§ 483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.
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Observations:
Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure the resident right to receive treatment and care in accordance with professional standards of practice and the residents' choices for one of three residents reviewed (Resident 1).
Findings include:
Review of facility policy, titled "Code Status Orders" last revised December 16, 2024, read, in part, "Code status communicates to the clinical staff whether the patient desires cardiopulmonary resuscitation (CPR) in the event of cardiopulmonary arrest. Patient identification mechanisms and information about each patient's code status will be easily accessible to the clinical staff for all patients. All patients require a code status order as soon as possible upon admission/re-admission, a change in patient preference, or a significant change in patient condition. Purpose: To ensure that the patient's desired resuscitation wishes are documented in the medical record. Upon admission/re-admission, a code status order is required as soon as possible as part of the patient's admission order set. Orders for code status include Full Code or Do Not Resuscitate (DNR). Staff should verify the patient's wishes with regard to code status (Full Code vs. DNR) upon admission. If the patient wishes are different from the admission orders, immediately document the patient's wishes in the medical record, notify the physician, and obtain the correct order."
Review of Resident 1's clinical record revealed diagnoses that included orthostatic hypotension (low blood pressure that occurs when standing or after sitting or lying down) and unspecified protein-calorie malnutrition (an imbalance between the nutrients the body needs to function and the nutrients it gets).
Review of Resident 1's clinical record revealed he was admitted to the facility from the hospital on August 6, 2026, around 5:30 PM, and was sent back to the hospital on August 7, 2026, around midnight.
Review of Resident 1's clinical record revealed a RN (Registered Nurse) Assessment late entry note written by Employee 1 (RN) on August 7, 2026, at 5:00 AM, detailing the Resident's change in condition that read, in part, "Received order to transfer resident out to the hospital. 911 was immediately called at 11:55 PM. This writer made a copy of resident discharge summary from the hospital for EMS (Emergency Medical Services) and noted that he had a blank POLST (Physician Orders for Life Sustaining Treatment- is a medical order that allows seriously ill or frail individuals to specify the types of medical treatment they want during emergencies), in his chart as well as a copy of a POLST that was filled out as a full code. Upon reviewing his discharge summary, it was noted that resident was to be comfort care and Hospice care but no POLST was filled out and he had no hospice book at the desk. EMS asked if we knew if resident would want intravenous fluids and staff was unsure at the time. Spoke with EMS about resident not having a POLST filled out despite having a DNR bracelet and he was going to be acknowledged as a full code according to EMS staff. Resident transported back to hospital. Responsible Party (RP) called into facility at 1:05 AM and explained situation to RP. RP stated 'I was told by the hospital social worker that everything was already set up there and the hospital called asking me what I wanted to do.' Explained to RP that more than likely everything was done but this writer did not really have [anything] to go back on hence why he was sent back out. RP was unsure about what to do with patient because he is supposed to be a DNR and RP was under the impression that he was a DNR while here but informed him that patient was a full code. Notified RP to let the hospital know that he just wants patient to be DNR, comfort measures, Hospice, and no IV fluids (intervention) for his low blood pressure. RP called back again at 1:14 AM, and reported that patient will be coming back to facility."
Review of Resident 1's POLST form scanned into his electronic health record and in his physical paper record revealed under the CPR section it was marked DNR (Do Not Resuscitate- a medical order indicating that a person does not want CPR or other life-saving measures if their heart or breathing stops) and dated March 18, 2026.
Review of Resident 1's clinical record failed to reveal any POLST form noting that he was a full code.
Review of Resident 1's physician orders revealed an order for DNR with a start date of March 18, 2026, and discontinued date of May 8, 2026; and an order for Full Code from May 13, 2026, with a discontinued date of August 4, 2026. Further review of Resident 1's physician orders failed to reveal an order for a code status at the time of his hospital transfer on August 7, 2026.
Review of Resident 1's clinical record revealed an After Visit Summary from his hospitalization from July 28, 2026, to August 6, 2026, that read, in part, "We discussed this case with your family, and the decision was made to pursue comfort measures and hospice care. You will be discharged on hospice care."
Review of Resident 1's clinical record revealed a document titled "New Admission" that was not dated, that noted his code status was DNR. It also noted he was on comfort care and long-term care with hospice.
Review of document titled "Admission Medication Reconciliation Checklist" dated August 6, 2026, revealed it was blank on the first page, including the section under "Discharge Documentation Review" noting "Code status verified and entered." The second page was checked off under "Second Nurse Verification" by Employee 1 on August 7, 2026, at 1:00 AM, and was checked as completed for "any discrepancies clarified with provider" and was left blank if there was a discrepancy found.
Review of hospital after visit summary from hospitalization on August 7, 2026, read, in part, "This patient was seen here in the ED but upon further investigation he is currently on comfort care and DNR/DNI (Do Not Intubate). I confirmed this information with the patient's son who requested the patient be transferred back to this nursing facility. He confirmed that the plan is to have this patient on comfort care."
During an interview with the Director of Nursing (DON) on August 19, 2026, at 11:28 AM, she acknowledged that there was a discrepancy between the hospital discharge summary, and the nurse's note of his code status. She revealed she was unable to locate the POLST for a full code that was referenced and she wasn't sure if the nurse had documented that in error, and education had been given to staff in response to this incident related to timely documentation of physician orders and recommendations from the hospital. She further revealed that the new admission document was likely from his hospital return on August 6, 2026, as it noted the new order from that hospitalization for morphine, and that his last bowel movement was on August 5, 2026.
During a follow up interview with the DONon August 19, 2026, at 11:47 AM, she revealed the facility has a process improvement plan in place to ensure the hospital admission process is completed properly, timely, and orderly.
28 Pa. Code 201.29 (a) Resident Rights
28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services
| | Plan of Correction - To be completed: 09/08/2026
The statements made on this plan of correction are not an admission to and do not constitute an agreement with the alleged deficiencies. To remain in compliance with all federal and state regulations, the facility has taken or will take actions set forth in the following plan of correction.
1.) Resident #1 no longer resides at the facility.
2.) An initial audit will be conducted of facility residents' Physician Orders for Life Sustaining Treatment (POLST) and coinciding physician's order to ensure accuracy. Corrections will be made as needed.
3.) Education will be provided to the facility licensed nursing staff on the facility's policy OPS422 Code Status Orders and process to complete the POLST form and obtain orders for code status on new and readmitted residents.
4.) Audits of newly admitted or readmitted facility residents will be conducted weekly x four and then monthly x three by the facility Director of Nursing or designee(s) to ensure residents' POLST and coinciding physician's order are accurate.
Corrections will be made as necessary and results of audits will be reported at the Quality Assurance Performance Improvement meetings.
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