Failure to Honor Resident's Advance Directive
Penalty
Summary
The facility failed to honor a resident's advance directive choices, leading to a deficiency in providing adequate and appropriate health care. The incident involved a resident who was found unresponsive by staff. Despite having an order documented in the electronic health record, the staff did not follow the procedure to verify the code status before initiating emergency measures. The staff nurse, upon finding the resident unresponsive, checked the electronic record and the backup code status binder but did not find the necessary documentation in the binder, leading to the initiation of emergency procedures contrary to the resident's wishes. The resident, who had been admitted with multiple diagnoses, including Type 2 diabetes, was care planned for a specific code status. However, due to human error, the staff nurse second-guessed the electronic record and relied on the absence of a document in the binder, which was supposed to be the primary source of validation. The Social Service Director later acknowledged that the document might have been removed for scanning and not replaced, which contributed to the confusion and subsequent actions taken by the staff. Interviews with various staff members, including the Director of Nursing, Unit Manager, and Risk Manager, revealed that the root cause was identified as human error. The staff nurse involved had been trained on the facility's Advance Directive policy, which emphasized the electronic health record as the primary source for code status verification. Despite this, the nurse did not communicate the resident's code status to emergency services, resulting in actions that were not aligned with the resident's documented wishes.
Plan Of Correction
Resident #1 was transferred to Good Samaritan Hospital and was pronounced at 5:51AM in the ER by Hospital personnel. No further corrective action could be taken. An audit was completed on current residents by the Unit Managers to ensure that residents have Form 1896 with appropriate signatures and date in their medical record and a copy in a red binder located at each nurses station. Irregularities were immediately corrected. Code status for new admissions and re-admissions will be reviewed daily Monday to Friday in AM clinical meetings by the Inter Disciplinary Team and on weekends by the Nursing Supervisor to ensure medical records reflect accurate code status and a copy of Form 1896 that is appropriately signed and dated is uploaded in the EHR and a copy is in the binder at the nurses station if there is an order present. An audit of crash carts located on each nurses station was completed by the Director of Clinical Services to ensure equipment was readily available in an emergency. An audit was completed by the HR Manager to ensure that current Licensed Nurses have a valid license in place. One nurse had no current license on file but has since been completed. Newly hired Licensed Nurses' cards will be verified during the Orientation process. Current team members were reeducated starting on by the Director of Education and/or Designee on code status, policy, and neglect and validation of code status in PCC. 100% compliance was achieved on Licensed Nurses Education to include policy and procedure written post quiz on code status and code procedures for all licensed nurses, checking code status in PCC by a Licensed nurse if a resident was discovered to be pulseless prior to initiating Attestations that were signed for acknowledgement and understanding of policy. New hires will be educated on the policy during the orientation process by the Director of Education/designee, with written post quiz to ensure competency. Enhanced Code blue drills were conducted starting on the shift, every shift x 7 days, then every other day on different shifts x 7 days, then weekly x 7, then one on each shift monthly to include weekends by the Director of Education and/or designee. Re-education post drills as needed. Code Blue Drills will continue monthly by the Director of Education/designee one on each shift to include weekends and holidays. Results will be presented at monthly QAPI meetings to ensure ongoing compliance. The Social Service Director/designee will continue weekly audits of orders to ensure that orders are accurate, and that Form 1896 is appropriately signed and dated and is in place in the EHR, and a copy is in the red binder at the nurses station in the event of a PCC or power outage. New hires will be educated on the center's policy during the Orientation process by the Director of Education or designee with written post quiz and attestations to ensure competency. Results of audits will be presented at the Monthly QAPI meeting to ensure ongoing compliance.