cpr regulations: cms update - michigan · all facilities must have policies and procedures that...
TRANSCRIPT
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CPR REGULATIONS: CMS UPDATE
G A I L M A U R E R R N , B S N
S T A T E O F M I C H I G A N L T C S U R V E Y M O N I T O R
H E N R I E T T A M A K O W S K I R N , B S N , M S
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INFORMATIONAL GOALS
Discuss the differences between Advanced Directives and Code Status
Discuss methods to develop systems to determine the resident's Code Status in an emergency situation
Discuss how to develop systems to determine which staff will be certified in BLS
Discuss methods to make sure that CPR certification is kept current
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REGULATORY GUIDANCE
F155
§483.10(b)(4) AND (8) RIGHTS REGARDING:
REFUSAL OF MEDICAL OR SURGICAL TREATMENT,
PARTICIPATION IN EXPERIMENTAL RESEARCH AND
ADVANCE DIRECTIVES .
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THE INTENT
The Intent is to promote the residents’ rights
by providing information so residents or their
representatives have information which will allow them
to make choices regarding medical treatment at the end
of life.
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ONE OF THE CENTRAL TENETS OF PERSON-
CENTERED, INDIVIDUALIZED CARE IS THE RIGHT TO
FORMULATE AN ADVANCE DIRECTIVE
ADVANCE DIRECTIVES:
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WHAT IS AN ADVANCE DIRECTIVE?
Written instruction prepared when the adult resident
was competent relating to the provision of medical care
in the event the resident becomes incompetent or
unable to participate in medical treatment decisions.
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FACILITY POLICIES ON ADVANCE DIRECTIVES NEED TO BE :
CLEAR
SPECIFIC
CONTAIN DEFINITIONS
DEFINE AUTHORITY
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REVIEW F-155 AND UTILIZE THE VERBAGE AND
DEFINITIONS IN THE DEVELOPMENT OF THE FACILITY
POLICY
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UTILIZE AVAILABLE TOOLS IN THE IMPLEMENTATION OF
THE POLICY
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MANY DIFFERENT TEMPLATES AVAILABLE:
STATE BAR OF MICHIGAN – ELDER LAW AND DISABILITY RIGHTS SECTION
GOOGLE SEARCH ON ADVANCE DIRECTIVES REVEALS A MULTITUDE OF TEMPLATES AVAILABLE
HAVE TEMPLATES AVAILABLE FOR RESIDENTS’ USE
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RESIDENT/FAMILY EDUCATION:
THE PUBLIC STILL UNAWARE OF THE PATIENT SELF DETERMINATION ACT OF 1990!!!
RESIDENTS NEED EDUCATION ABOUT THE BENEFITS OF COMPLETING AN ADVANCE DIRECTIVE.
NOT THE RIGHT TIME!! NOT THE RIGHT PLACE!!
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IF NOT NOW, WHEN!!!!!!
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ADVANCE CARE PLANNING TRACKING FORM-
INTERACT VERSION 3.0 TOOL
ADVANCING EXCELLENCE IN AMERICA NURSING HOME WEBSITE
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DELINEATE BETWEEN THE ADVANCE DIRECTIVE
POLICY AND THE CODE STATUS POLICY!!!
THEY ARE NOT ONE IN THE SAME!!!
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ADVANCE DIRECTIVE COVERS MORE ISSUES
THAN CODE STATUS OF A RESIDENT:
RIGHT TO REFUSE
RIGHT TO EXPERIMENTAL TREATMENT
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STAFF EDUCATION IS AN INTEGRAL ROLE IN THE
IMPLEMENTATION OF THE ADVANCE
DIRECTIVE POLICY
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STAFF NEEDS TO BE EDUCATED ON THE ADVANCE DIRECTIVE
POLICY
STAFF NEEDS TO BE AWARE OF WHERE THAT INFORMATION IS KEPT
ON THE RESIDENT
STAFF NEEDS TO KNOW THAT THE ADVANCE DIRECTIVES ARE TO BE
DISCUSSED WITH THE PHYSICIAN AND ORDERS NEED TO BE
WRITTEN AND ARE REFLECTIVE OF THE RESIDENT’S WISHES.
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GOOD OPPORTUNITY TO
EDUCATE STAFF FOR
THEMSELVES AND THEIR
FAMILIES!
