Inconsistent Advance Directive Documentation
Penalty
Summary
The facility failed to establish clear and consistent resident wishes regarding advance directives for a resident reviewed for advance directive concerns. The clinical record review of the resident's physical chart revealed a POLST signed by a physician and the resident, indicating the resident desired CPR but refused intubation. However, the active physician orders in the resident's electronic medical record instructed staff to implement Full Code treatment without any limitations. Interviews with two registered nurses revealed that they would refer to the electronic medical record, which did not indicate a DNR status, and would initiate CPR without limitations. The nurses confirmed that the electronic medical record did not reflect the resident's wish to refuse intubation as indicated in the POLST. The surveyor reviewed the omission with the Director of Nursing, highlighting the inconsistency between the resident's POLST and the electronic physician orders.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements. 1. Resident 118's physician order and banner notification were updated to reflect resident 118's desire for CPR and refusal of intubation (i.e. DNI). There was no harm to resident 118. 2. All current resident records will be reviewed to ensure that the Banner Bar and the physician order, which may also reflect any limited interventions (such as intubation) match the residents code preferences noted on the POLST and/or the Advanced Directive as indicated. 3. The DON or Designee will educate all RNs, LPNs, and Social Workers on the need to ensure that the Banner Bar and the physician order, which may also reflect any limited interventions (such as intubation) match the residents code preferences noted on the POLST and/or the Advanced Directive as indicated. 4. Social worker or designee will audit to ensure that the Banner Bar and the physician order, which may also reflect any limited interventions (such as intubation) match the residents code preferences noted on the POLST and/or the Advanced Directive as indicated. 5 resident charts will be audited weekly x4 then 5 resident charts will be audited monthly x2 or until substantial compliance is achieved. Results will be reported at the QAPI meeting.