Failure to Honor Resident's Advance Directive
Summary
The facility failed to honor a resident's advance directive choices, resulting in a serious deficiency. The incident involved a resident who had a Do Not Resuscitate (DNR) order documented in the electronic health record. However, when the resident became unresponsive, the staff did not follow the procedure to verify the code status in the electronic record. Instead, they relied on a physical binder, which did not contain the necessary documentation due to an oversight by the Social Service Director. The staff nurse, upon finding the resident unresponsive, checked the electronic record and confirmed the DNR order but second-guessed herself and looked for the physical document in the binder, which was missing. Consequently, the nurse called 911 and initiated resuscitation efforts, contrary to the resident's documented wishes. This action was based on the facility's outdated practice of relying on the physical document as the primary source of verification, despite the electronic record being the official source. The incident was further complicated by the nurse's failure to communicate the resident's DNR status to emergency responders, leading to the continuation of resuscitation efforts upon their arrival. The facility's policy required that the electronic health record be the primary source for verifying code status, but this was not adhered to, resulting in a breach of the resident's rights and the facility's procedures.
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 with a 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 meeting 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 on by the Director of Clinical Services to ensure equipment was readily available in an emergency. An audit was completed on by the HR Manager to ensure that current Licensed Nurses have a valid license in place; one nurse had no current on file but has since been completed on. Newly hired Licensed Nurses cards will be verified during the Orientation process. Current Team members were reeducated started 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 License 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 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 started on on the shift, every shift x 7 days, then every other day on different shift 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 centers policy during the Orientation process by the Director or 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.
Removal Plan
- Education on code status, policy, and neglect policy initiated for current license staff. With post quiz and attestation.
- New hired licensed nurses will be educated on the advanced directive policy with post quiz and attestation. Ongoing.
- Resident's chart review completed.
- Audit of medical records of current residents to validate orders.
- Federal immediate report submitted with the notification to DCF and law enforcement.
- Code books reviewed for accuracy. Books located at each nursing station.
- The nurse involved in the incident was removed from the schedule pending investigation.
- Code blue drills to be performed to include weekends and holidays starting on until all nurses have attended a code blue drill with no deficiencies, alternating different scenarios of code status to increase staff understanding.
- Medical director notified of events and interventions.
- Crash carts audited.
- cards audited for validation.
- Ad hoc meeting with Interdisciplinary Team (IDT) and medical director.
- Quiz presented to licensed nurses to validate knowledge on code status and procedures competency as needed.
- Licensed nurse hires to be educated on current advanced directive policy attestation and competency and post quiz. Ongoing.
- New admissions/readmissions records to be reviewed daily by the nursing supervisor for accurate status. Ongoing.
- Reeducate SSD, UM, DCS, DQA on policy and obtaining form DH1896 (document) with physician and resident representative signature as soon as an order is received for.
- SSD/designee will do audit daily during clinical meeting of binders kept at the nurses' station to ensure that form 1896 is in place for those residents with an order for.
- Results and outcome of audits of binders for Form 1896 to be presented monthly.
- Audit results and outcome of drills to be presented at ad hoc meeting. Then monthly or until compliance to determine the effectiveness of the plan. Plan to be revised as necessary.
- Federal five day report submitted.
- Report to the board of nursing.
- Physician to be re-educated on signing and dating Form 1896.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Advance Directive Not Maintained in Resident Record: A resident with dementia, muscle weakness, and protein-calorie malnutrition had documentation indicating an advance directive was in the chart, but record review did not locate a living will or DPOA for health care. The CNO confirmed the record did not include an advance directive and the facility did not have a living will on file.
Incomplete Advance Directive Documentation: The facility failed to keep complete and accurate advance directive records for two residents. One resident's chart contained a representative-signed acknowledgement that did not specify the type of advance directive, and another resident's record had no signed acknowledgement showing that advance directives were discussed. The SSD stated she was responsible for the documentation and that one form was filled out incorrectly while the other resident's paperwork could not be found.
The facility failed to timely respond to changes in condition for two residents, including one with severe cognitive impairment and another with dementia, CHF, diabetes, and a history of UTIs. Family members and DPOAs reported concerns about confusion, agitation, pain, SOB, and other worsening symptoms, but hospital evaluation was delayed while staff waited for physician input. Both residents were later admitted to the hospital with serious infections and other acute conditions, including sepsis, pneumonia, and respiratory failure.
A facility failed to ensure that active physician orders matched residents’ POLST code status for three residents. One resident with COPD, A-Fib, and anxiety had a POLST indicating DNR but no active code status order; another resident with dementia, hypothyroidism, and HTN had a POLST indicating DNR but a physician order for CPR; and a third resident with COPD, respiratory failure, and diabetes had a POLST indicating DNR but no active code status order. The DON confirmed the records were inconsistent and that physician orders and POLST should match.
A resident with dementia with agitation, stroke, and PE had an advanced directive noted in a care conference review, but the document could not be found in the medical record. Staff later confirmed the resident did not have an advance directive on file.
Failure to offer a resident the opportunity to create an advance directive. Record review showed the resident had no advance directive on file, and the SS Director stated there was no documentation that education was provided or that any attempts were made to obtain one. The resident had HTN, CKD, and mild cognitive impairment.
