staff attempt to verify the resident's actual wishes.
Properly maintained advance directives also protect nursing facilities from legal liability. When residents' documented wishes align with their actual preferences and physician orders match those preferences, facilities demonstrate compliance with federal regulations requiring respect for resident autonomy.
Additional Violations Compound Safety Concerns
Beyond the immediate jeopardy citation, inspectors identified two additional violations that raised questions about the facility's overall safety protocols.
Oxygen Administration Error
Staff administered oxygen to Resident 9 at 3.5 liters per minute despite physician orders specifying 2 liters per minute. The error persisted across multiple days before being corrected during the inspection. Oxygen therapy requires precise dosing because excessive oxygen can cause complications including respiratory depression, while insufficient oxygen can lead to hypoxemia and organ damage.
The resident's care plan specifically stated oxygen should be provided "at 2 L per minute via nasal cannula to maintain O2 saturation above 92%," yet staff consistently delivered higher flow rates. This violation demonstrated a breakdown in medication administration protocols and staff oversight of physician orders.
Incident Reporting Deficiencies
The facility failed to properly investigate and report a physical altercation between Resident 33, who had severe dementia, and a family member during a feeding interaction. A Licensed Practical Nurse documented observing the family member "push his fist into resident upper middle left chest wall where current bruising on the chest wall was noted yesterday."
The resident reportedly said "I'm scared" during the incident, yet facility administrators were not properly informed of the situation. The Director of Nursing stated she was told only about feeding difficulties, not about physical contact or existing bruising.
Federal regulations require nursing homes to investigate all injuries of unknown origin and report suspected abuse. The facility's failure to follow these protocols could have left the vulnerable resident at continued risk.
Industry Standards and Best Practices
Medicare and Medicaid regulations require nursing homes to maintain accurate, up-to-date advance directive documentation. The Centers for Medicare & Medicaid Services emphasizes that resident preferences must be clearly communicated throughout the care team and reflected in all relevant documentation.
Best practices include regular review of advance directives during care planning meetings, immediate notification of physicians when residents change their preferences, and systematic auditing to ensure electronic records match signed documents. Many facilities use electronic alert systems to flag discrepancies between advance directives and physician orders.
Professional nursing standards also require medication administration at prescribed rates and proper incident reporting procedures. These standards exist to protect vulnerable populations who depend on nursing homes for comprehensive care.
Facility Response and Corrective Measures
Lake Moultrie Nursing Home implemented an immediate removal plan that included auditing all resident charts to compare advance directives with physician orders. The facility scanned all advance directive documents into the electronic medical record system and provided education to licensed nurses about proper protocols.
The corrective action plan established daily monitoring of new admissions for three months and implemented twice-weekly compliance checks. Staff education focused on the facility's advance directive policy, appropriate forms for different code status requests, and electronic record navigation.
A Quality Assurance Performance Improvement project was established to monitor ongoing compliance with advance directive protocols. The facility committed to reviewing code status preferences during quarterly care planning meetings and ensuring immediate notification of physicians when residents change their wishes.
The immediate jeopardy designation was removed after inspectors validated implementation of the corrective measures, though the citation remains on the facility's inspection record. The violation's severity level was reduced from immediate jeopardy to substantial harm with potential for more than minimal impact.
These violations demonstrate the critical importance of accurate documentation systems in nursing home care, where communication failures can have life-threatening consequences for vulnerable residents who depend on staff to honor their medical wishes and provide appropriate emergency care.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Lake Moultrie Nursing Home from 2025-01-22 including all violations, facility responses, and corrective action plans.
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