Inaccurate Documentation of Advanced Directives
Penalty
Summary
The facility failed to ensure that the medical records for a resident were accurate and complete regarding advanced directives. The resident's admission record and physician's order both indicated a full code status, while the social services assessment and care plan documented a Do Not Resuscitate (DNR) order. This inconsistency in documentation led to conflicting information about the resident's code status across different parts of the medical record. During interviews, the resident stated not recalling any discussion about DNR status, and the Director of Nursing confirmed that the resident was a full code with no DNR order on file. The Director also acknowledged that the assessment and care plan were inaccurate due to an error by social services. The facility's policy requires code status to be verified upon admission and reviewed regularly, but this process was not properly followed for the resident in question.