Advance Directive Not Maintained in Resident Record
Penalty
Summary
The facility failed to ensure that a copy of a resident's advance directive was maintained in the medical record for Resident #32, who was admitted with multiple diagnoses including dementia, muscle weakness, and protein-calorie malnutrition. The resident's care plan, revised 5/12/22, documented that the resident and appointed healthcare representative were to receive education regarding advance directives as needed, and a care conference evaluation dated 6/26/26 documented that the resident had an advance directive in the record. However, on 7/8/26, review of the medical record did not locate a living will or durable power of attorney for health care, and the CNO later confirmed that the record did not include an advance directive and the facility did not have a living will on file.
Incomplete Advance Directive Documentation
Penalty
Summary
The facility failed to ensure documentation regarding advance directives was complete and accurate for 2 of 7 residents reviewed. A policy titled "Advance Directives and Refusal of Treatment" stated that upon admission the Social Services Designee should obtain a copy of any existing Living Will, Health Care Proxy, Durable Power of Attorney for Health Care Decisions, or other recorded declaration and enter a progress note regarding the existence of an advance directive. Resident #7 was admitted with diagnoses including hemiplegia and hemiparesis following a nontraumatic intracerebral hemorrhage affecting the right dominant side. The record contained a "Resident Rights & Advance Directive Acknowledgement" signed by the resident's representative that indicated the resident had an advance directive, but the form did not identify the type of advance directive. Resident #81 was admitted with end stage renal disease, and the medical record contained no signed acknowledgement showing that advance directives were discussed with the resident or representative. The Social Services Director stated she was responsible for advance directive documentation, that the form for Resident #7 was filled out incorrectly and should have been corrected, and that the missing paperwork for Resident #81 meant the facility would not know whether the resident had an advance directive.
Delayed Response to Changes in Condition and Family Requests for Hospital Evaluation
Penalty
Summary
The facility failed to timely provide requested medical evaluation and treatment for two residents with changes in condition. The deficiency was identified during review of Complaint #3035494 and involved delayed responses to worsening symptoms, resulting in delayed medical treatment, worsening of condition, and dissatisfaction with care. For one resident with diagnoses including Alzheimer's disease and other medically complex conditions, the record showed severely impaired cognition and inability to make decisions. A family member reported that the resident had a decline in health about a week before hospitalization, with severe UTI and stool impaction. The hospital record documented that the resident arrived from the nursing home via EMS with confusion and altered mental status that had worsened since several days earlier, and the ED physician suspected sepsis. The resident was febrile, tachycardic, had elevated white blood cell count and creatinine, and was diagnosed with proctitis, cystitis, sepsis, NSTEMI, and acute kidney injury. The urine culture was positive for gram-negative rods/Pseudomonas aeruginosa. For another resident with diagnoses including diabetes mellitus, a history of UTIs, CHF, Alzheimer's disease, and dementia, the progress notes showed family concerns about abnormal behavior, confusion, agitation, shortness of breath, congestion, lethargy, and shallow breathing. The resident's DPOA reported repeatedly expressing concern that something was wrong and requesting hospital evaluation, but the facility did not immediately send the resident out and instead contacted the physician first. The change-in-condition documentation noted altered mental status and respiratory symptoms, and the physician initially recommended a nebulizer treatment before later directing transfer to the ED. The resident was admitted to the hospital with bilateral pneumonia, acute hypoxic respiratory failure, likely demand ischemia, chronic diastolic CHF, fluid overload, severe anemia, and human metapneumovirus infection.
Physician Orders Did Not Match POLST Code Status
Penalty
Summary
The facility failed to ensure that active physician orders reflected residents’ end-of-life wishes as documented on their Pennsylvania POLST forms for three residents. Facility policy stated that residents are presumed to consent to CPR unless there is documentation in the medical record showing a DNR order, and that all DNR orders must be rewritten by the attending physician for each admission or readmission. Review of the clinical records showed that Resident R14 had diagnoses including COPD, A-Fib, and anxiety, and had a POLST indicating DNR, but the current physician orders lacked evidence of code status. Resident R38 had diagnoses including dementia, hypothyroidism, and high blood pressure, and had a POLST indicating DNR; however, a physician order dated in the record indicated CPR, creating inconsistency between the POLST and the physician orders. Resident R50 had diagnoses including COPD, respiratory failure, and diabetes, and had a POLST indicating DNR, but current physician orders also lacked evidence of code status. During interviews, the DON confirmed that Resident R14’s record lacked active physician orders reflecting code status and that Resident R38’s physician orders and POLST were not consistent, and further confirmed that resident physician orders and POLST should match regardless of the POLST.
Advance Directive Not Available in Resident Record
Penalty
Summary
The facility failed to ensure a resident exercised the right to formulate an Advance Directive. Review of the State Operations Manual, record review, and staff interview showed that Resident #5 had an advanced directive documented on a Care Conference Review Comprehensive dated 4/3/26, but the document could not be located in the medical record. Resident #5 was admitted and later readmitted to the facility with diagnoses including dementia with agitation, stroke, and pulmonary embolism. On 6/26/26 at 9:48 AM, a request was made for a copy of Resident #5's advanced directive. Later that day at 11:19 AM, the CEO confirmed that Resident #5 did not have an advanced directive on file. The report states that this deficiency involved 1 of 5 residents whose records were reviewed.
Failure to Offer Advance Directive Opportunity
Penalty
Summary
The facility failed to ensure residents were offered the opportunity to create an advance directive for Resident #13, who was re-admitted with multiple diagnoses including hypertension, chronic kidney disease, and mild cognitive impairment. Record review on 6/24/26 showed that Resident #13 did not have an advance directive on file. On 6/25/26 at 2:43 PM, the Social Service Director stated there was no documentation that education was provided to Resident #13 and no attempts were made to obtain an advance directive.
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