Failure to Honor Resident's Advance Directive
Penalty
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 This action was based on the facility's outdated practice of relying on the physical document as the primary source of verification, despite the electronic record being the official source.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.