Discrepancy in Resident's Advance Directive Documentation
Penalty
Summary
The facility failed to ensure that a resident's right to request or refuse medical treatments was accurately reflected in the resident's clinical record. Specifically, for Resident R86, there was a discrepancy between the physician's orders and the resident's POLST form regarding life-saving interventions. The physician's orders indicated a 'Full Code' status, allowing all interventions needed to restore breathing or heart functioning, while the POLST form, signed by the resident, indicated a 'Do Not Resuscitate' (DNR) status, meaning the resident did not want life-saving interventions in the event of no pulse and stopped breathing. This inconsistency was confirmed during an interview with Employee E5, a licensed nurse, who acknowledged that Resident R86's wishes regarding life-saving medical treatments were not accurately reflected in the clinical record. The nurse indicated the need to clarify the resident's wishes with both the resident and the physician. This deficiency highlights a failure in accurately documenting and respecting the resident's advance directives, as required by facility policy and state regulations.
Plan Of Correction
1. R86 POLST form and order were updated and accurately reflect the residents' wishes. 2. An initial audit was conducted to ensure all POLST forms and physicians orders match per residents wishes. Variances were addressed at the time of the audit and placed on the facility audit tool. 3. Social Services and licensed nursing staff were educated by DON/designee to ensure POLST form and orders coincide. 4. DON/Designee will conduct an audit on POLST forms/physicians orders for advanced directives 3 times per week for 4 weeks then 1 time per month for 2 months. Audit findings will be addressed and submitted to the Quality Assurance Performance Improvement Committee for further review and recommendations as needed.