Deupree House II - Residential Care Facility

Based on medical record review, interviews and policy review, the facility failed to provide accurate Do Not Resuscitate (DNR), emergency code status information to emergency medical services when a resident was transferred to the hospital. This affected one (#29) of three residents reviewed for accurate DNR physician orders. The facility census was 70.

Findings include:

Review of Resident #29's medical record revealed the resident was admitted to the facility on 06/23/22. Resident #29 was admitted to the hospital on 08/23/25 at 9:20 P.M. and discharged back to the facility on 08/29/25. Diagnoses include hypertension, diverticulosis, depression and anxiety.

Review of Resident #29's Functional Assessment and Service Plan, dated 02/18/25, revealed the resident had intact cognition and was independent in Activity Daily Living skills.

Review of Resident #29 information face sheet revealed the resident was listed to receive Do Not Resuscitate Comfort Care, (DNRCC) code status.

Review of a DNR order form provided by the Director of Nursing, (DON), dated 03/13/24, revealed the physician signed Resident #29's DNRCC code status.

Review of the facility provided incident report, revealed the former Security Staff #50 documented on 08/23/25 at 8:41 P.M. that Resident #29 was in her room, with her private duty nurse and requested the Security Staff #50 called the emergency medical services, (EMT), due to the resident spiked a high blood pressure. Security Staff #50 obtained the transfer packet, maintained at the facility front desk, and presented the transfer packet to the EMT's when they arrived. Further review of the Resident #29 transfer packet revealed a cover sheet, in bold lettering, stated FULL CODE. Resident #29 face information sheet was included, with the code status of DNRCC. There was no signed DNR order form in the transfer packet.

Review of facility provided audit sheet date 04/29/25 revealed Resident #29 had a transfer file at the front desk. There were no other details of the audit and there were other audits made available by the facility staff.

Interview on 09/09/25 at 9:33 A.M. of Resident #29 revealed the resident knew she had signed a form for a DNRCC code status a while ago and expressed continued interest in that code status.

Interview on 09/09/25 at 9:45 A.M. with Security Staff #24 and the DON verified Resident #29 transfer packet, provided to EMT during an emergency transfer, had Full Code and DNRCC listed in the packet, with no physician signed DNR orders. The DON verified since there were no physician signed DNR orders, Resident #29 would have received Full Code emergency measures instead of the DNRCC measures as ordered by the physician. The DON verified there was no additional documentation the facility residents' DNR code orders had been audited for physician order accuracy annually.

Interview on 09/09/25 at 11:39 A.M. , the EMT Supervisor #60 stated on 08/23/25 when EMT staff arrived to emergency transfer Resident #29 , the facility Security Staff #50 provided the resident's transfer packet which contained a cover sheet of FULL CODE, DNRCC face information sheet and no physician signed orders for any code status. EMT Supervisor #60 stated the EMT's would have defaulted to Full Code status and performed full code status measures, in discrepancy to Resident #29 wishes because they did not have the actual signed physician order or the appropriate DNR form.

Review of the facility policy, Communication of Code Status, dated 09/09/25, revealed the facility will implement procedures to communicate a resident's code status to those individuals who need this information. The nurse who notes the physician order is responsible for documenting the directions in all the relevant sections of the medical record. The residents' code status will be reviewed at least annually.

This violation represents non-compliance investigated under Complaint Number OH00168002.

Based on record review and staff interview, the facility failed to ensure residents capable of self-evacuation were evacuated to safe areas or to the exterior of the residential care facility in at least two fire drills a year on each shift. This had to potential to affect all 68 residents in the facility. The facility census was 68.

Findings include

Review of the facility Fire Drill Reports for the prior twelve months revealed no fire drill evacuations were completed during first shift, second shift, or third shift.

Interview on 04/07/25 at 02:35 P.M. Residential Services Manager (RSM) verified there were no fire drill evacuations completed on first, second, or third shift.

Interview on 04/07/25 at 02:38 P.M. Executive Director of Hospitality Services verified there were no fire drill evacuations completed on first, second, third shift since the last survey.

Based on record review and staff interview, the facility failed to ensure employees attended fire prevention training course conducted by the state fire marshal or township, municipal or local legally consituted fire department. This had the potential to affect all 68 residents in the facility. The facility census was 68.

Findings include:

Review of the Fire Safety Documents for the facility revealed none of the employees have attended a fire prevention training course.

Interview on 04/07/2025 at 2:35 P.M., Residential Services Manager (RSM) verified employees did not have evidence of completing a fire prevention training course.