Medilodge Of Grand Rapids

facility staff must provide basic life support, including CPR, prior to the arrival of emergency medical

jeopardy to resident health or or a DNR order.

Review of the facility's Admissions to the Facility policy, reviewed/revised date safety [DATE], stated, .Prior to or at the time of admission, the resident's Attending Physician must provide the facility with information needed for the immediate care of the resident, including orders covering

planning team can conduct a comprehensive assessment.Assure that the facility receives appropriate medical records.prior to or upon the resident's admission.Applying the reasonable person concept, one who wished to be do not resuscitate would not want CPR performed to save their life.

These lifesaving acts would be in direct contradiction of medical care and life wishes and would have both physical and psychosocial harm.The Immediate Jeopardy that began on [DATE] was removed and the deficient practice corrected on [DATE] when the facility took the following actions to remove the Immediacy and correct the noncompliance: 1.

Identification of residents affected or likely to be affected: -Blanket audit completed for 50/50 facility residents on [DATE] to ensure medical record accurately reflects residents code status and a signed copy of advanced directive has been uploaded into PCC (electronic health record).

There were no noted concerns or required corrections at this time.2.

Actions to prevent occurrence/Reoccurrence:-CPR and Advanced Directive policy reviewed by NHA and DON on [DATE] and remains appropriate.

The social service director audited all residents in the facility 50/50 to ensure proper code status were in place. 50/50 residents reviewed on [DATE] to ensure medical record accurately reflects residents code status and a signed copy of advanced directive has been uploaded into PCC and no changes required at that time.

Additionally, The DON completed a separate Audit on last 14 days of admissions on [DATE] to ensure proper code status in place for all new admissions during this timeframe, this was completed as an additional audit as the resident noted in the PNC (past non-compliance) was a new admission to the facility in the past 14-day timeframe. On the audit looking at the last 14 days of admissions completed by the DON 7/50 residents were reviewed on this audit on [DATE], there were no discrepancies noted and no corrections made.-Additionally, the admission policy was reviewed [DATE] and deemed appropriate.-All Licensed Nurses 22/22 educated on [DATE]. 18/22 educated in person face to face, 4 educated verbally via phone on completing advanced directives paperwork on admission with designated responsible party and notifying physician to obtain orders and place into PCC.-Process: Nurse educated on [DATE] that they will meet with resident/Responsible party immediately upon admission to address code status wishes.

Appropriate paperwork will be completed addressing residents' wishes and immediately communicated to the physician to obtain orders to be placed in PCC (facility's electronic medical record system).-The new facility process for immediate action regarding code status is that the admitting nurse will fax the document to a preprogramed number on the facility fax machine that transmits the document to the provider email and the document can be signed and returned via provider phone to facility fax.

Nurses will also contact provider via phone to ensure they are aware of the incoming document.

This process was initiated, educated and in place by the DOC (date of correction) for the PNC [DATE]-Audits started on [DATE] and will be completed by DON weekly x 12 weeks to ensure any new admissions code status documentation is obtained and completed by admitting nurse and facility procedure and policy is being followed.

Audits will continue until the QAPI (quality assurance and performance improvement) committee deems facility has achieved substantial compliance.