Failure to Update Resident's Advance Directives
Penalty
Summary
The facility failed to ensure the accuracy of a resident's advance directives, specifically for a resident who had changed their Medical Orders for Life Sustaining Treatment (MOLST) from Do Not Resuscitate (DNR) to Full Code. Despite the resident being cognitively intact and having updated their MOLST during a quarterly care plan meeting, the facility did not update the electronic medical record or the physical indicators, such as the red sticker on the resident's door, to reflect this change. The physician signed the updated MOLST, but the physician orders were not updated accordingly, leading to a discrepancy between the resident's wishes and the documented orders. Interviews with facility staff revealed a breakdown in communication and procedure adherence. The Social Work Director was unaware of why the physician orders were not updated, and Licensed Practical Nurse #1 was not informed of the change in the resident's code status. The Director of Nursing indicated that social workers were responsible for notifying nursing staff of changes, but this did not occur in this instance. This lack of communication and failure to update records resulted in the facility not honoring the resident's current advance directive preferences.
Plan Of Correction
Plan of Correction: Approved April 4, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** P(NAME) F578: I. Immediate Corrective Actions: Resident # 82 1) The Primary Physician reviewed the Medical Orders for Life Sustaining Treatment (MOLST) and ensured it was revoked and the physician DNR order in the medical record was discontinued. 2) The RNS with the SW ensured DNR identifiers were removed for Resident # 82. 3) The IDT Team met with Resident # 82 and updated the Care Plan updating to Full Code status and documented in the Medical Record. II. Identification of Others: 1) The facility respectfully states that all residents had the potential to be affected. 2) The DON and Director of Social Work obtained a list of all Advanced Directives. This list will be utilized by SW and RNS to review all residents orders for Advanced Directives including MOLST forms to ensure all Advanced Directives are accurate and current. No issues were noted. III. Systemic Changes: 1) The Administrator, Medical Director, DON, and Director of SW reviewed the Facility PP for Advanced Directives and found same to be compliant. All Physicians, NPs, Licensed nurses, Social workers, and IDT Team members will be in serviced by the Designee: - Topic of Inservice is as follows: - On admission the SW or admission RN will provide information on Advanced Directives and document the education in the medical record. - The admitting RN will ascertain if the resident has an existing Advanced Directive and inform physician for follow up orders as needed. - If the resident is unable to discuss advanced directives on admission the SW in conjunction with the physician and IDT Team will discuss advanced directives with the resident representative/surrogate and/or Health Care Proxy (HCP) as indicated. - All established Advanced Directives will be documented on the Medical Orders for Life Sustaining Treatment (MOLST) form signed by the physician/NP. - The SW will be responsible for ensuring all accurate Facility identifiers for DNR are in place. - The Advanced directives will also be documented in the physician order [REDACTED]. - In cases where advanced directives are changed by the resident or HCP the SW will immediately inform the physician and document in Medical Record. - Any prior MOLST form will be revoked and a new MOLST form signed by the physician will be completed as needed. - The RN will be informed and ensure physician orders [REDACTED]. IV. Quality Assurance: 1) The Administrator developed an audit tool to monitor the Facility compliance with ensuring all residents’ Advanced Directives are accurate. This audit will be done by the Director of SW for 4 randomly selected residents weekly x 4 weeks followed by 4 residents monthly x 11 months. 2) All audit findings will be discussed at Morning Meeting and presented at the Quarterly QA meeting for input and follow up as needed. V. Person Responsible: Director of Social Work