Discrepancy in Advanced Directives for a Resident
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards of practice for a resident's advanced directives. Resident 51, who has Alzheimer's disease and type 2 diabetes mellitus, had a POLST form indicating a Do Not Resuscitate (DNR) status, dated December 23, 2024. However, the resident's physician orders, dated July 3, 2024, incorrectly stated Full Code, meaning resuscitation should be attempted if the resident was found without a pulse and not breathing. This discrepancy was confirmed during an interview with the Nursing Home Administrator, who acknowledged that the resident's orders should have reflected her DNR status.
Plan Of Correction
1. At time of discovery, the resident R51 code status was updated to reflect the wishes to be a DNR. 2. A whole house audit was completed upon discovery and all patients had correlating orders and POLSTs reflective of their wishes. 3. Education was provided by the Director of Nursing to Social Services and licensed clinical staff to ensure that the POLST is reflective of any advanced directive orders. New admissions and any patient with a change in code status will be audited weekly x 4 to ensure proper code status is reflective in the order. 4. Results of the audit will be taken to QAPI for review of findings and further interventions if indicated.