Inconsistency in Resident's Advance Directive Documentation
Penalty
Summary
The facility failed to ensure consistency between a resident's Physician Order for Life Sustaining Treatment (POLST), physician's orders, and care plan. Specifically, for one resident, there was a discrepancy between the POLST, which indicated a Full Code status, and the physician's orders, which stated Do Not Attempt Resuscitation (DNR). The care plan also reflected a Full Code status, which was inconsistent with the physician's DNR order. The resident involved had diagnoses including Parkinson's disease and hypertension. During an interview, the Director of Nursing confirmed the inconsistency between the resident's POLST, physician's orders, and care plan. The facility's policy requires that the plan of care for each resident be consistent with their documented treatment preferences and/or advance directive, which was not adhered to in this case.
Plan Of Correction
All residents will have advanced directives that accurately reflect their wishes. Resident R121's Advance Directive was corrected immediately upon notification to reflect accuracy. The Director of Nursing/Designee will do an initial audit on all Advance Directives to ensure they are consistent with resident wishes and care plans. The Director of Nursing/Designee will educate nursing staff on how to properly care plan advanced directives and to ensure completion upon admission, quarterly, and any change of status. Moving forward, the Director of Nursing will perform an audit of 25% of all new residents, resident quarterly meetings, and resident change of status's 5 times a week for two weeks, weekly times two weeks, and monthly times two months and ongoing monthly. Results of audits will be brought to monthly Quality Assurance meetings.