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Record review of the medical record of Patient ID # 6 revealed he was admitted to the facility on 02-05-14 with admission diagnoses of Mitrol Valve Regurgitation and Pulmonary Hypertension.

Further review of the clinical record revealed a form titled: " Resuscitation Orders/Consent " completed for Patient ID # 6. The top portion had the box checked beside " Do Not Resuscitate. "

In addition, the section below this " Full Resuscitation " was checked that read:
" All indicated methods of resuscitation are to be used.

Under resuscitation technique ( " Circle yes or No " ), NO was circled for the following:

? chest compression,
? ventilation with ' ambu-bag '
? intubation and mechanical ventilation,
? intravenous medication as indicated
? Defibrillation or cardioversion
? Transverse or Transthoracic Pacemaker
? External pacemaker.

This was signed by the patient and witnessed by staff on 02-05-14.

Handwritten on some blank lines of this same Resuscitation order was the following: " Patient changed his directive to Full Code on 02-18-14. " This documentation was not signed or dated by a physician or by any staff member.

Interview on 03-11-14 at 1:30 p.m., with Interim Chief Nursing Officer (CNO) Staff ID # 1 she acknowledged this was a confusing Resuscitation order and could be misinterpreted by the staff. She went on to say that if a patient made any changes in their wishes regarding resuscitation, a new order should be written, witnessed, and signed by the patient. All resuscitation orders must be signed and dated by the physician.

Review of facility policy titled " DNR, Cardiopulmonary Arrest, Directive For Care, revised date 01-2014, read: " ...The order must be signed by the physician.. "

Based on interview and record review, the facility failed to ensure that medical record were accurately written for 2 of 10 sampled patients ( Patient ID # 5, # 10).

Patient # 5: incorrect date recorded on an electrocardiogram (EKG) exam.

Patient # 10: inconsistent documentation in the nursing notes as compared to documentation contained in a family grievance form.

Findings include:

TX # 00190396

Patient ID # 5

Record review of the medical record of Patient ID # 5 revealed she was 83 years old and admitted to the facility on 02-26-14. She had a recent history of cardiac arrest, congestive heart failure, and chronic kidney disease.

Review of a physician order, dated 02-28-14 (timed 0031) read: " electrocardiogram (EKG ) Now. " Review of the EKG results for Patient # 5 failed to reveal an EKG dated 02-28-14. The only EKG readout for Patient # 5 was dated " 14-January-1980. "

Interview on 03-11-14 at 12;45 p.m. with Respiratory Therapist (RT) ID # 6 she stated the EKG machine had been out for service and someone must have forgot to re-program the machine with the correct date. She acknowledged there was no way to verify the actual date the EKG had been conducted on Patient ID# 5.

Patient ID # 10

Record review of the medical record of Patient ID # 10 revealed she was 79 years old and admitted to the facility on 07-08-13 with a diagnosis of Sepsis.

Review of a facility Grievance Form, dated 07-21-13 read: ' (Patient ID # 10) found strapped to wheelchair with sheet by the double elevators by the patient ' s daughter ...this happened about 3:30 p.m. on 07-20-13. She had a recent history of cardiac arrest, congestive heart failure, and chronic kidney disease.

Review of nursing notes for Patient ID # 10, dated 07-20-13 (1530) read " Patient is in a chair waiting for family to come ... "

Review of facility policy titled " Documentation Standards, revised date 04-01-11, read: " Purpose: 1. Provide a current, complete and concise description of the patient ' s status ...10. Dating and Timing entries:.A.all entries must be dated ... "