Failure to Update Resident's Advanced Directive
Penalty
Summary
The facility failed to update a resident's advanced directive in the medical record after the resident decided to change it from full code to a do not resuscitate (DNR) status. This deficiency was identified for one of nine residents reviewed for advanced directives. The resident, who had a moderately impaired cognitive status, expressed their wish not to be resuscitated if found without vital signs. However, the electronic medical record (EMR) and the paper chart continued to reflect a full code status, contrary to the resident's documented wishes on the New Jersey Practitioner Orders for Life-Sustaining Treatment (POLST) form. Interviews with facility staff, including a Licensed Practical Nurse (LPN) and the Social Service Director (SSD), revealed discrepancies between the resident's documented wishes and the information in the medical records. The SSD and the Administrator acknowledged that the resident's POLST form, signed by both the resident and their physician, indicated a DNR status, but the EMR and paper chart were not updated accordingly. This oversight had the potential to result in the resident receiving unwanted cardiopulmonary resuscitation (CPR).
Plan Of Correction
1/7/25 Resident #66 medical records were immediately updated to reflect NEX Ord order. All residents with Advance Directives could have the potential to be affected. U.S. FOIA (b) (6) and licensed nursing staff were in-serviced by Administrator or designee on updating Medical Records and Physician Orders with any changes with Advance Directives/POLST. Director of Social Services will present Advance Directive/POLST updates to the team during Morning meeting on a daily basis, and nursing will ensure orders are updated accordingly. Director Of Nursing will conduct audits on a sample of 10 residents per month to ensure that medical records reflect the most updated Advance Directive orders. Director of Social Services or designee will review all resident medical records to ensure Advance Directives are updated weekly for 3 months, then monthly thereafter. Results of these audits will be provided to the Administrator on a monthly basis. Director of Nursing and Director of Social Services will report results of all audits at the quarterly QAPI meeting for the next 2 quarters. Evaluation by the committee to determine continuing frequency of audits.