Incomplete Advance Directives Documentation
Penalty
Summary
The facility failed to accurately and completely document advance directives for three residents, leading to potential non-compliance with residents' medical care preferences. Resident #37 was admitted with a DNR order in the physician's orders, but there was no signed paperwork in the resident's chart confirming this status. The social worker was unsure if the resident was informed about the code status, and the resident himself was uncertain about his preference and whether he had signed any related documents. The nursing home administrator confirmed the absence of specific code status paperwork for this resident. Resident #312 had a DNR order, but the required documentation was incomplete. The DNR form was signed by the second advocate instead of the first, and there was no capacity form or two physician signatures to confirm the resident's inability to make decisions. The social worker acknowledged the missing documentation, and the nursing home administrator mentioned efforts to improve the process. Similarly, Resident #60 had a DNR order without signed documentation from the resident and physician. The social worker admitted that hospital discharge paperwork indicating a DNR status could not be used for the facility's DNR order and was unaware of the issue until it was brought to attention.
Plan Of Correction
Element #1: Resident #37, #312, and #60 Advanced Directives have been updated to reflect patient goals of care. Element #2: Residents that currently reside in the facility have potential to be affected. Element #3: Facility Social Workers have been re-educated on Michigan Do-Not-Resuscitate Procedure Act. Advanced Directives of residents currently residing in the facility have been audited; any identified concerns will be corrected in the moment. Element #4: Social Worker/Designee will complete 5 weekly Advanced Directive audits to ensure they meet requirements of the Michigan Do-not-Resuscitate Act and resident goals of care. Variances to be corrected at time of observation. Audits to be submitted to facility QAPI for review and further recommendations. Element #5: The Administrator is responsible for sustained compliance.