Inconsistent Advance Directive Documentation
Penalty
Summary
The facility failed to ensure that advance directives were accurate and consistent for one resident. Upon review, the resident's electronic medical record indicated a change in code status from Do Not Resuscitate Comfort Care Arrest (DNRCCA) to Do Not Resuscitate Comfort Care (DNRCC) as ordered by the physician. However, the paper chart for the same resident still contained a signed DNRCCA form, which did not reflect the updated code status. This discrepancy was confirmed during an interview with a registered nurse, who acknowledged that the advance directives in the electronic and paper records did not match. The facility's policy required that copies of advance directives be placed on the chart, but the records were not updated to reflect the most current physician orders. The resident involved had multiple diagnoses, including epilepsy, atherosclerotic heart disease, cerebrovascular disease, hyperlipidemia, COPD, schizoaffective disorder, angina, Parkinson's disease, and adult failure to thrive.
Plan Of Correction
This plan of correction does not constitute an admission to any of the allegations contained within the State of Deficiency. Rather, this plan of corrections has been prepared and executed because state and federal law require it, and not because Park Health Nursing Home and Rehabilitation Center agrees with the citation. The facility maintains that the alleged deficiency does not individually or collectively jeopardize the health and safety of the residents. This plan of correction is not meant to establish any standard of care contract, obligation or position, and Park Health Nursing Home and Rehabilitation Center reserves all rights to raise all possible contentions and defenses in any civil or criminal claim, action or proceeding. This plan of correction shall also operate as the facility's credible allegation of compliance. Please accept 4/22/2025 as our date of compliance. The facility will continue to ensure accurate advanced directives are maintained. On 3/25/2025, the unit nurse verified with resident #2 she wanted his advanced directives to remain a DNRCC. Order verified in her electronic medical record and the current DNRCCA form was replaced with signed DNRCC in her hard chart. An initial audit was conducted on 3/31/2025, by the facility DON with no negative findings noted on current residents' charts. The Regional clinical manager reviewed current facility process with Medical Records clerk, DON and ADON on 4/14/2025. By 4/17/2025, the DON and or designee will reeducate licensed nursing staff on facility process for obtaining advanced directives, maintaining advanced directives records, and managing changes to desired code status/advance directives. Weekly for 2 weeks, the DON and or designee will audit 5 random residents ensuring proper documentation and record keeping for current desired advanced directives. Negative findings will be corrected by ensuring proper records/orders, and reeducating staff. Negative findings will also be reported to the QA committee for review and recommendations. The DON is responsible for the ongoing compliance and the Administrator will review the weekly audits ensuring completion.