Failure to Honor Advance Directive Choices
Penalty
Summary
The facility failed to honor the advance directive choices for a resident, identified as Resident 175. The clinical record review revealed that on August 1, 2024, the resident's responsible party indicated that the resident was a full code, meaning staff was to start CPR if necessary. However, on February 27, 2025, the responsible party completed a POLST form and a facility code status form, both indicating a Do Not Resuscitate (DNR) status for the resident. These forms were also signed by the physician on the same day, February 27, 2025. Despite the completion and signing of the DNR forms, there was no documentation that the facility changed Resident 175's code status order from full code to DNR until March 6, 2025. This oversight was identified during an interview with the Nursing Home Administrator on March 6, 2025, at 3:39 PM. The failure to update the resident's code status in a timely manner represents a deficiency in the facility's compliance with the requirements for honoring advance directives.
Plan Of Correction
1. All residents were unharmed, including Resident 175. Resident 175 Advanced Directive was reconciled and corrected immediately. 2. The Facility Administrator and the Interdisciplinary Team promptly assessed all existing residents to verify that their advanced directive and code status were accurate, up-to-date, and readily available to staff in the event of an occurrence. 3. All staff members received training on how to find the code status in the event of an occurrence. Additionally, all nurses were instructed and educated on the significance of updating residents upon their return from the hospital to ensure that the advance directives are accurate and up-to-date in case of an incident. 4. The Director of Nursing or designee will conduct weekly audits for a duration of four weeks, followed by monthly audits for three months. Physician Orders, Care Plan and spine of hard chart will be reviewed to verify accuracy and currency of each residents advance directive. The findings will be presented at the monthly Quality Assurance meeting for review.