Failure to Accurately Document Advance Directives
Penalty
Summary
The facility failed to ensure that the clinical records accurately reflected the advance directives for two residents. For the first resident, the clinical record indicated a full code status, despite the legal representative's preference for a different code status. The MDS Coordinator acknowledged the error but did not correct the code status in the medical record. The Director of Nursing and the Nursing Home Administrator confirmed that the required documentation for the preferred code status was missing, and the medical record was not updated accordingly. For the second resident, the clinical record also inaccurately reflected a full code status. The resident's son, who held power of attorney, indicated that the resident did not consistently comprehend healthcare decisions and preferred a different code status. The facility staff did not consult the son regarding the code status, and the Licensed Practical Nurse who admitted the resident documented a full code status without following up on the resident's preference. The Director of Nursing was unaware of the resident's indecision on code status due to a lack of documentation and communication. Both cases highlight a failure in the facility's process for verifying and documenting residents' advance directives. The facility did not ensure that the residents' or their representatives' preferences were accurately recorded and reflected in the medical records, leading to discrepancies in the documented code statuses.
Plan Of Correction
1. Resident #5 and #8 records updated to accurately reflect status and valid Florida yellow forms obtained. 2. Facility-wide audit of advanced directives completed. 3. Education commenced and completed on for clinical staff on federal and Florida requirements for advance directives. 4. Weekly audits for 4 weeks, then monthly for 3 months; reviewed in QAPI led by Social Worker or designee. 5. Report to QA committee will continue monthly for recommendations and or revisions. Reviewed in QAΑΡΙ. Correction completion date: