Failure to Align Advance Directives with Physician Orders
Penalty
Summary
The facility failed to establish clear advance directives for a resident, identified as Resident 108, which led to a discrepancy between the resident's documented wishes and the physician's orders. Upon admission on January 3, 2025, Resident 108 was recorded as a 'Full Code' in the physician's orders, indicating that resuscitation efforts should be made in the event of cardiac or respiratory arrest. However, the facility's 'Advanced Directives Discussion Document' and the resident's Living Will, both signed by the resident's Power of Attorney and a registered nurse, indicated that the resident did not want cardiopulmonary resuscitation (CPR). This inconsistency was not addressed until a meeting with the Nursing Home Administrator and Director of Nursing on January 29, 2025. The discrepancy was identified during a review of the resident's records, which revealed that the resident's care plan and physician orders were not aligned with the resident's advance directives. The facility documentation showed that the resident's wishes to withhold CPR were clearly marked, yet the physician's order initially indicated otherwise. This oversight was confirmed in a follow-up interview with the Nursing Home Administrator and Director of Nursing, who acknowledged the error and subsequently updated the physician's order to reflect the resident's Do Not Resuscitate (DNR) status.
Plan Of Correction
The facility clarified the advanced directives for resident 108. An audit of the advanced directives for all current residents was conducted to ensure that a written copy of the advanced directives was on file, and that the written copy matched each resident's orders and care plan. Education on ensuring accurate advanced directives was provided to facility licensed staff and the interdisciplinary team. Audits will be conducted by the Administrator of all new admissions x60 days to ensure that the advanced directives match the orders and the care plan. The results of the audits will be reviewed at the facilities QAPI meeting for recommendations.