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“THE ABILITY OF A DYING PERSON TO CONTROL
DECISIONS ABOUT MEDICAL CARE AND DAILY
ROUTINES HAS BEEN IDENTIFIED AS ONE OF THE KEY
ELEMENTS OF QUALITY CARE AT THE END OF LIFE”
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INVESTIGATIONAL PROTOCOL
OBJECTIVES
During the survey process the surveyor will follow the
investigational protocols set forth by CMS;
to determine whether a facility has promoted the
resident’s right to formulate an advance directive.
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F-309
483.25 End of Life
Each resident must receive and the facility must provide the
necessary care and services to attain or maintain the highest
practicable physical, mental, and psychosocial well-being, in
accordance with the comprehensive assessment and plan of care.
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Prior to the arrival of emergency medical services (EMS), nursing
homes must provide basic life support, including initiation of
CPR, to a resident who experiences cardiac arrest (cessation of
respirations and/or pulse) in accordance with that resident’s
advance directives or in the absence of advance directives or a
Do Not Resuscitate (DNR) order
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INTENT
All Facilities must have policies and procedures that reflect that CPR
must be performed on all individuals who do not have a DNR status
All Facilities must ensure that there is at least one qualified person
capable of carrying out CPR in the facility at all times.
The facility must be able to identify the code status of each resident.
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FACILITY POLICY DEVELOPMENT
MUST, AT A MINIMUM, DIRECT STAFF TO INITIATE CPR
AS APPROPRIATE.
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CPR TO BE INITIATED:
FOR RESIDENTS WHO HAVE REQUESTED CPR
FOR RESIDENTS WHO HAVE NOT FORMULATED AN
ADVANCE DIRECTIVE
FOR RESIDENTS WHO DO NOT HAVE A VALID DNR
ORDER
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FOR RESIDENTS WHO DO NOT SHOW AHA SIGNS
OF CLINICAL DEATH
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• POLICY INCLUDES THE INITIATION OF CPR AND
THE CONTINUATION UNTIL EMS ARRIVES
• POLICY SHOULD INCLUDE WHO IS CPR
CERTIFIED AT THE FACILITY
• LICENSED STAFF ONLY?
• CNA’S?
• OTHER ANCILLARY STAFF?
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• SHOULD INCLUDE IN THE POLICY HOW
EMERGENCY SUPPLIES ARE:
• KEPT
•MAINTAINED
• LOCATED
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IF ALL LICENSED STAFF IS NOT CERTIFIED, HOW
IS IT ENSURED THAT A CERTIFIED STAFF IS ON
DUTY AT ALL TIMES?????
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• NEED TO IDENTIFY WHEN STAFF WILL BE
TRAINED:
• UPON HIRE?
•WITHIN PROBATIONARY PERIOD?
• NEED TO IDENTIFY WHO WILL TRACK
CERTIFICATION AND NEED TO RECERTIFY
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• POLICY SHOULD ADDRESS HOW RESIDENT CODE
STATUS IS IDENTIFIED:
•MUST MAINTAIN PRIVACY AND DIGNITY
•MUST BE EASY TO IDENTIFY AND HAVE QUICK
ACCESS TO CODE STATUS
•MUST HAVE A SYSTEM IN PLACE TO UPDATE
AS CONDITION CHANGES
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ADDITIONAL POINTS FOR CONSIDERATION:
• RESIDENT WISHES/ADVANCE DIRECTIVES ARE
REVIEWED WITH PHYSICIAN AND ORDERS WRITTEN
AND TRANSCRIBED APPROPRIATELY
• INCORPORATED INTO THE RESIDENT PLAN OF CARE
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• MOCK CODES/DRILLS SHOULD BE PRACTICED
• DOCUMENTATION OF AN EMERGENCY MEDICAL
SITUATION/CODE IS CRITICAL.
• A STRONG NARRATIVE NOTE WITH A TIGHT
TIMELINE WILL AVOID PROBLEMS IN THE
LONG RUN!
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SURVEY IMPLICATIONS
Record review of the facility’s policy and procedure
regarding administration of CPR will be reviewed.
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Interview the NHA, DON or other person as designated
to determine the process to ensure there is a qualified
staff person in house at all times and how they
determine when the code status should be re-
evaluated.
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INTERVIEW
Interview staff to determine their understanding of the
policy.
Interview staff to determine how a resident’s code status
is designated.
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INTERVIEW CONT’D
Interview the resident, or their representative to ensure
that their understanding of the resident’s code status
is reflected in the resident’s plan.
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OBSERVATION
Observe to ensure that the code status is easy to
determine according to the policy.
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CLOSED RECORD REVIEW
Closed record review :
should not reflect instances where the resident was a
full code (either requested CPR or had not formulated
an advance directive which indicated a DNR) and CPR
was not initiated by staff..